title: Two approaches to the clinical dilemma of treating TTP with therapeutic plasma exchange in patients with a history of anaphylactic reactions to plasma.
abstract: BACKGROUND
  Thrombotic thrombocytopenic purpura (TTP) is a rare but serious disease caused by autoantibody-mediated deficiency in von Willebrand factor (VWF) cleaving protease, ADAMTS-13. The primary acute treatment is therapeutic plasma exchange (TPE). However, some patients can develop allergic/anaphylactic reactions to the replacement (i.e., donor) plasma over time. Two potential treatment strategies for patients with TTP who demonstrate severe allergic reactions to plasma used for exchange were examined.
  
  
  METHODS
  Two patients with TTP exacerbations who developed severe allergic reactions to donor plasma were identified. One patient's TPE was re-initiated with Octaplas, a lot-batched solvent and detergent treated, type-specific, pooled donor plasma product. The other patient was exchanged with primarily albumin, followed by slow incremental exposures to donor plasma to mitigate exposures and allergic risks. Both patients were assessed for anaphylaxis.
  
  
  RESULTS
  Both treatment strategies were successful in preventing any further clinically significant allergic/anaphylactic reactions and facilitated both patients' TTP remissions.
  
  
  CONCLUSIONS
  Based on our experience with two similar patients with TTP exacerbations and history of anaphylactic reactions to plasma during TPE, we have identified two possible treatment protocols to achieve remission in this clinical dilemma. Substituting Octaplas for standard plasma or, alternatively, using albumin with slowly increasing amounts of standard plasma may help to mitigate the risk of further anaphylactic adverse events. J. Clin. Apheresis 32:158-162, 2017. © 2016 Wiley Periodicals, Inc.
authors.affiliation: Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, 06510.|Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, , T2N 1N4, Canada.
authors.forename: Davinder
authors.initials: D
authors.lastname: Sidhu
authors.affiliation: Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, 06510.
authors.forename: Edward L
authors.initials: EL
authors.lastname: Snyder
authors.affiliation: Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, 06510.|Pathology & Laboratory Medicine Service, VA Connecticut Healthcare System, West Haven, Connecticut, 06516.
authors.forename: Christopher A
authors.initials: CA
authors.lastname: Tormey
mesh_terms: D000071120:ADAMTS13 Protein / Q000276:immunology; D000328:Adult; D000707:Anaphylaxis / Q000209:etiology / Q000517:prevention & control*; D001323:Autoantibodies / Q000096:biosynthesis / Q000097:blood; D005260:Female; D006801:Humans; D010949:Plasma / Q000276:immunology; D010951:Plasma Exchange / Q000009:adverse effects*; D011697:Purpura, Thrombotic Thrombocytopenic / Q000628:therapy*; D000075462:Serum Albumin, Human / Q000008:administration & dosage
chemical_list: D001323:Autoantibodies; D000071120:ADAMTS13 Protein; C099604:ADAMTS13 protein, human; D000075462:Serum Albumin, Human
keywords: therapeutic plasma exchange; thrombotic thrombocytopenic purpura