Therapeutische Plasmapherese in der Intensivmedizin

Was ist neu?

Sepsis und Multiorganversagen Die Rolle der therapeutischen Plasmapherese (TP) in der Therapie der Sepsis mit Multiorganversagen ist noch nicht abschließend geklärt (Kategorie III der American Society for Apheresis, ASFA). Zwar zeigen die verfügbaren randomisiert kontrollierten Studien (RCT) keinen eindeutigen Überlebensvorteil, prospektive Daten von 2018 belegen jedoch ein gutes Sicherheitsprofil und eine günstige Beeinflussung von Surrogatparametern auch bei hoch Katecholamin-pflichtigen Patienten im septischen Schock.

Akutes Leberversagen Eine multizentrische RCT von 2016 konnte einen signifikanten Überlebensvorteil durch die Durchführung von „High Volume“-TP bei Patienten im akuten Leberversagen zeigen. Dies galt allerdings nur in der Subgruppe der nicht transplantierten Patienten.

Katastrophales Antiphospholipid-Antikörper-Syndrom (CAPS) Retrospektive Datenauswertungen von 2016 zeigten einen deutlichen Überlebensvorteil einer 3-Fachtherapie, welche die TP beinhaltet. Dies veranlasste die ASFA in ihren neuen, 2019 erschienenen Leitlinien das CAPS erstmals in die ASFA-Kategorie I einzustufen.

Thyreotoxische Krise Retrospektive Analysen von 2018 ergaben eine effektive Elimination von Schilddrüsenhormonen durch die TP. Aufgrund dessen erkennt die ASFA in ihren neuen Leitlinien die TP als Zweitlinientherapie der thyreotoxischen Krise an.

Abstract

Therapeutic plasma exchange (TPE) is used to eliminate toxins, hormones or antibodies from the blood and replace the lost volume with fresh frozen plasma, albumin or crystalloids. In this article, recent advances in the usage for TPE for four different critical disease entities are explored: Septic shock, acute liver failure, catastrophic antiphospholipid syndrome (CAPS) and thyrotoxic storm.

Septic shock Even though randomized controlled trials have not been able to demonstrate a clear benefit of TPE in septic shock, recent data demonstrates a sufficient safety profile for usage in critically ill, highly catecholamine dependent individuals. Moreover, an improvement in several surrogate parameters has been demonstrated.

Acute liver failure High volume TPE has been shown to improve outcome in patients in acute liver failure in a multicenter, randomized controlled trial. However, this was only true for a subgroup of patients which did not receive a liver transplant. This raises the question about the effectiveness for TPE as a bridge to transplant therapy.

CAPS Retrospective data analysis demonstrates a clear benefit in survival when a triple therapy containing anticoagulation, corticosteroids and TPE or intravenous immunoglobulin is used. However, there was no difference in survival between the usage of intravenous immunoglobulin or TPE and no added benefit in using both.

Thyrotoxic storm Thyroid hormones can be eliminated using TPE. This has been shown in a retrospective data analysis of 2018 and caused the ASFA to view TPE as a second line therapy for thyrotoxic storm in the most recent 2019 guidelines.

Schlüsselwörter

therapeutische Plasmapherese - Sepsis - akutes Leberversagen - thyreotoxische Krise - katastrophales Antiphospholipid-Antikörper-Syndrom

Key words

therapeutic plasma exchange - sepsis - acute liver failure - catastrophic antiphospholipid syndrome - thyrotoxic storm

• Literatur

• 1 Padmanabhan A, Connelly-Smith L, Aqui N. et al Guidelines on the Use of Therapeutic Apheresis in Clinical Practice – Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher 2019; 34: 171-354 . doi:10.1002/jca.21705
• 2 Stahl K, Schmidt JJ, Seeliger B. et al Effect of therapeutic plasma exchange on endothelial activation and coagulation-related parameters in septic shock. Crit Care 2020; 24: 71 . doi:10.1186/s13054-020-2799-5
• 3 Rimmer E, Houston BL, Kumar A. et al The efficacy and safety of plasma exchange in patients with sepsis and septic shock: a systematic review and meta-analysis. Crit Care 2014; 18: 699 . doi:10.1186/s13054-014-0699-2
• 4 David S, Stahl K. To remove and replace-a role for plasma exchange in counterbalancing the host response in sepsis. Crit Care 2019; 23: 14 . doi:10.1186/s13054-018-2289-1
• 5 Knaup H, Stahl K, Schmidt BMW. et al Early therapeutic plasm a exchange in septic shock: a prospective open-label nonrandomized pilot study focusing on safety, hemodynamics, vascular barrier function, and biologic markers. Crit Care 2018; 22: 285 . doi:10.1186/s13054-018-2220-9
• 6 Huang YK, Tan DM, Xie YT. et al Randomized controlled study of plasma exchange combined with molecular adsorbent re-circulating system for the treatment of liver failure complicated with hepatic encephalopathy. Hepatogastroenterology 2012; 59: 1323-1326 . doi:10.5754/hge12203
• 7 Larsen FS, Schmidt LE, Bernsmeier C. et al High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol 2016; 64: 69-78 . doi:10.1016/j.jhep.2015.08.018
• 8 Stahl K, Hadem J, Schneider A. et al Therapeutic plasma exchange in acute liver failure. J Clin Apher 2019; 34: 589-597 . doi:10.1002/jca.21737
• 9 Stahl K, Busch M, Fuge J. et al Therapeutic plasma exchange in acute on chronic liver failure. J Clin Apher 2020; 35: 316-327 . doi:10.1002/jca.21799c
• 10 Tan EX, Wang MX, Pang J. et al Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review. World J Gastroenterol 2020; 26: 219-245 . doi:10.3748/wjg.v26.i2.219
• 11 Legault K, Schunemann H, Hillis C. et al McMaster RARE-Bestpractices clinical practice guideline on diagnosis and management of the catastrophic antiphospholipid syndrome. J Thromb Haemost 2018;
• 12 Rodríguez-Pintó I, Moitinho M, Santacreu I. et al Catastrophic antiphospholipid syndrome (CAPS): Descriptive analysis of 500 patients from the International CAPS Registry. Autoimmun Rev 2016; 15: 1120-1124 . doi:10.1016/j.autrev.2016.09.010
• 13 Marson P, Bagatella P, Bortolati M. et al Plasma exchange for the management of the catastrophic antiphospholipid syndrome: importance of the type of fluid replacement. J Intern Med 2008; 264: 201-203 . doi:10.1111/j.1365-2796.2008.01942.x
• 14 Garla V, Kovvuru K, Ahuja S. et al Severe Hyperthyroidism Complicated by Agranulocytosis Treated with Therapeutic Plasma Exchange: Case Report and Review of the Literature. Case Rep Endocrinol 2018; 2018: 4135940 . doi:10.1155/2018/4135940