Spremembe v hemostazi pri bolnikih zdravljenih s citratno membransko plazmaferezo z ali brez nadomeščanja faktorjev koagulacije

Zrimšek, Matej (author), Marn Pernat, Andreja (mentor)

Uvod. Terapevtska membranska plazmafereza (MPF) je aferezno zunajtelesno zdravljenje, pri katerem odstranimo bolnikovo plazmo z namenom odstranitve bolezenskih protiteles in drugih sestavin plazme. Plazmo praviloma nadomestimo z mešanico humanih albuminov in elektrolitske raztopine, kar zniža koncentracije faktorjev koagulacije. Namen naše raziskave je bil preučiti vpliv MPF na bolnikovo hemostazo, ocenjeno s standardnimi testi koagulacije ter z globalnima preiskavama ROTEM in celokupni hemostatski potencial, in primerjati učinkovitost dodatka koncentrata fibrinogena po MPF z dodatkom sveže zamrznjene plazme (SZP) kot del nadomestne tekočine na izboljšanje bolnikove hemostaze. Bolniki in metode. Izvedli smo prospektivno raziskavo na 40 odraslih bolnikih, ki so potrebovali intenzivno zdravljenje z MPF in niso imeli znanih motenj hemostaze. Opravili smo 75 plazmaferez, ki smo jih razvrstili v tri skupine glede na bolnikovo tveganje za krvavitev. Pri skupini z nizkim tveganjem nismo nadomeščali faktorjev koagulacije. Skupina z zmerno zvečanim tveganjem za krvavitev je za popravo hemostaze po MPF dodatno prejela koncentrat fibrinogena, ki se do sedaj še ni uporabljal v ta namen. Skupini z visokim tveganjem za krvavitev smo en del bolnikove odstranjene plazme nadomestili s SZP. Primerjali smo rezultate testov hemostaze pred in po vsaki MPF. Rezultati. Z vsemi testi smo potrdili zmanjšano sposobnost strjevanja krvi po MPF. Izvidi globalnih testov so že pred proceduro pri večini kazali manjšo sposobnost hemostaze, kar kaže na večjo občutljivost testov v primerjavi s testoma aPTČ in PČ/INR. Kljub primerljivim vrednostim fibrinogena med skupinama, kjer smo nadomestili samo fibrinogen ali koagulacijske faktorje s SZP, so se testi ROTEM po MPF značilno razlikovali. Rezultati večine testov hemostaze so bili bolj ugodni v skupini, ki je prejela koncentrat fibrinogena v primerjavi s skupino, ki nadomestnih faktorjev ni prejela. Zaključek. Membranska plazmafereza brez ali z le delnim nadomeščanjem faktorjev koagulacije poveča nagnjenost h krvavitvi. Koncentrat fibrinogena je učinkovit, vendar ne v enaki meri kot dodatek SZP.

• Language: Slovenian
• Keywords: membranska plazmafereza, koncentrat fibrinogena pri membranski plazmaferezi, spremembe hemostaze pri membranski plazmaferezi, nadomestne tekočine pri membranski plazmaferezi, nadomeščanje faktorjev koagulacije pri membranski plazmaferezi
• Work type: Doctoral dissertation
• Organization: MF - Faculty of Medicine
• Year: 2023
• PID: 20.500.12556/RUL-152288
• Publication date in RUL: 17.11.2023

Secondary language

• Language: English
• Title: Changes in hemostasis after therapeutic plasmapheresis with citrate angicoagulation with or without coagulation factors replacement

Abstract

Background. Therapeutic plasma exchange (TPE) is an extracorporeal procedure which removes the patient’s plasma and replaces it with a replacement fluid which is usually a mix of electrolyte solution and albumin. This lowers concentrations of coagulation factors. The aim of our study was to compare the effect of TPE on patients’ hemostasis evaluated with standard coagulation tests and global tests ROTEM and overall hemostatic potential and to compare the efficacy of fibrinogen supplementation with fibrinogen concentrate to the addition of fresh frozen plasma (FFP) as a part of replacement fluid. Patients and methods. Forty adult patients who needed intensive TPE treatment with no known coagulation abnormalities were included in the study. 75 TPE procedures were made and were randomized in three study groups depending on their estimated bleeding risk. Patients with low risk did not receive any coagulation factor replacement. Group with medium risk received fibrinogen concentrate after TPE to substitute solely for the loss of fibrinogen. Highest bleeding risk group received a partial coagulation factor replacement with FFP. We compared coagulation tests before and after TPE procedures. Results. Tests showed lower coagulation ability after TPEs. Results of global tests showed worse hemostasis even before procedures, which indicates higher test sensitivity comparing to standard coagulation tests. Concentrations of fibrinogen in medium- and high-risk groups were similar before and after TPEs. Nevertheless, most coagulation tests showed better coagulation ability after TPEs in the group which received FFP. Results of most tests of the group which received fibrinogen concentrate were favorable to the group which received no coagulation factors. Conclusion. Therapeutic plasma exchange without or with only partial coagulation factor replacement increases the risk of bleeding. Treatment with fibrinogen concentrate is efficient, but not to the same extent as partial substitution of all coagulation factors with FFP.

• Keywords: plasma exchange, therapeutic plasmapheresis, fibrinogen concentrate used with plasma exhange, fibrinogen concentrate used with plasmapheresis, changes in hemostasis with plasma exhange, coagulation factor replacement with plasma exchange