Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study.

Abstract

INTRODUCTION:Limited data are available describing indications for and outcomes of therapeutic plasma exchange (TPE) in cardiac transplantation. METHODS:In a retrospective study of patients who underwent cardiac transplantation at Duke University Medical Center from 2010 to 2014, we reviewed 3 TPE treatment patterns: a Single TPE procedure within 24 h of transplant; Multiple TPE procedures initiated within 24 h of transplant; and 1 or more TPE procedures beginning >24 h post-transplant. Primary and secondary outcomes were overall survival (OS) and TPE survival (TS), respectively. RESULTS:Of 313 patients meeting study criteria, 109 (35%) underwent TPE. TPE was initiated in 82 patients within 24 h, 40 (37%) receiving a single procedure (Single TPE), and 42 (38%) multiple procedures (Multiple TPE). Twenty-seven (25%) began TPE >24 h after transplant (Delayed TPE). The most common TPE indication was elevated/positive panel reactive or human leukocyte antigen antibodies (32%). With a median follow-up of 49 months, the non-TPE treated and Single TPE cohorts had similar OS (HR 1.08 [CI, 0.54, 2.14], P = .84), while the Multiple and Delayed TPE cohorts had worse OS (HR 2.62 [CI, 1.53, 4.49] and HR 1.98 [CI, 1.02, 3.83], respectively). The Multiple and Delayed TPE cohorts also had worse TS (HR 2.59 [CI, 1.31, 5.14] and HR 3.18 [CI, 1.56, 6.50], respectively). Infection rates did not differ between groups but was independently associated with OS (HR 2.31 [CI, 1.50, 3.54]). CONCLUSIONS:TPE is an important therapeutic modality in cardiac transplant patients. Prospective studies are needed to better define TPE's different roles in this patient population.

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Citation

Published Version (Please cite this version)

10.1002/jca.21622

Publication Info

Onwuemene, Oluwatoyosi A, Steven C Grambow, Chetan B Patel, Robert J Mentz, Carmelo A Milano, Joseph G Rogers, Ara D Metjian, Gowthami M Arepally, et al. (2018). Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study. Journal of clinical apheresis, 33(4). pp. 469–479. 10.1002/jca.21622 Retrieved from https://hdl.handle.net/10161/27018.

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Scholars@Duke

Onwuemene

Oluwatoyosi Adefunke Onwuemene

Associate Professor of Medicine
Grambow

Steven C. Grambow

Associate Professor of Biostatistics & Bioinformatics

I am an academic statistician with a focus on educational leadership and administration, teaching, mentoring, and collaborative clinical research. I serve as the director of multiple education programs, both formal degree programs and certificate-based training programs. I also provide administrative oversight of multiple graduate degree programs and educational initiatives focusing on clinical and translational science workforce development at the student, staff, and faculty levels.

I have many years of experience with in-person and online teaching across a variety of teaching venues (formal degree programs, domestic and international certificate-based training programs, faculty development seminars, residency/fellowship training programs) and health sciences audiences (medical students, residents, fellows, faculty, and other health professionals), including more than 21 years as a statistics course director in the Duke Clinical Research Training Program.

As a collaborative scientist I have experience with a broad range of clinical research areas and clinical research designs, including observational studies, epidemiology investigations, and randomized clinical trials, including those utilizing web, mobile, and telemedicine-based health behavior interventions. I have collaborated on projects spanning a broad range of clinical research areas, including amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder (PTSD), Prader-Willi syndrome (PWS), prostate cancer, quality of colorectal cancer care, osteoarthritis, lifestyle modification through weight loss, CVD risk reduction through hypertension control, smoking cessation, and substance abuse recovery.

Patel

Chetan B. Patel

Associate Professor of Medicine
Mentz

Robert John Mentz

Associate Professor of Medicine

I am a cardiologist with a clinical and research interest in heart failure (going from Failure to Function), including advanced therapies such as cardiac transplantation and mechanical assist devices or “heart pumps."

I serve our group as Chief of the Heart Failure Section.

I became a heart failure cardiologist in order to help patients manage their chronic disease over many months and years. I consider myself strongly committed to compassionate patient care with a focus on quality of life and patient preference.

I am the Editor in Chief of the Journal of Cardiac Failure - The official journal of the Heart Failure Society of America.

My research interests are focused on treating co-morbid diseases in heart failure patients and improving outcomes across the cardiovascular spectrum through clinical trials and outcomes research. Below, you will find my specific research interests:

  •     Cardiometabolic disease
  •     Co-morbidity characterization (diabetes, sleep apnea, renal failure) in heart failure
  •     Phenotypic characterization and risk prognostication of patients with heart failure
  •     Role of surrogate and nonfatal endpoints in clinical heart failure trials
  •     Biomarkers in heart failure
  •     Novel pharmacological and non-pharmacological approaches to heart failure
  •     Improving site-based heart failure research
Milano

Carmelo Alessio Milano

Joseph W. and Dorothy W. Beard Distinguished Professor of Experimental Surgery
Arepally

Gowthami Morey Arepally

Professor of Medicine

Gowthami M. Arepally, M.D. is a Professor of Medicine in the Division of Hematology at Duke University Medical Center.  Her clinical interests are in immune thrombocytopenias, thrombotic disorders, and complement-mediated diseases.  Dr. Arepally’s long-standing research program investigates the immune pathogenesis of heparin induced thrombocytopenia (HIT).  Current laboratory efforts focus on the role of complement activation in antibody production and thrombosis in HIT, studies of complement inhibitors for immune-complex mediated diseases and diagnostic biomarkers of platelet activation.  

Ortel

Thomas Lee Ortel

Chief, Division of Hematology in the Department of Medicine

My research program investigates the molecular mechanisms whereby various congenital and acquired abnormalities result in ‘dysfunctional’ hemostasis (i.e., hemorrhage or thrombosis) to better understand the molecular mechanisms and interactions that are necessary for normal hemostasis. We are particularly interested in the mechanisms whereby antibodies and other inhibitors can interfere with normal hemostatic mechanisms. Several projects extensively overlap and focus on the assembly and function of procoagulant (e.g., factor X-ase and prothrombinase) and anticoagulant (e.g., activated protein C complex) phospholipid membrane-dependent complexes.

We utilize a variety of approaches in these studies. Monoclonal antibodies, single-chain variable domain fragments, polyclonal antibodies prepared from patients with factor VIII inhibitors, and site-specific mutagenesis have all been used to characterize structure-function relationships in coagulation factor VIII. Our laboratory has also extensively characterized anti-factor V antibodies, investigating autoantibodies as well as xenogenic antibodies developing after exposure to topical bovine thrombin preparations which contain trace amounts of contaminating bovine factor V. We have also characterized how antiphospholipid antibodies interfere with the activated protein C complex, a lipid-dependent natural anticoagulant complex that proteolytically inactivates factor Va and factor VIIIa.

Our current studies are focusing on two antibody-mediated thrombotic syndromes, heparin-induced thrombocytopenia and antiphospholipid antibody syndrome. First, we are initiating a large clinical trial investigating the incidence of clinically-significant heparin-induced thrombocytopenia in patients who develop anti-heparin/platelet factor 4 antibodies following cardiac bypass procedures. While these antibodies are commonly seen following cardiac bypass, the true incidence of thromboembolic complications related to these prothrombotic antibodies remains unknown. We are also collaborating with investigators in the Center for Human Genetics on a large, multi-center study exploring the genetics of familial antiphospholipid antibody syndrome. In addition, we have used a genomic strategy to investigate patients with antiphospholipid antibody syndrome and have identified a gene expression profile that appears to be unique to patients with this syndrome in contrast to patients with venous thromboembolism who do not have these autoantibodies.

We also participate in a variety of collaborative research efforts, both with individual investigators as well as participating in multi-center clinical research studies. For example, we are one of seventeen centers participating in the NIH-supported Transfusion Medicine/Hemostasis Network, and we are currently conducting a trial through this network to define the optimal dose of platelets for patients needing platelet transfusions for hypoproliferative thrombocytopenia. We are also part of a multi-center registry of patients with thrombotic thrombocytopenic purpura, and we are one of eight centers in the Hemostasis and Thrombosis Center pilot program sponsored by the Centers for Disease Control and Prevention. Participation in these registries and networks provides us with access to the patient populations that we study in the research laboratory.


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