Indications for and outcomes of therapeutic plasma exchange after cardiac transplantation: A single center retrospective study.
Date
2018-08
Journal Title
Journal ISSN
Volume Title
Repository Usage Stats
views
downloads
Citation Stats
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.
Type
Department
Description
Provenance
Subjects
Citation
Permalink
Published Version (Please cite this version)
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.
This is constructed from limited available data and may be imprecise. To cite this article, please review & use the official citation provided by the journal.
Collections
Scholars@Duke
Oluwatoyosi Adefunke Onwuemene
Steven C. Grambow
Transforming research education through innovation, mentorship, and collaboration.
Steven C. Grambow, PhD is Associate Professor and Associate Chair of Education in the Department of Biostatistics and Bioinformatics at Duke University School of Medicine. He serves as Director of the Clinical Research Training Program (CRTP), Duke’s flagship degree-granting program for clinical and translational research education, and as Co-Director of the Workforce Development Pillar of the Duke Clinical and Translational Science Institute (CTSI). Dr. Grambow provides strategic oversight for multiple educational and workforce development initiatives that span the full continuum of learners, from students to faculty.
With over two decades of experience in graduate and professional education, Dr. Grambow has taught statistical methods and research design to more than 1,000 physician-scientists, clinical fellows, and faculty at Duke and the NIH. He has led the CRTP’s core statistics course for over 21 years and has directed or co-directed national and international certificate programs across multiple institutions. His expertise spans classroom, hybrid, and online environments, and he has served as a leader in designing programs that respond to evolving workforce and research needs.
A central focus of Dr. Grambow’s work is building pathways into clinical and translational research careers. He has cultivated longstanding partnerships with academic and community institutions, including North Carolina Central University and Durham Technical Community College, to create educational models that prepare learners for impactful roles in research. His efforts emphasize strong mentorship, practical experience, and tailored program design to meet learners where they are and help them advance.
Dr. Grambow is also at the forefront of educational innovation, leading initiatives that explore the integration of artificial intelligence into biostatistical training and academic workflows. His current work includes faculty development in AI literacy, emerging pedagogical models that support active learning and reflective practice, and new frameworks for clinical research education that emphasize adaptability and cross-disciplinary collaboration.
As a collaborative statistical scientist, Dr. Grambow has contributed to a wide range of clinical research studies, including observational studies, randomized trials, and epidemiologic investigations. His research collaborations have addressed public health and clinical challenges such as amyotrophic lateral sclerosis (ALS), post-traumatic stress disorder (PTSD), Prader-Willi syndrome (PWS), prostate cancer, cardiovascular risk reduction, and substance use recovery.
Dr. Grambow’s leadership has been recognized through institutional and national awards, including teaching honors from the American Statistical Association and Duke University. He brings a unique combination of academic rigor, educational strategy, and programmatic leadership to his roles, helping to shape the future of clinical research training through thoughtful innovation and sustained collaboration.
Chetan B. Patel
Robert John Mentz
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
Carmelo Alessio Milano
Ara Dickran Metjian
Gowthami Morey Arepally
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.
Thomas Lee Ortel
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.
Unless otherwise indicated, scholarly articles published by Duke faculty members are made available here with a CC-BY-NC (Creative Commons Attribution Non-Commercial) license, as enabled by the Duke Open Access Policy. If you wish to use the materials in ways not already permitted under CC-BY-NC, please consult the copyright owner. Other materials are made available here through the author’s grant of a non-exclusive license to make their work openly accessible.