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VOLUME 24 , ISSUE 3 ( March, 2020 ) > List of Articles

CASE REPORT

Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series

Sushmita RS Upadhya, Chakrapani Mahabala, Jayesh G Kamat, Jayakumar Jeganathan, Sushanth Kumar, Mayur V Prabhu

Keywords : Gram negative, Management, Microangiopathic hemolytic anemia, Peripheral smear, Plasmapheresis, Schistocyte, Sepsis, Sepsis and intensive care unit, Thrombotic microangiopathy

Citation Information : Upadhya SR, Mahabala C, Kamat JG, Jeganathan J, Kumar S, Prabhu MV. Plasmapheresis in Sepsis-induced Thrombotic Microangiopathy: A Case Series. Indian J Crit Care Med 2020; 24 (3):195-199.

DOI: 10.5005/jp-journals-10071-23374

License: CC BY-NC 4.0

Published Online: 00-03-2020

Copyright Statement:  Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.


Abstract

Introduction: Cytokines and granulocyte elastase produced in sepsis cleave a disintegrin and metalloprotease with thrombospondin type I motif 13 (ADAMTS13) and deplete its levels. By this mechanism, sepsis results in microangiopathic hemolytic anemia (MAHA) with thrombocytopenia. Hence, the hypothesis is that plasmapheresis may help in sepsis-induced thrombotic microangiopathy (sTMA), by removing the factors responsible for low levels of ADAMTS13. In tropical countries like India, the contribution of sepsis to intensive care unit (ICU) mortality is high; and hence, it is essential to look out for newer modalities of sepsis treatment. There is abundant literature on the use of plasmapheresis in sepsis but data on its use in sTMA are limited, thus necessitating further research in this field. Case description: This case series studies the outcomes of five patients admitted with sTMA in the ICU and attempts to evaluate the effectiveness of plasmapheresis in improving their outcomes. All patients diagnosed with sTMA and treated with plasmapheresis, between January 2016 and August 2018 at our tertiary care center, were selected for the study. The diagnosis of sepsis was based on sepsis-3 definition. Results: Four different gram-negative organisms were found to have caused MAHA, with the commonest source being either urinary tract infection (UTI) or lower respiratory tract infection. Three of five patients required hemodialysis and two had disseminated intravascular coagulation (DIC). All five had good outcome and recovered well from the acute episode post plasmapheresis. Discussion: In two of five patients, the initial smear was negative and hence the need for repeated examination of the peripheral blood smear should be kept in mind in cases of sTMAs. The median of the number of plasmapheresis sessions required in sTMA is six, which is lesser than that required for primary thrombotic thrombocytopenic purpura (TTP). Hence, the duration of central line placement and the risk of catheter-related complications are low. Based on the observations made in this case study, further exploratory studies are required to evaluate the efficacy of plasmapheresis in sTMA secondary to tropical infections.


  1. Ono T, Mimuro J, Madoiwa S, Soejima K, Kashiwakura Y, Ishiwata A, et al. Severe secondary deficiency of von Willebrand factor-cleaving protease (ADAMTS13) in patients with sepsis-induced disseminated intravascular coagulation: its correlation with development of renal failure. Blood 2006;107(2):528–534. DOI: 10.1182/blood-2005-03-1087.
  2. Nguyen TC, Han YY. Plasma exchange therapy for thrombotic microangiopathies. Organogenesis 2011;7(1):28–31. DOI: 10.4161/org.7.1.14027.
  3. Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, 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 seventh special issue. J Clin Apher 2016;31(3):149–162. DOI: 10.1002/jca.21470.
  4. Pene F, Vigneau C, Auburtin M, Moreau D, Zahar JR, Coste J, et al. Outcome of severe adult thrombotic microangiopathies in the intensive care unit. Intensive Care Med 2005;31(1):71–78. DOI: 10.1007/s00134-004-2505-0.
  5. Singer M, Deutschman CS, Seymour CW, Shankar-Hari M, Annane D, Bauer M, et al. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016;315(8):801–810. DOI: 10.1001/jama.2016.0287.
  6. Sakr Y, Jaschinski U, Wittebole X, Szakmany T, Lipman J, Ñamendys-Silva SA, et al. Sepsis in intensive care unit patients: worldwide data from the intensive care over nations audit. Open Forum Infect Dis 2018;5(12):ofy313. DOI: 10.1093/ofid/ofy313.
  7. Chaturvedi S, Abbas H, Mccrae KR. Increased morbidity during long-term follow-up of survivors of thrombotic thrombocytopenic purpura. Am J Hematol 2015;90(10):E208. DOI: 10.1002/ajh.24138.
  8. Rimmer E, Houston BL, Kumar A, Abou-Setta AM, Friesen C, Marshall JC, 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(6):699. DOI: 10.1186/s13054-014-0699-2.
  9. Gårdlund B, Sjölin J, Nilsson A, Roll M, Wickerts C-J, Wikstrom B, et al. Plasmapheresis in the treatment of primary septic shock in humans. Scand J Infect Dis 1993;25(6):757–761. DOI: 10.3109/00365549309008575.
  10. Stegmayr B, Abdel-Rahman EM, Balogun RA. Septic shock with multiorgan failure: from conventional apheresis to adsorption therapies. Semin Dial 2012;25(2):171–175. DOI: 10.1111/j.1525-139X.2011.01029.x.
  11. Bennett CL, Weinberg PD, Rozenberg-Ben-Dror K, Yarnold PR, Kwaan HC, Green D. Thrombotic thrombocytopenic purpura associated with ticlopidine. A review of 60 cases. Ann Intern Med 1998;128(7):541–544. DOI: 10.7326/0003-4819-128-7-199804010-00004.
  12. Nguyen TC, Kiss JE, Goldman JR, Carcillo JA. The role of plasmapheresis in critical illness. Crit Care Clin 2012;28(3):453–468. DOI: 10.1016/j.ccc.2012.04.009.
  13. Darmon M, Azoulay E, Thiery G, Ciroldi M, Galicier L, Parquet N, et al. Time course of organ dysfunction in thrombotic microangiopathy patients receiving either plasma perfusion or plasma exchange. Crit Care Med 2006;34(8):2127–2133. DOI: 10.1097/01.CCM.0000227659.14644.3E.
  14. Mayr FB, Yende S, Angus DC. Epidemiology of severe sepsis. Virulence 2014;5(1):4–11. DOI: 10.4161/viru.27372.
  15. Chatterjee S, Bhattacharya M, Todi S. Epidemiology of adult-population sepsis in India: a single center 5 year experience. Indian J Crit Care Med 2017;21(9):573–577. DOI: 10.4103/ijccm.IJCCM_240_17.
  16. Couriel D, Weinstein R. Complications of therapeutic plasma exchange: a recent assessment. J Clin Apher 1994;9(1):1–5. DOI: 10.1002/jca.2920090102.
  17. Doerfler ME, Kaufman B, Goldenberg AS. Central venous catheter placement in patients with disorders of hemostasis. Chest 1996;110(1):185–188. DOI: 10.1378/chest.110.1.185.
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