EBMT 2015 - Physicians Abstract (including Data and Quality Management)
Topic area: Transplant-specific topics
Topic: 12. Graft-versus-host disease – clinical
EBMT15-ABS-1151
Successful use of therapeutic plasma exchange to overcome technical limitation of extracorporeal photopheresis in a case of severed hypertriglyceridemia and graft-versus-host disease
RITA DE CASSIA TAVARES1, MARCIA SILVA* 1, VANIA KUSSUMI1, IARA MOTTA2, ANDRE SOUZA2, MARIA CLAUDIA MOREIRA1, DECIO LERNER1, RENATO CASTRO1, LUIS FERNANDO BOUZAS1
1Bone Marrow Transplant Unit, 2HEMOTHERAPY SERVICE, NATIONAL INSTITUTE OF CANCER, RIO DE JANEIRO, Brazil
Introduction: Extracorporeal photopheresis (ECP) is recommended as second-line immunomodulatory treatment for steroid-refractory graft-versus-host disease (GVHD). Severe hypertriglyceridemia and hyperbilirubinemia may difficult buffy coat separation during ECP. Therapeutic plasma exchange (TPE) is largely used in autoimmune diseases to lower the serum level of auto reactive antibodies and can also be used to lower a harmful level of lipids such as triglycerides.
Materials (or patients) and methods: A 42 year-old male patient underwent a second HLA-identical sibling bone marrow transplantation (BMT) for relapsed acute myeloid leukemia. The conditioning regimen consisted of cyclophosphamide and total body irradiation. CSA and short-term methotrexate was used for GVHD prophylaxis and ursodeoxycholic acid for sinusoidal obstruction syndrome prophylaxis. Laboratory values on day 0 revealed hypertriglyceridemia (464 mg/dL) and hypercholesterolemia (279 mg/dL). By day +18 he developed grade III skin and biopsy-proven GI tract acute GVHD initially responsive to steroid therapy. He was discharged by day 22. Despite pharmacological (simvastatin, fenofibrate) and nutritional treatments, cholesterol and triglycerides levels increased progressively leading to renal dysfunction, early CSA discontinuation and deep-venous thrombosis on his left leg. By day +84 his triglycerides levels were 1112 mg/dL and he developed diffuse lichen-planus like skin lesions and hyperbilirubinemia with 13 mg/dL of total bilirubin (TB). The steroid dose was increased and tacrolimus was started. After two weeks without response, MMF was added resulting in a 40% drop of TB levels. By day +147 triglycerides levels increased up to 1675 mg/dL, gamma-GT and TB levels were 3251 and 7.7 mg/dL respectively. A double-lumen central catheter was inserted and ECP was unsuccessfully tried due to severe lipemia. TPE was performed in two consecutive days without complications. The volume treated was one total plasma volume and replacement fluid consisted of human albumin and fresh frozen plasma.
Results: The triglycerides levels decreased to 570 mg/dL in less than 24 hours. ECP could be started after two TPE procedures and was performed in three consecutive days. After two days, laboratory exams showed 469 mg/dL triglycerides, 2039 mg/dL gamma-GT and 5 mg/dL TB. Bilirubinemia progressively decreased to 1.3 mg/dL, triglycerides levels remained stable and an improvement in skin lesions was noted in a month from ECP start.
Conclusion: The efficiency of mononuclear cell collection is crucial for ECP immunomodulatory effects and results. However, optimal leucocytes isolation is very difficult to obtain in patients with lipemic plasma. To our knowledge, this is the first reported case of TPE use to allow ECP treatment for GVHD in a patient with severe lipemia and very high levels of bilirubin.
References: 1)Cancer Immunol Immunother. 2014 Aug;63(8):757-77. Epub 2014 Jul 5.
2)Rev Bras Ter Intensiva. 2012 Sep;24(3):302-307.
3)Crit Care Nurse. 2013 Aug;33(4):18-23
4)G Ital Nefrol. 2012 Jan-Feb;29 Suppl 54:S31-5
Disclosure of Interest: None Declared
Keywords: extracorporeal photopheresis, graft versus host disease, plasmapheresis