Medical Clinic V | Nephrology, Rheumatology.
Blood Purification Academic Teaching Hospital Braunschweig, Germany.
Nephrol Dial Transplant. 2017 Sep 1;32(9):1457-1460. doi: 10.1093/ndt/gfx084.
'Mind the gap' is a recorded warning phrase used in the London Tube since 1969. The following article is meant to be a warning of an increasing knowing-doing gap in routine practice of therapeutic plasma exchange (TPE), a treatment method that is used more and more throughout the world. The American Society of Apheresis recommendations, including the most recent ones from 2016, suggest using a TPE volume of 1.0-1.5 times the actual calculated plasma volume of the patient. There are only a few exceptions to that rule, such as the recommnded exchange volume in vasculitis or mushroom poisoning. The published literature suggests that in routine clinical practice in many institutions in several countries the exchanged volume might in fact be lower than recommended by the guidelines. In the following article we argue for a high dose of exchanged plasma volume, yet sketch different scenarios on how this time-averaged high dose can be delivered in various ways depending on the underlying disease, refuting a one-size-fits-all strategy that might facilitate the procedure but may result in 'underpheresis' in many patients. Further, the objectives underlying the use of smaller exchange volumes, especially the gap between the cost of blood products and the reimbursement of TPE are discussed. Lastly, the knowing-guiding gap is described, which can only be overcome by collecting high-quality data and conducting prospective clinical trials in the field of TPE.
“小心间隙”是自 1969 年以来在伦敦地铁中使用的录音警告短语。本文旨在警告治疗性血浆置换（TPE）常规实践中日益扩大的知行差距，这种治疗方法在世界范围内越来越多地被使用。美国血浆分离协会的建议，包括 2016 年的最新建议，建议使用患者实际计算的血浆体积的 1.0-1.5 倍的 TPE 体积。该规则只有少数例外，例如在血管炎或蕈中毒中推荐的交换量。已发表的文献表明，在许多国家的许多机构的常规临床实践中，实际交换量可能低于指南推荐的量。在本文中，我们主张使用高剂量的交换血浆量，但根据潜在疾病的不同，勾勒出不同的方案，说明如何以不同的方式输送这种时间平均的高剂量，反驳一种可能使程序更容易但可能导致许多患者“治疗不足”的一刀切策略。此外，还讨论了使用较小交换量的基本目标，特别是血液制品成本与 TPE 报销之间的差距。最后，描述了知行差距，只有通过收集高质量的数据并在 TPE 领域进行前瞻性临床试验才能克服这一差距。
