Division of Hematology, Department of Medicine, Duke University Medical Center, Durham, North Carolina.
Department of Pharmacy, Duke University Medical Center, Durham, North Carolina.
Transfusion. 2019 May;59(5):1870-1879. doi: 10.1111/trf.15191. Epub 2019 Feb 14.
Therapeutic plasma exchange (TPE) removes coagulation proteins, but its impact on therapeutic anticoagulation is unknown. We performed a systematic review of the literature to determine the coagulation effects of TPE in patients receiving systemic anticoagulation. We searched MEDLINE, CINAHL, EMBASE, and Web of Science until June 2018 for studies combining controlled vocabulary and keywords related to therapeutic plasma exchange, plasmapheresis, anticoagulants, and therapy. The primary outcome was the effect of TPE on anti-Xa activity, activated partial thromboplastin time (aPTT), or international normalized ratio (INR). The secondary outcome was reports of post-TPE bleeding or thrombosis. A total of 1830 references were screened and eight studies identified. Our selected studies (five case reports and three case series) involved 23 patients and evaluated the effects of seven anticoagulants. Six studies of unfractionated heparin, low-molecular-weight heparins, and direct oral anticoagulants demonstrated an anti-Xa level decline. Two studies of unfractionated heparin and low-molecular-weight heparins showed an aPTT increase. One study of warfarin showed a post-TPE INR increase. Reports of post-TPE bleeding occurred in two patients and thrombosis in one. In patients receiving therapeutic anticoagulation, TPE is associated with anti-Xa activity decline and aPTT and INR increase. These coagulation changes do not appear to significantly increase bleeding or thrombotic risk. Our data suggest the need for prospective studies to investigate the true clinical impact of TPE on therapeutic anticoagulation.
治疗性血浆置换（TPE）可去除凝血蛋白，但它对治疗性抗凝的影响尚不清楚。我们对文献进行了系统评价，以确定接受全身抗凝治疗的患者中 TPE 的凝血作用。我们在 MEDLINE、CINAHL、EMBASE 和 Web of Science 上搜索了截至 2018 年 6 月的文献，使用了与治疗性血浆置换、血浆分离术、抗凝剂和治疗相关的受控词汇和关键词。主要结局是 TPE 对抗 Xa 活性、活化部分凝血活酶时间（aPTT）或国际标准化比值（INR）的影响。次要结局是 TPE 后出血或血栓形成的报告。共筛选了 1830 篇参考文献，确定了 8 项研究。我们选择的研究（5 例病例报告和 3 例病例系列研究）共涉及 23 例患者，评估了 7 种抗凝剂的效果。6 项关于未分级肝素、低分子量肝素和直接口服抗凝剂的研究显示抗 Xa 水平下降。2 项关于未分级肝素和低分子量肝素的研究显示 aPTT 增加。1 项关于华法林的研究显示 TPE 后 INR 增加。有 2 例患者报告 TPE 后出血，1 例患者报告 TPE 后血栓形成。在接受治疗性抗凝的患者中，TPE 与抗 Xa 活性下降、aPTT 和 INR 增加相关。这些凝血变化似乎并没有显著增加出血或血栓形成的风险。我们的数据表明需要前瞻性研究来调查 TPE 对治疗性抗凝的真正临床影响。
