ASAIO GOLD
The 25 Landmark ‘Milestone’ Papers
Published by ASAIO
1955-2003
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Your Commentary --- Milestone Papers to Add
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Plasmapheresis
1.
Malchesky, P.S.,
Asanuma, Y., Smith, J.W., Kayashima, K., Zawicki,
Commentary: One of Woody
Allen’s best lines in a movie was “Ninety percent of
success is just showing up.” In the field of medical therapy, ninety percent of
progress is in the recognition of the problem with current therapies and in
posing a logical and hypothetical solution. This paper by Malchesky,
Nose starts on a philosophical note, recognizing the ancient logic that most
diseases are related to “humoral imbalance.” Then it
clearly and succinctly lists the immunological and metabolic diseases for which
this macromolecular or protein-bound toxins appear to be the cause, toxins that
can be removed only by pheresis and plasma exchange.
It then recognizes the various “disincentives” of plasma exchange, problems
which are still faced today: loss of
plasma solutes, requirement for replacement plasma products, risk of
contamination, an potential loss of essential plasma
constituents.
Malchesky and coworders then describe
two elegant solutions to this problem, both allowing selective removal of the
maligned toxin or globulin and return of the plasma to the patient, mostly
cleared of the toxin. First is sorbent column
regeneration of the plasma. The authors review efficacy of removal of bilirubin and bile acids from plasma by sorbent
columns such as anion exchange (see also three excellent papers in this same
ASAIO Transactions on this topic by: Asanuma, Nose and coworkers; Idezuki, Tanzawa and coworkers;
Sideman, Brandeis and coworkers). This concept of plasmafiltration
and sorbent regeneration of plasma is now
time-proven, being pursued, optimized and proven today. Note the Prometheus
machine (Falkenhagen), FPSA (Ronco),
the general use of staph protein A and antiglobulin antibody columns in immunopheresis, the protein-toxin removing MARS device (Stange and Mitzer) and our own PF
device. Good ideas stay; bad ideas just reappear now and then.
The second and even more novel approach for
regenerating plasma is “cold filtration” of plasma and removal of cryoprecipitated (or gelled) globulins. There were only two
prior publications on this concept, both from Malchesky
and Nose’s research group. In this paper the exact design of the cold
filtration plasma regenerating apparatus is described, including the cooling
circuit and the optimal membranes for removing the precipitated globulins.
Clinching the argument for safety and efficacy, the authors describe clinical
application of cryopheresis in patients with
rheumatoid arthritis for up to one year with good success. This publication
established the basic concept and value of pheresis with plasma regeneration. -- Stephen R. Ash, MD, FACP
*****