Lab Med Online.  2019 Apr;9(2):107-112. 10.3343/lmo.2019.9.2.107.

Two Cases of Hypersensitivity Reactions Caused by Human Serum Albumin During Therapeutic Plasma Exchange

• Kim TY
• Shin DW
• Hong YJ
• Kim H
• Park KU
• Han KS

• KMID: 2441833
• DOI: http://doi.org/10.3343/lmo.2019.9.2.107

Abstract

Iso-oncotic human serum albumin (HSA) is the primary replacement fluid of choice during therapeutic plasma exchange (TPE). Hypersensitivity reactions to HSA are rare, but require proper evaluation and management. In this article, we report two cases of hypersensitivity reactions to 5% HSA during TPE and discuss strategies to address this problem. The first case was a 60-year-old female patient, who was scheduled for TPE for treatment of recurrent focal segmental glomerulosclerosis after ABO-incompatible kidney transplantation. She developed a pruritic rash on her entire body during the first two sessions of TPE using 5% HSA. The third session was conducted using 500 mL normal saline, 1,000 mL 10% pentastarch, and 750 mL 5% HSA, where she eventually developed a pruritic rash when HSA was infused. There were no adverse events during the fourth and fifth session when fresh frozen plasma was used in place of HSA. The second case was a 50-year-old male patient diagnosed with optic neuritis, who was admitted for five sessions of TPE. The patient developed a pruritic rash on his entire body during the first session of TPE using 5% HSA. The patient experienced no adverse events during the following four sessions using fresh frozen plasma. Certain elements contained in HSA, such as albumin aggregates, prekallikrein activator, and caprylate-modified albumin, might be the reason for these hypersensitivity reactions. Careful selection of alternative replacement fluids is important to avoid premature termination of TPE procedures and secure optimal treatment options for patients.

Keyword

Human serum albumin; Hypersensitivity; Plasma exchange; Prekallikrein activator; Caprylates; Albumin aggregates

MeSH Terms

Caprylates
Exanthema
Factor XIIa
Female
Glomerulosclerosis, Focal Segmental
Humans*
Hydroxyethyl Starch Derivatives
Hypersensitivity*
Kidney Transplantation
Male
Middle Aged
Optic Neuritis
Plasma Exchange*
Plasma*
Serum Albumin*
Caprylates
Factor XIIa
Hydroxyethyl Starch Derivatives
Serum Albumin

Figure

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  Fig. 1. Proposed algorithm for replacement fluid selection when hypersensitivity to HSA is suspected during TPE. Replacement with HSA from different lots or manufacturers should be the first choice. If infusion of the new HSA still leads to hypersensitivity reactions, the following three options are recommended: 1) a mixture of crystalloids, synthetic colloids, and/or FFP, 2) synthetic colloids alone, or 3) FFP alone. Abbreviations: HSA, human serum albumin; FFP, fresh frozen plasma; TPE, therapeutic plasma exchange.

Reference

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