For Endocrinologists

Plasmapheresis in diabetes mellitus

An autoimmune mechanism is characteristic of the development of type 1 diabetes mellitus, which is an indication for various plasmapheresis methods.

Disorders of lipid metabolism in type 2 diabetes mellitus (DM) lead to the rapid development of atherosclerosis and its complications in this category of patients. The most frequent variant of dyslipidemia in DM is an increase in the level of triglycerides and low-density lipoproteins (LDL) and a decrease in the concentration of high-density lipoproteins (HDL) - a lipid triad that is atherogenic irrespective of the degree of increase of the total cholesterol level, and an increase in the concentration of lipoprotein (a), atherosclerosis with the development of complications and thromboses. The majority of patients with atherogenic dyslipidemia are insulin-resistant. The wide introduction into practice of extracorporeal treatment methods, which make it possible to remove lipoproteins from the bloodstream, to improve blood rheology and microcirculation, to increase the sensitivity of the body to medicinal, including hypoglycemic, drugs and to overcome insulin resistance, makes it possible to use these treatment methods with a pronounced effect in patients with DM. The most severe complications requiring prevention and treatment are diabetic retinopathy, nephropathy, neuropathy and diabetic foot.

The most widely used are the methods of plasmapheresis (PA), cascade plasma filtration (CPF) and heparin – LDL precipitation (HELP).

Indications:

  • Disorders of lipid metabolism resistant to lipid-lowering drug therapy, especially with marked hypertriglyceridemia, increased Lp(a) and hypoalphacholesterolemia, accompanied by hyperviscosity and insulin resistance.
  • Presence of autoantibodies in patients with type 1 diabetes mellitus.
  • Diabetic retinopathy.
  • Diabetic nephropathy.
  • Diabetic polyneuropathy.
  • Diabetic foot and other circulatory disorders.

Contraindications:

  • Hemodynamic instability, heart failure.
  • Internal bleeding.
  • Allergy to the components of the procedure.
Ендокринологу — ілюстрація

Procedure technique:

The course of plasmapheresis consists of 3-12 procedures with removal of 25-40% of the CPV with replacement by crystalloid solutions at an interval of 2-3 days. The most effective is the use of CPF, 1-3 procedures (in individual cases up to 12, with an interval of 4-7 days) in a volume of 500-800 ml, or HELP in a volume of 3 l of plasma. Programs for the regression of atherosclerotic vascular changes provide for the use of rheopheresis methods for 1,5-2 years with an interval of 2-3 weeks under the control of Doppler ultrasound or angiography.

Efficacy criteria:

  • Reduction of the degree of severity of the main clinical manifestations of the above-mentioned complications of diabetes mellitus.
  • Correction of disorders of lipid metabolism, elimination of hyperviscosity and of microcirculation disorders, elimination of insulin resistance with normalization of the blood glucose level.
  • Improvement of tissue perfusion, healing of ulcers in a patient with diabetic foot.

With long-term use of PA methods, stabilization and/or regression of atherosclerotic plaques according to the data of Doppler ultrasound or angiography.

Membrane plasmapheresis in diseases of the thyroid gland

The main cause of the development of autoimmune thyroiditis (Hashimoto's goiter) is the accumulation of autoantibodies (microsomal or to thyroglobulin). In this case immune inflammation arises in the gland with initial stimulation of its function and thyrotoxicosis, with subsequent suppression of function and the development of persistent hypothyroidism. In the pathogenesis of diffuse toxic goiter autoimmune mechanisms with a stimulating effect of autoantibodies on the synthesis of thyroid hormones can also be traced.

Indications:

  • Autoimmune thyroiditis (Hashimoto's goiter).
  • Thyrotoxicosis before surgery.
  • Thyrotoxic crisis after surgery.
  • Hypothyroidism.
  • Exophthalmos (Graves' ophthalmopathy).
  • Those general for efferent therapy.

Procedure technique:

The course of PA consists of 3-5 sessions with removal of 25-30% of the CPV and replacement by crystalloid solutions in an equal volume.

Efficacy criteria:

  • Reduction of the degree of thyrotoxicosis.
  • Reduction of the content of autoantibodies and immune complexes in the blood.
  • Reduction of the degree of exophthalmos in Graves' ophthalmopathy.