Zugl.: Aachen, Techn. Hochsch., Diss., 2004.

Die Doppelfiltrationsapherese stellt eine Therapieform zur extrakorporalen Entfernung von atherogenen Lipoproteinen bei Patienten mit schweren Lipidstoffwechselstörungen und konsekutiven kardiovaskulären Erkrankungen dar. Das Ziel der vorliegenden Studie bestand darin, optimale Behandlungsbedingungen für eine neuere synthetische Fraktionierungsmembran (FractioPESTM 200; 3M Deutschland GmbH, Neuss) für die Doppelfiltrations-Lipoproteinapherese im Rahmen eines In-vivo-Modells am Schaf zu definieren. In einer prospektiven und randomisierten "Crossover–Studie" an vier Schafen wurde hierzu die Permselektivität der Fraktionierungsmembran unter unterschiedlichen Plasmaflussraten (PF 30, 36 und 42 ml/min), umgekehrter Plasmaflussrichtung (Outside- In-Filtration) und erhöhter Plasmatemperatur untersucht. Nach definierten behandelten Plasmavolumina wurde dafür die In-vivo-Performance der Fraktionierungsmembran anhand von Reduktionsrationes und Siebkoeffizienten für die relevanten Moleküle LDL, HDL, Fibrinogen, Albumin und IgG gemessen. Entsprechend des Therapieziels war die Fraktionierungsmembran für LDL-Cholesterin während aller Behandlungseinstellungen nahezu undurchlässig, was sich an niedrigen SK und statistisch sich nicht unterscheidenden Reduktionsrationes (49,0 ± 8,9 (Outside-In) bis 60,6 ± 9,7 % (PF 36)) zeigte. Lediglich bei 600 ml behandeltem Plasmavolumen wurde unter PF 42 und Outside-In ein signifikant höherer LDL-SK (0,165 ± 0,022 bzw. 0,194 ± 0,068) im Vergleich zu PF 30 und 36 (p < 0,05) bestimmt. Eine gewünschte geringe Membrandurchlässigkeit fand sich ebenfalls für Fibrinogen, wobei signifikant höhere und damit ungünstigere SK für Outside-In nach 600 ml (0,229 ± 0,03 (p < 0,05)) gegenüber allen anderen Behandlungsmethoden und nach 900 ml (SK 0,369 ± 0,12 (p < 0,05)) im Vergleich zu PF 30 und PF 42 gemessen wurden. Bezüglich der unerwünscht entfernten Substanzen waren zwischen den Behandlungsmethoden keine Unterschiede bei HDL-Cholesterin und Albumin nachweisbar. Lediglich für IgG lag nach 900 ml ein höherer SK (1,047 ± 0,070 (p = 0,049)) bei PF 42 im Vergleich zu PF 30 (0,573 ± 0,321) vor.Grundsätzlich stiegen bei allen Behandlungsarten die SK für alle Substanzen mit zunehmendem Plasmavolumen teilweise signifikant an. Eine Ausnahme stellte der Outside-In-Modus dar, bei dem es nach 600 ml zu einem Abfall der SK kam. Bei PF 42 war die günstigste HDL/LDL-Ratio der Reduktionsrationes nachweisbar, d.h. die höchste Retention atherogenen LDL bei geringster Entfernung des vasoprotektiven HDL. Die Anwendung verschiedener Behandlungsbedingungen bei Verwendung der FractioPESTM 200-Membran führte nur zu geringen Unterschieden bei der Entfernung der Zielsubstanzen. Als günstigste Einstellung erwies sich die höchste Plasmaflussrate, PF 42 ml/min, in standardmäßiger Flussrichtung, während sich die Outside-In-Filtration nachteilig auswirkte. Der Grund dafür dürfte im asymmetrischen Wandaufbau der Fraktionierungsmembran mit den kleinsten Poren, d.h. der Separationsschicht, innen liegen, der zu Unterschieden beim Verstopfen („Clogging“) der Membranporen führt. Das Schafsmodell erwies sich erneut als zuverlässiges und auf die klinische Doppelfiltrations-Lipoproteinapherese übertragbares In-vivo-Experiment. / Double filtration apheresis is a form of therapy for the extracorporeal removal of atherogenic lipoproteins in patients with severe lipid metabolism disorders and consecutive cardiovascular diseases. The aim of this study was to define optimal treatment conditions for a newer synthetic fractionation membrane (FractioPESTM 200; 3M Germany GmbH, Neuss) for double filtration plasmapheresis within a setting of an in-vivo model on a sheep. In a prospective and randomized "crossover study" on four sheeps, the permselectivity of the fractionation membrane was investigated during different plasma flow rates (PF 30, 36 and 42 ml/min), reverse plasma flow direction (outside-in filtration) and increased plasma temperature. After defined treated plasma volumes, the in-vivo performance of the fractionation membrane was measured based on reduction rations and sieving coefficients for relevant molecules LDL, HDL, fibrinogen, albumin and IgG. Accordingly the therapy goal, the fractionation membrane was nearly impermeable to LDL-cholesterol during all treatment settings, evidenced by low SK and statistically indistinguishable reduction rations (49.0 ± 8.9 (outside-in) to 60.6 ± 9.7% (PF 36)). Only at 600 ml treated plasma a significantly higher LDL-SK (0.165 ± 0.022 and 0.194 ± 0.068) during PF 42 and outside-in compared to PF 30 and 36 (p < 0.05) was determined. A desired low membrane permeability was also found for fibrinogen, shown by the significantly higher and thus less favorable SK for outside-in after 600 ml (0.229 ± 0.03 (p < 0.05)) compared to all other treatment methods and after 900 ml (SK 0.369 ± 0.12 (p<0.05)) compared to PF 30 and PF 42. Regarding the undesirably removed substances, no differences in HDL-cholesterol and albumin could be detected between the treatment methods. Only for IgG there was a higher SK (1.047 ± 0.070 (p = 0.049)) at PF 42 compared to PF 30 (0.573 ± 0.321) after 900 ml. Basically, with all types of treatment, the SK for all substances increased, partially significant, with increasing plasma volume. The outside-in mode was an exception, in which there was a decrease in the SK after 600 ml. At PF 42, the most favorable HDL/LDL ratio of the reduction ration was detectable, i.e. the highest retention of atherogenic LDL with the lowest removal of the vasoprotective HDL. The application of different treatment conditions when using the FractioPESTM 200 membrane resulted in only minor differences in the removal of the target substances. The best setting proved to be the highest plasma flow rate, PF 42 mL/min, in the standard flow direction, while outside-in filtration had a disadvantageous effect. The reason for this may be the asymmetrical wall structure of the fractionation membrane and the small pores, i.e. a separation layer lying inside, which leads to differences in clogging of the membrane pores. The sheep model again proved to be a reliable in-vivo experiment transferable to clinical double filtration lipoprotein apheresis.

Para o estabelecimento do quadro sangüíneo de eqüinos durante a hiperimunização para produção de soro hiperimune anti-crotálico e após as sangrias de produção e a plasmaferese, foram utilizados 20 animais, obedecendo as normas do protocolo de hiperimunização do Instituto Butantan. As amostras foram colhidas antes das inoculações do antígeno (veneno crotálico), antes e depois das sangrias de produção, após as plasmafereses e 15, 30 e 45 dias após a última sangria, totalizando 340 colheitas, realizadas em 17 momentos. Nas amostras, foram determinados valores do hemograma (número de hemácias, volume globular, teor de hemoglobina, VCM, HCM, CHCM, número de leucócitos, contagem diferencial de leucócitos) e de alguns parâmetros de bioquímica sérica (ferro, transferrina e bilirrubinas). Significativas variações no quadro hematológico dos eqüinos foram observadas na fase de hiperimunização, caracterizando anemia normocítica, normocrômica, sem alterações significativas do leucograma. Além disso, verificou-se diminuição significativa da sideremia associada ao aumento da concentração de transferrina sérica, permitindo classificar-se a anemia, como do tipo ferropriva. Nas fases de sangrias, observou-se evidentes variações no quadro hematológico demonstrando uma anemia hipocitêmica normocítica hipercrômica pós-sangrias, sem variações nos valores do leucograma, mas com significativas variações nos constituintes bioquímicos (diminuição do ferro sérico e aumento da concentração de transferrina). No período de repouso foi evidente a eficácia da plasmaferese, com pronta , mas parcial recuperação do hemograma e da sideremia dos animais anêmicos, facilitando o rápido retorno para normalidade hematológica, tornando-os aptos a nova produção de soro hiperimune. / Twenty animals were used to assess the blood profile of horses during hyperimmunization for anticrotalic hyperimmune serum production and after the bleedings of production and the plasmapherese, obeying the protocol schedule of Instituto Butantan. The samples were obtained before the antigen inoculations (crotalic poison), before and after the bleedings of production, right after the plasmapherese and 15, 30 and 45 days after the last one, making a total of 340 collections in 17 moments. Samples were analyzed for hemogram (number of erythrocytes, packed cell volume, hemoglobin, MCV, MCH, MCHC, white cell count, differential leukocytes count) and some serum biochemical components (iron, transferrin and bilirrubin). Significant variations were observed on the blood profile of the horses throughout the hyperimmunization, showing normocytic, normochromic anemia, without significant alterations on leukogram. Beside that, a significant reduction of the hemosiderin was observed in association with the elevation of the serum transferrin concentration, making possible its classification as an iron deficiency-like anemia. During the bleedings phases, evident variations were observed on the blood profile showing pos-sangrias hypocitemic normocytic, hyperchromic anemia without changing the leukogram values, but with significant variations on the biochemical components (reduction of serum iron and increase of transferrin concentrations). During rest periods, the efficacy of plasmapherese was evident with a rapid but partial recuperation of the hemogram and the hemosiderin of the anemic animals, making easier the fast return of hematologic normality and making them capable to a new hyperimmune serum production.

Para o estabelecimento do quadro sangüíneo de eqüinos durante a hiperimunização para produção de soro hiperimune anti-crotálico e após as sangrias de produção e a plasmaferese, foram utilizados 20 animais, obedecendo as normas do protocolo de hiperimunização do Instituto Butantan. As amostras foram colhidas antes das inoculações do antígeno (veneno crotálico), antes e depois das sangrias de produção, após as plasmafereses e 15, 30 e 45 dias após a última sangria, totalizando 340 colheitas, realizadas em 17 momentos. Nas amostras, foram determinados valores do hemograma (número de hemácias, volume globular, teor de hemoglobina, VCM, HCM, CHCM, número de leucócitos, contagem diferencial de leucócitos) e de alguns parâmetros de bioquímica sérica (ferro, transferrina e bilirrubinas). Significativas variações no quadro hematológico dos eqüinos foram observadas na fase de hiperimunização, caracterizando anemia normocítica, normocrômica, sem alterações significativas do leucograma. Além disso, verificou-se diminuição significativa da sideremia associada ao aumento da concentração de transferrina sérica, permitindo classificar-se a anemia, como do tipo ferropriva. Nas fases de sangrias, observou-se evidentes variações no quadro hematológico demonstrando uma anemia hipocitêmica normocítica hipercrômica pós-sangrias, sem variações nos valores do leucograma, mas com significativas variações nos constituintes bioquímicos (diminuição do ferro sérico e aumento da concentração de transferrina). No período de repouso foi evidente a eficácia da plasmaferese, com pronta , mas parcial recuperação do hemograma e da sideremia dos animais anêmicos, facilitando o rápido retorno para normalidade hematológica, tornando-os aptos a nova produção de soro hiperimune. / Twenty animals were used to assess the blood profile of horses during hyperimmunization for anticrotalic hyperimmune serum production and after the bleedings of production and the plasmapherese, obeying the protocol schedule of Instituto Butantan. The samples were obtained before the antigen inoculations (crotalic poison), before and after the bleedings of production, right after the plasmapherese and 15, 30 and 45 days after the last one, making a total of 340 collections in 17 moments. Samples were analyzed for hemogram (number of erythrocytes, packed cell volume, hemoglobin, MCV, MCH, MCHC, white cell count, differential leukocytes count) and some serum biochemical components (iron, transferrin and bilirrubin). Significant variations were observed on the blood profile of the horses throughout the hyperimmunization, showing normocytic, normochromic anemia, without significant alterations on leukogram. Beside that, a significant reduction of the hemosiderin was observed in association with the elevation of the serum transferrin concentration, making possible its classification as an iron deficiency-like anemia. During the bleedings phases, evident variations were observed on the blood profile showing pos-sangrias hypocitemic normocytic, hyperchromic anemia without changing the leukogram values, but with significant variations on the biochemical components (reduction of serum iron and increase of transferrin concentrations). During rest periods, the efficacy of plasmapherese was evident with a rapid but partial recuperation of the hemogram and the hemosiderin of the anemic animals, making easier the fast return of hematologic normality and making them capable to a new hyperimmune serum production.

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