Case Report

Use of therapeutic plasmapheresis in a case of

canine immune-mediated hemolytic anemia
Kathryn L. Crump, BVSc and Ravi Seshadri, DVM, DACVECC, DABVP
Abstract
Objective To investigate the clinical application and potential utility of plasmapheresis in canine immune-
mediated hemolytic anemia.
Case Summary A 7-year-old spayed female Maltese diagnosed with immune-mediated hemolytic anemia
was initially treated with prednisone, cyclosporine, and received multiple transfusions of packed RBC.
Because of the progression of clinical signs despite traditional medical therapy, plasmapheresis was initiated.
Plasma immunoglobulin G and immunoglobulin M levels were measured before, during, and after treatment
to help determine if there had been a signicant decrease in immunoglobulin levels with plasmapheresis.
Plasmapheresis was successfully performed over a 2.5-hour period in this dog with minimal complications.
Hypocalcemia was identied as a known complication of circuit anticoagulation, and was corrected through
calcium supplementation. Post-plasmapheresis there was a decrease in immunoglobulin G and immunoglobulin
M levels, and the patient showed clinical improvement. Following discharge the dog had no known
complications of therapy, and had complete resolution of the anemia.
New or Unique Information Provided Plasmapheresis was performed successfully with minimal
complications. Because transfusion requirements appeared to be reduced, and the procedure was well
tolerated, there may be a place for this modality in severe cases to act as a bridge until medical therapy takes
full effect. Because of the cost of performing this therapy, and the potential requirement for multiple
treatments, it should be reserved for selected patients.
(J Vet Emerg Crit Care 2009; 19(4): 375380) doi: 10.1111/j.1476-4431.2009.00431.x
Keywords: autoimmune, hemolysis, plasma exchange, RBC, transfusion medicine
Introduction
Therapeutic plasmapheresis was rst used to treat
hyperviscosity syndrome in humans and has been ap-
plied to diseases ranging from autoimmune disorders
to toxicities.
1
Plasmapheresis reduces the levels of an-
tibodies in the plasma and if effective, leads to a tem-
porary remission of the disease.
2,3
After separation of
plasma from the whole blood, the plasma can be treated
and returned to the patient, or discarded and replaced.
In human immune-mediated disease, plasmapheresis is
commonly used in combination with immunosuppres-
sive protocols to achieve rapid control of clinical signs,
and to reduce adverse effects of therapy. In veterinary
medicine, the use of plasmapheresis has been reported
for systemic lupus erythematosus,
4
immune-mediated
hemolytic anemia (IMHA),
5
myasthenia gravis,
6
and
hyperviscosity syndrome.
7
Previous veterinary reports
have used centrifugal cell separation technique. The
case described here is the rst known veterinary report
for IMHA utilizing membrane ltration technique.
One of the most common immune-mediated diseases
seen in dogs is IMHA. Treatment traditionally involves
immunosuppression with steroids in combination
with cyclosporine, azathioprine, IV immunoglobulin,
or other immunosuppressive medications.
2,8,9
The
pathophysiology and treatments for IMHA have been
well described in the veterinary literature, with
reported treatment success rates of 4070%.
8,10
For
refractory cases treatment options can be limited, and
animals may require multiple transfusions before med-
ical therapy takes effect to slow autoantibody produc-
tion and hemolysis. The case described in this report
was managed with a combination of traditional immu-
nosuppressive therapy, and a single plasma exchange
for treatment of IMHA. Immunoglobulin levels were
quantied to help monitor the efcacy of clearance of
immunoglobulin G (IgG) and immunoglobulin M (IgM)
with treatment.
Address correspondence and reprint requests to
Kathryn Crump, 1409 Clark Lane, Redondo Beach, CA 90278, USA.
Email: kathcrump@gmail.com
From the Advanced Critical Care and Internal Medicine, Tustin, CA 92780.
Journal of Veterinary Emergency and Critical Care 19(4) 2009, pp 375380
doi:10.1111/j.1476-4431.2009.00431.x
& Veterinary Emergency and Critical Care Society 2009 375
Case Summary
A 7-year-old spayed female Maltese, weighing 4 kg,
was referred to Advanced Critical Care and Internal
Medicine for further evaluation of acute anemia, leth-
argy, and anorexia. Bloodwork at the primary veteri-
narian showed a PCV of 17% (reference interval
3755%), total plasma protein (TPP) of 62 g/L (6.2g/dL)
(reference interval 5878 g/L [5.87.8 g/dL]), platelet
count of 737 10
9
/L (reference interval 175500
10
9
/L), bilirubin of 17.1 mmol/L (1.0 mg/dL) (refer-
ence interval 015.4 mmol/L [00.9 mg/dL]), and alka-
line phosphatase of 631 IU/L (reference interval
5131 IU/L). Remaining parameters were within refer-
ence intervals.
Physical examination abnormalities included pale
mucous membranes and mild clinical dehydration.
Other than mild hepatomegaly, the abdominal and tho-
racic radiographs were within reference limits. The
PCV was 18% with TPP of 72 g/L (7.2 g/dL). A saline
autoagglutination test was performed and was strongly
positive. Coagulation parameters were within reference
intervals with a prothrombin time of 9.5 seconds
(reference interval 6.711.4 s), and activated partial
thromboplastin time of 14.1 seconds (reference interval
11.920 s). The dog was mildly tachycardic with a heart
rate (HR) of 140/min, and tachypneic with a respira-
tory rate (RR) of 55/min. The patient was transfused
because she was clinically affected by the anemia, with
tachycardia, tachypnea, and clinical weakness noted on
physical examination. Mild ptyalism was noted, and
the dog retched several times after abdominal palpa-
tion. A transfusion was started using 15 mL/kg of
washed, leukocyte-reduced packed RBC that increased
the patients PCV to 30%. The TPP was 70 g/L (7.0 g/
dL). The dog appeared clinically brighter with a stable
HR, RR, and systolic blood pressure of 114mm Hg using
an ultrasonic Doppler ow monitor. An abdominal
ultrasonographic examination was within reference lim-
its apart from mild hepatosplenomegaly. The dog was
started on prednisone
a
(1.8 mg/kg, PO, q 12 h), cyclos-
porine
b
(5 mg/kg, PO, q 12 h), sucralfate
c
(50 mg/kg, PO,
q 8h), dolasetron
d
(0.6 mg/kg, IV, q 24 h), doxycycline
e
(5mg/kg, PO, q 12 h), famotidine
f
(0.5 mg/kg, PO, q
24 h), enoxaparin
g
(1 mg/kg, SC, q 12 h), and balanced
isotonic crystalloid uids
h
(60mL/kg/d).
The CBC submitted on initial presentation showed a
normocytic, normochromic anemia with a HCT of 16%
(reference interval 3755%), WBC count of 15.6 10
9
/L
(reference interval 5.716.3 10
9
/L) with a neutro-
philia of 13.1 10
9
/L (reference interval 3.011.5 10
9
/L)
and a lymphopenia of 0.94 10
9
/L (reference interval
1.04.8 10
9
/L), moderate polychromasia, anisocyto-
sis, and slight spherocytosis. The anemia was classied
as regenerative (absolute reticulocyte count 139 10
9
/
L; reference interval 060 10
9
/L), and the Coombs
test was positive at a dilution of 1:64. Over the next
3 days of hospitalization the PCV continued to rapidly
drop and 3 further transfusions of packed RBC were
required.
Options considered for treatment included oxyglo-
bin, additional immunosuppressants, IV immunoglob-
ulin, and plasmapheresis. Plasmapheresis was chosen
to reduce the rate of hemolysis allowing more time for
immunosuppressive therapy to take effect. Informed
consent was obtained. The pretreatment PCV was 12%
and TPP 62g/L (6.2 g/dL). The patient was transfused
with 10mL/kg packed red cells before and during
plasmapheresis. The pretreatment temperature, HR, RR,
and blood pressure were within reference intervals. CBC,
venous blood gas/electrolyte panel, serum biochemical
prole, and prothrombin time and partial thromboplastin
time were performed. Abnormalities included an
alkaline phosphatase of 295IU/L (reference interval
5131 IU/L) and bilirubin 35.9 mmol/L (2.1 mg/dL)
(reference interval 015.4 mmol/L [00.90 mg/dL]). A
pretreatment sample was obtained and frozen at 181C
(01F) for 2 weeks for immunoglobulin analysis.
An 8-Fr double-lumen, short-term, silicon dialysis
catheter
i
was placed using the percutaneous Seldinger
technique. A continuous renal replacement therapy1
therapeutic plasma exchange machine
j
was used along
with a plasma lter
k
with an effective surface area of
0.35 m
2
, and a total extracorporeal circuit volume of
88 mL. Immediately before use, the blood access lines,
hemolter, and total extracorporeal circuit were primed
with 0.9% saline. Fresh frozen plasma was chosen as the
replacement solution. The plasma volume was calcu-
lated using the following formula:
Plasma volume mL 1 HCT total bloodvolume
Plasma volume mL 1 0:7 90 4 252 mL
The dogs plasma volume was estimated to be
250 mL (PCV was estimated at 30% as the patient was
receiving a transfusion during plasmapheresis). Plasma-
pheresis was performed by removing 500 mL of plasma
from the patient, with concurrent replacement of
500 mL of fresh frozen plasma delivered over 2.5 hours.
The blood ow rate through the extracorporeal circuit
was set at 20 mL/min (using human guidelines of 2
5 mL/kg/min). Sodium citrate anticoagulation
l
of the
blood access line, blood return line, and plasmapheresis
lter was started using a commercial sodium citrate
solution
l
at 18 mL/h delivered through a Y-set at the
proximal blood access line. A calcium chloride
solution
m
(56 mg/h) was administered through the
peripheral catheter to counter hypocalcemia.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00431.x 376
K.L. Crump & R. Seshadri
Plasmapheresis was well tolerated, with mild hypo-
thermia of 37.51C (99.51F) countered through IV uid
line warming and cage heat support. Hypocalcemia
(ionized calcium, 0.93 mmol/L; reference interval
1.121.4 mmol/L) was noted within 30 minutes of start-
ing plasmapheresis, so the calcium chloride
m
infusion
rate was increased gradually to 70 mg/h to counter this.
Throughout treatment the electrolyte/blood gas panel
was checked every 30 minutes with samples drawn
from the extracorporeal circuit and the patient. If the
extracorporeal circuit calcium was 40.4 mmol/L the
sodium citrate rate was increased to improve anticoag-
ulation of the blood in the circuit, and prevent the blood
lter from clotting during treatment. Additional serum
samples were obtained every 30 minutes and frozen at
181C (01F) for 2 weeks for immunoglobulin analysis
(see Table 1).
Postplasmapheresis diagnostic testing showed a PCV
of 42% and TPP 50 g/L (5.0 g/dL). A CBC was
performed and was within reference intervals. The pa-
tients acid-base status remained normal although ion-
ized hypocalcemia persisted (0.7 mmol/L, reference
interval 1.121.4 mmol/L). The chemistry panel
showed mild hypoalbuminemia (22 g/L [2.2 g/dL],
reference interval 2339 g/L [2.33.9 g/dL]). The hypo-
calcemia improved with the ionized calcium increasing
to 1.14 mmol/L within 6 hours without the need for
further calcium supplementation.
Over the next 24 hours the dog returned to a normal
activity level. The PCV remained stable at 3538%,
as did the TPP of 5054 g/L (5.05.4 g/dL). The dog
remained in the hospital for a further 3 days and was
discharged on prednisone
a
(1.8 mg/kg, PO, q 12 h),
cyclosporine
b
(5 mg/kg, PO, q 12 h), and sucralfate
c
(75 mg/kg, PO, q 8 h). Subsequent recheck examina-
tions were performed through the primary veterinarian
with medications tapered and discontinued over the
following 3 months with no recurrence of the anemia.
Discussion
Therapeutic plasmapheresis has been used for many
years in human medicine as an adjunctive treatment in
a wide variety of conditions. In veterinary medicine the
use of plasmapheresis has been limited by the expense
and availability of technology. Other than 1 case report
describing the use of membrane ltration plasma-
pheresis for the treatment of myasthenia gravis,
6
previ-
ously documented veterinary case reports have used
a centrifugal technique with a continuous cell separa-
tor.
4,5,7
Centrifugal plasma exchange involves the re-
moval of patient blood into an automated system that
continuously separates the plasma and returns the
blood components to the patient. Automated centrifu-
gal systems are less user-friendly than newer mem-
brane separation units, and require a more expensive
and less portable machine. The removal of blood cells
from the plasma is also not as complete with this
method. This leads to high numbers of RBC and plate-
lets being lost through discarded plasma, potentially
leading to anemia and thrombocytopenia posttreat-
ment. In recent years technology advancements have
led to membrane separation techniques as an effective
alternative. This technique utilizes a microporous mem-
brane to separate the plasma from the blood, and results
in minimal losses of other blood components. The more
efcient separation of plasma, and replacement of blood
components within the machine, make treatments more
rapid and allow other applications such as double-ltra-
tion plasmapheresis possible. The case reported here is,
to the authors knowledge, the rst reported veterinary
case describing the use of a continuous membrane sep-
aration technique for treatment of IMHA.
The main indications for plasmapheresis are removal
of autoantibodies, immune complexes, endotoxin, and
toxins.
1,11
A single treatment provides a period of de-
creased serum concentration of the target substance
that reduces clinical signs transiently, allowing more
time for medical therapy to take effect.
2
The most common
uses for plasmapheresis in human medicine are condi-
tions such as Guillain-Barre syndrome,
12,13
Goodpastures
syndrome,
13
myasthenia gravis,
12,13
autoimmune hemo-
lytic anemias,
13
autoimmune thrombocytopenias,
12
and
acute hepatic failure as a bridge to liver transplant.
13
In
IMHA or immune-mediated thrombocytopenia plasma-
pheresis decreases transfusion requirements, and reduces
Table1: Quantitative immunoglobulin analysis of serial plasma samples
Pretreatment
(0 min)
30
minutes
60
minutes
90
minutes
120
minutes
Posttreatment
(150 min)
IgG (g/L) (reference interval 57.517 g/L) 8 7.8 6 5.2 5.1 5
IgG (mg/dL) (reference interval 57501700mg/dL) 800 780 600 520 505 500
IgM (g/L) (reference interval 50.451.5 g/L) 1.1 1 0.4 0.3 0.3 0.3
IgM (mg/dL) (reference interval 545150 mg/dL) 114 100 40 25 25 25
IgG, immunoglobulin G; IgM, immunoglobulin M.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00431.x 377
Plasmapheresis for IMHA in a dog
the risk of life-threatening hemorrhage, respectively.
11
In many of these conditions there has been signicant
improvement in clinical signs and disease outcome, so
research continues into other potential applications.
Resynthesis of autoantibodies occurs continuously so
immunoglobulin levels will inevitably rebound after
treatment.
11
Each plasma exchange reduces plasma IgG
concentration by 3260%.
1,6
Achieving the goal IgG
concentration of o4 g/L (o400 mg/dL) may require
multiple treatments.
3,14,15
In this case the IgG and IgM
levels were reduced by 37% and 75%, respectively (see
Table 1). The goal as seen in this case is to decrease the
total levels of IgG and IgM to subnormal levels, as they
will rapidly rebound within 2472 hours after treat-
ment. As this is a single case it is difcult to determine
if this is signicant, although this decrease in immuno-
globulins occurred in conjunction with a slowing of
hemolysis as evidenced by a more stable HCT post-
treatment. An alternative way of characterizing the
response to treatment would be to use ow cytometry
for the detection of IgG on RBC before and after
plasmapheresis. This has been found to be a very sen-
sitive and specic test for IMHA in dogs, and could be
a useful adjunctive way to determine the success of
therapy with plasmapheresis.
16
Plasmapheresis performed through membrane sepa-
ration as in this case, is achieved in a similar fashion to
hemodialysis. The dialysis catheter placed allows a
high rate of blood ow (minimum of 20 mL/min) to be
cycled through an extracorporeal circuit and hemolter.
The hemolter separates and removes the plasma con-
tinuously before returning the remaining blood cell
components to the patient.
17,18
As in hemodialysis, the
lter comprises a semipermeable membrane in a hol-
low ber design, encased in a polycarbonate casing.
19
In plasmapheresis the pore size is much larger than in
hemodialysis allowing molecules up to 13 million Da
to be removed (compared with up to 55,000 Da in
hemodialysis).
15
Immunoglobulins such as IgG and
IgM are 150,000 and 950,000 Da, respectively, so they
are effectively cleared by a plasmapheresis lter (but
would not be removed by a hemodialysis lter). Mi-
croltration is the process of using both positive and
negative pressure to move uid across a semipermeable
membrane along a pressure gradient. As the blood
moves through the circuit it passes through the lter at
high pressure before returning to the patient. This uid
moves across the semipermeable membrane from the
high-pressure blood side, to the low-pressure efuent
side of the circuit. The efuent circuit therefore contains
all the plasma components and molecules that are l-
tered and will be discarded. A negative pressure is ap-
plied through a pump on the efuent side of the circuit
to help drive this pressure gradient. It is the combina-
tion of the positive pressure on the blood side, and
the negative pressure on the efuent side that creates
the transmembrane pressure (TMP) that drives micro-
ltration. This is a very similar process to ultraltration
in hemodialysis, although the larger pore size allows
the passage of larger solutes such as proteins through
the membrane. In hemodialysis the TMP needs to be
kept at a higher level to maintain efcient uid re-
moval. In plasmapheresis uid removal is not the goal,
so the TMP should be kept o100 mm Hg to reduce the
risk of hemolysis, which is induced by higher pres-
sures. The other main transport mechanism used in
plasmapheresis is convection, which involves the
movement of solutes through solvent drag with the
water ow that is generated by microltration. This al-
lows very efcient solute removal without signicant
uid removal. The time required for the plasma
exchange is dependent on the size of the patient, as it
is proportional to the plasma volume removed. In this
patient, we followed the current human recommenda-
tions, replacing twice the patients plasma volume with
fresh frozen plasma. Plasmapheresis in this patient took
2.5 hours, with the plasma delivered to the patient at
approximately 3mL/min. This plasma combines with
the blood that has passed through the lter, to be deliv-
ered back to the patient through the blood return line.
In IMHA the xation of IgG or IgM antibodies onto
components of the red cell membrane leads to prema-
ture destruction of the RBC.
20
The cornerstone of ther-
apy continues to be immunosuppression, although the
response to immunosuppressive therapy is variable. If
hemolysis is rapid and severe, multiple transfusions
and extended hospitalization may be required.
2
In these
cases an adjunctive therapy such as plasmapheresis
may be used to rapidly remove antibodies, immune-
complexes, and activated complement components
until immunosuppression becomes effective.
2,13
The
effects are transient as IgG and IgM synthesis will con-
tinue, leading to the need for multiple treatments in
many cases. In this case there was a decrease in both the
IgG and IgM levels posttreatment although repeat sam-
ples were not tested in the following days to evaluate
the rebound phenomenon.
The effectiveness of the plasma exchange relies on
the distribution of IgG and IgM, with 45% of IgG being
distributed intravascularly compared with 70% of
IgM.
1
As IgM antibodies predominate in intravascular
hemolysis, plasmapheresis may be more effective in
these cases, although large scale clinical trials have not
been performed. In the patient described in this report
there was a greater decrease in the IgM levels consistent
with this increased intravascular distribution.
In human medicine plasmapheresis can be used in
acute hepatic failure patients with hyperbilirubinemia
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00431.x 378
K.L. Crump & R. Seshadri
to reduce hepatotoxins as a bridge to liver transplantation.
An average decrement of 45% in bilirubin is seen with
each plasmapheresis treatment, with a 100% rebound
within 48 hours.
1
This may be useful in patients with
hyperbilirubinemia associated with IMHA, although
double ltration plasmapheresis with immunoadsorbtion,
or techniques such as the molecular adsorbent recircula-
tion system used for liver failure, may be more effective at
reducing bilirubin.
21
In this patient the preplasmapheresis
bilirubin was mildly elevated, and was normal on
all post-plasmapheresis blood samplings. This was likely
through a combination of both clearance through
the plasmapheresis treatment in addition to decreased
hemolysis.
In humans the most commonly chosen replacement
solutions are human albumin or fresh frozen plasma.
Properties of the replacement solution required include
volume replacement, restoration of oncotic pressure,
and replacement of immunoglobulins and coagulation
factors. In coagulopathic patients fresh frozen plasma is
preferred to replenish coagulation factors. Expense and
risks of disease transmission have meant that human
albumin is often preferred as the primary replacement
solution in humans, although plasma remains the
mainstay of therapy for many disease conditions. Pre-
viously in veterinary medicine fresh frozen plasma has
been utilized, although the use of human albumin for
colloid support has been described.
22
Recently concerns
over human albumin causing severe acute and delayed
hypersensitivity reactions have been described in ani-
mals, leading to reservations with its use.
23,24
In veter-
inary medicine viral transmission through plasma
transfusions has not been described, and anaphylaxis
is uncommonly seen. This made plasma the preferred
replacement solution for this case. There is a risk of
hypovolemia during the initiation of plasmapheresis in
small animals as the total circuit blood volume is 88 mL.
As our patient was anemic pre-plasmapheresis and
hypovolemia was a concern, we transfused packed RBC
concurrently.
The choice of anticoagulant is another important
consideration, with the most commonly used anticoag-
ulants being heparin or sodium citrate. Sodium citrate
binds ionized calcium to inhibit the coagulation cascade
in the circuit without affecting the patients coagulation
status.
25
Calcium is then delivered to the patient post-
lter through a peripheral catheter to prevent hypo-
calcemia. As citrate increases bicarbonate production in
the body, close monitoring for alkalosis is recom-
mended. In this case sodium citrate was successfully
used as the anticoagulant although moderate hypo-
calcemia was created. In this case higher rates of
calcium supplementation should have been considered
to correct the hypocalcemia, although a balance must be
found between anticoagulation and prevention of lter
clotting. This patients calcium levels corrected once the
plasmapheresis was completed and no further calcium
supplementation was required.
Side effects are uncommon in human plasmapheresis
facilities with minimal hemodynamic compromise noted
in their patients. The most common complication is hem-
orrhage from the dialysis catheter site that is generally
mild and self-limiting. Vascular access problems can oc-
cur particularly in small patients where placing a large
bore dialysis catheter can be difcult. Inadequate vascu-
lar access can lead to decreased blood ow rates, in-
creased clotting of lters, and interruption in therapy.
Hypersensitivity reactions to the replacement uid,
3
hypotension, citrate-induced hypocalcemia, coagulation
abnormalities, and viral transmission from blood prod-
ucts have also been reported.
1
We did not note any signs
of hypovolemia or hemodynamic instability during the
plasmapheresis with normal blood pressures, HR, and
pulse quality. The use of plasmapheresis in veterinary
patients requires specialized equipment that is becoming
more available in veterinary referral centers. As experi-
ence grows with the use of this technology, plasma-
pheresis may become more accessible and potentially
benecial in conditions such as IMHA, ITP, and acute
myasthenia gravis crisis. Currently we are limited to us-
ing a lter that makes its use in small patients more
challenging due to the extracorporeal volume. Another
limitation is the cost of treatment, although this may be
comparable to additional days in the ICU with multiple
blood transfusions. The cost of treatment is dependant on
the size of the patient, and the potential need for multiple
sessions of plasmapheresis. In this patient the cost of one
plasmapheresis treatment was approximately $2200 USD,
although this cost will vary between different hospitals
and regions. To our knowledge this therapy is not cur-
rently offered in any other facilities, although the lter
can be used with a standard hemodialysis machine. Be-
cause of the lack of controlled trials investigating its ef-
cacy it is not currently offered as a standard therapy for
IMHA. It may, however, hold promise as an adjunct to
other therapies if traditional therapy has failed.
This case demonstrates that it is possible to perform
plasmapheresis safely and effectively in the veterinary
ICU. The use of plasmapheresis in this case resulted in
a more stable HCT, and slowed the rate of hemolysis
with a single treatment. Further clinical trials are indi-
cated to identify patient populations that may benet
from this therapy.
Footnotes
a
Prednisone, West-ward Pharmaceutical Corp, Eatontown, NJ.
b
Gengraf modied Cyclosporine capsules, USP, Abbott Laboratories,
North Chicago, IL.
& Veterinary Emergency and Critical Care Society 2009, doi: 10.1111/j.1476-4431.2009.00431.x 379
Plasmapheresis for IMHA in a dog
c
Sucralfate tablets, Nostrum Laboratories Inc, Kansas City, MO.
d
Anzemet, dolasetron mesylate injection, Sano-Aventis, Bridgewater,
NJ.
e
Doxycycline Hyclate capsules, West-ward Pharmaceutical Corp.
f
Pepcid-AC, Johnson & Johnson/Merck, New Brunswick, NJ.
g
Lovenox, Sano Aventis, Quebec, Canada.
h
Normosol-R, CEVA Laboratories, Overland Park, KA.
i
HemoCath, MedComp Inc, Harleysville, PA.
j
Prisma CRRT and TPE Control Unit, Gambro (Renal Care Products) Inc,
Lakewood, CO.
k
Prisma TPE2000 Set, Gambro (Renal Care Products) Inc; surface area
and volume data per manufacturer specications.
l
Anticoagulant acid-citrate-dextrose (ACD) solution, Formula A, Baxter
Healthcare Corporation, Deereld, IL.
m
10% calcium chloride, American Pharmaceutical Partners Inc, Los
Angeles, CA.
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