Extracorporeal Immunoglobulin Elimination for the Treatment of Severe Myasthenia Gravis

Figure 1

Our modification of immunoadsorption (modified by Borberg et al. [9, 10]). Vascular access for the extracorporeal circuit is established via two peripheral veins. Plasma without cellular elements obtained after high-speed centrifugation with a quality separator (Cobe-Spectra, Denver, USA) is drawn through an adsorbent Adsopak capsule. Plasma flow is continuous. After filling the adsorbent capsule, the Adasorb device (Medicap, Ulrichsteinn, Germany) switches automatically to the second adsorbent capsule; the first capsule is washed with glycine, PBS buffer, and saline to prepare it for reuse so the procedure can be repeated as necessary. Regeneration solutions are drained into a waste bag. Clean, washed plasma flows from the column back to the separator where it is mixed with blood elements and returns to the patient’s peripheral veins. Anticoagulation is maintained by a continuous supply of citrate solution (ACD-A Baxter, Germany), and it is secured by an initial application of 2500 U heparin i.v., subsequent continuous infusion of 50 U of heparin/min and gradual dose lowering such that heparin application ceases in the middle of immunoadsorption.