Automated red blood cell exchange for acute drug removal in a patient with sirolimus toxicity

UMMS Affiliation

Department of Medicine, Division of Transfusion Medicine; Department of Pathology; Department of Medicine, Division of Hematology/Oncology



Document Type



Hematology | Hemic and Immune Systems | Hemic and Lymphatic Diseases | Therapeutics


Sirolimus is an immunosuppressant used to prevent graft versus host disease in allogeneic hematopoietic stem cell transplant recipients. It has a large volume of distribution (12 +/- 7.5 l/kg) and within the intravascular space approximately 95% of it is bound to red blood cells. Because of potential toxic effects at high trough levels, therapeutic drug monitoring is recommended for sirolimus. We present a case of severe hepatic dysfunction due to Hepatitis B and sirolimus toxicity, in a 51-year-old male stem cell transplant recipient. An automated red cell exchange decreased his blood sirolimus level from 22.6 to 10.3 ng/ml (55% reduction) and improved his liver enzymes. Re-equilibration of sirolimus from other compartments to the blood necessitated a series of four red cell exchanges, after which the sirolimus level was 4.7 ng/ml. Although the patient ultimately succumbed to multiorgan failure, red cell exchange may be considered for acute removal of sirolimus in selected patients.

Rights and Permissions

Citation: J Clin Apher. 2015 Dec;30(6):367-70. doi: 10.1002/jca.21381. Epub 2015 Jan 24. Link to article on publisher's site

Related Resources

Link to Article in PubMed


apheresis, drug overdose, immunosuppression, liver failure, stem cell transplant

PubMed ID