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

Publication Date


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.


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

DOI of Published Version



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

Journal/Book/Conference Title

Journal of clinical apheresis

Related Resources

Link to Article in PubMed

PubMed ID