بسم الله الرحمن الرحيم Salwa Hindawi

Introduction to Apheresis SALWA HINDAWI MSc, MRCPath, CTM RCPE. Consultant Haematology & Transfusion Medicine Director of the blood Transfusion Services King AbdAlaziz University Hospital Phlebotomy Course, 11-13 April 2006 Salwa Hindawi

Early History The word apheresis means, "to take away from" Blood letting, Egyptian and Greek Leeches, blood sucking worms. Salwa Hindawi

Late History In the1950s discontinuous-flow manual procedure. The twentieth century separating blood components were recognized as a therapy called apheresis.  In the1950s discontinuous-flow manual procedure. In the 1960s, continuous-flow hemapheresis machines introduced. Salwa Hindawi

Late History cont.   By the end of the twentieth century highly sophisticated machines has been developed. In May 1981, one of the most important educational and scientific contributions to the apheresis practice, was establishing the American Society for Apheresis (ASFA) Salwa Hindawi

What is Aphereis? Collection of a particular blood component from a Donor / patient and the remaining constituents are Returned to the donor or patient. Salwa Hindawi

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Methods 1. Centrifugation (specific gravity) Intermittent flow IFC Contineous flow CFc Immunoadsorption Apheresis by membrane filteration 3. Photopheresis Salwa Hindawi

Applications 1. Component collections Plateletpheresis Leucopheresis Erythrocytapheresis Plasmapheresis Stem cell collection Salwa Hindawi

2. Therapeutic Procedure Therapeutic cytapheresis Therapeutic plasmapheresis (plasma exchange) Salwa Hindawi

Donation Criteria Donors for apheresis procedure must meet the criteria applicable as the donors for normal donation. CBC, ABO and Rh typing, andtibody screening and testing for transfusion and transmitted diseases(VDRL, anti-HIV I&II, HIV-1 RNA, anti-HCV, HCV-RNA, HBsAg, ANTI-HTLV I&II, RPR, anti-HBc and Anti-HBs if Anti-HBc positive) SHOULD BE DONE. A drug history should be obtained; donors who have taken aspirin or aspirin containing medications within 3 days of donation should be temporarily deferred Salwa Hindawi

Donation Interval The interval between platelet donations should be at least 48 hours, with no more than two donations in a week and 24 donations in a year. plasmapheresis donors may donate as often as every 48 hours but not more than twice in a 7-day period. If it becomes impossible to return the donor's red cells during apheresis, at least 8 weeks shall elapse before subsequent apheresis procedure, unless the red cell loss was less than 200 ml. Salwa Hindawi

Important points to be considered The technical staff must be properly trained to care for donors and patients. Attention must be given to the patients medication schedule and/or fluids replacement. Written informed consent must be obtained from the donor & patient Salwa Hindawi

Important points to be considered Technical difficulties: Access Anticoagulation Volume shift Salwa Hindawi

Total blood volume according to body mass/ml rate Newborn 82-86 ml/kg Premature 89-105 ml/kg Infant 73-82 ml/kg 70ml/kg Adult Extracorporeal volume (ECV) and TBV ECV not more than 15% of TBV Salwa Hindawi

Guidelines For Therapeutic Apheresis Category I standard medical care and accepted as primary therapy or first-line therapy in conjunction with other initial therapies. Category II Generally accepted, but usually as adjunctive therapy to other treatment modalities. Category III Published data is insufficient to establish efficacy or risk/benefit. Heroic effort treatment Category IV Published control trials lack evidence of efficacy. Salwa Hindawi

Therapeutic Cytapheresis Plateletpheresis (thrombocytopheresis) the platelet count can be decreased by as much as one-third to One-half the initial value. 2. Leucopheresis : e.g leukemia 3. Lymphocytespheresis & photopharesis. 4. Erythrocytapheresis : e.g SCA, severe parasite infections. 5. Stem cells harvesting, Donor or patient. Salwa Hindawi

Guidelines for Therapeutic Cytapheresis Category I Category II Leukemia with hyperleukocytosis syndrome Sickle cell syndrome Thrombocytosis, symptomatic Cutaneous T-cell lymphoma (cytoreduction or photopheresis) Hairy cell leukemia Hyperparasitemia (e.g., malaria) Peripheral blood stem cell collections for Hematopoitic reconstitution (Rheumatoid arthritis) Salwa Hindawi

Category III Category IV Life-threatening hemolytic Transfusion reactions Multiple sclerosis Organ transplant rejection (also photopheresis) Sickle cell disease (prophylactic use in pregnancy) Leukemia without hyperleukocytosis syndromes Hypereosinophilia Polymyositis / dermatomyositis Salwa Hindawi

Therapeutic Plasmapheresis It is the removal and retention of the plasma with return of all cellular components to the patient. Recommended 1-1.5 plasma volumes be exchanged One volume exchange(2-4 L)  unwanted plasma component to 30% of its initial value . Salwa Hindawi

Guidelines for Therapeutic Plasmapheresis Category I Category II Thrombotic Thrombocytopenic Purpra (TTP). Coagulation factor inhibitors Cryoglobulinemia Goodpasture’s syndrome Guillain-Barre syndrome Homozygous familial hypercholesterolemia Hyperviscosity syndrome Myasthenia gravis Postransfusion purpura Refsum’s disease Rapidly progressive glomerulonephritis Chronic inflammatory demyelinating polyneuropathy Cold agglutinin Drug overdose and poisoning (protein-bound toxins) HUS Pemphigus vulgaris Systemic vasculitis (primary or secondary to rheumatoid Arthritis or systemic lupus Erythematosus) Salwa Hindawi

Category III Category IV ABO-incompatible organ or marrow transplantation Maternal treatment of Maternal-fetal incompatibility (HDN) Thyroid storm, Multiple sclerosis Progressive systemic sclerosis Pure RBC aplasia , Transfusion refractorines due to Alloantibodies (RBC, platelet, HLA) Warm autoimmune hemolytic anemia AIDS (for symptoms of immunodeficiency) Amyotrophic lateral sclerosis Aplastic anemia Fulminant hepatic failure ITP (chronic) , Lupus nephritis Polymyositis / dermatomyositis Psoriasis , Renal transplant rejection Rheumatoid arthritis Salwa Hindawi

Adverse Effects of Apheresis 1- Citrate toxicity 2- Vascular complications hematoma, sepsis, phlebitis, neuropathy. 3- Vasovagal reaction. 4- Hypervolemia. 5- Allergic reaction. 6- Haemolysis. 7- Air embolus. Salwa Hindawi

Adverse Effects of Apheresis cont. 8- Depletion of clotting factors. 9- Circulatory and respiratory distress. 10- transfusion transmitted diseases. 11- loss of lymphocytes. 12- depletion of proteins and immunoglobulin Salwa Hindawi

Signs and Symptoms, Possible Causes, and Treatment of Adverse Effects during Therapeutic Apheresis Signs and Symptoms Possible Cause(s) Suggested Treatment(s) Bradycardia, hypotension, diaphoresis, pallor, nausea,feeling of doom Vasovagal reaction, anxiety, full bladder, or unknown cause Put patient in Trendelenburg’s position or elevate feet, administer saline bolus, offer bedpan, fan patient, stimulate patient (ie, have patient move extremities as much as possible), administer ammonia spirit, aromatic (be sure to protect patient’s eyes) Tingling in fingertips or toes,flushing, diaphoresis,hypotension/hypertension, tachycardia, seizures Hyperventilation, anxiety Have patient breathe in paper bag, offer fan, encourage very slow deep breathing. If patient is hypotensive, place patient in Trendelenburg’s position and administer saline bolus. Salwa Hindawi

Tachycardia, hypotension, diaphoresis Antihypertensive Rx: Beta blockers Ca channel blockers Hypovolemia Hold antihypertensive Rx before next procedure. Administer saline bolus, put patient in Trendelenburg’s position, increase fluid balance, review type and volume of replacement fluids, increase % of colloid if using crystalloid replacement. Circumoral paresthesias that may progress over entire body, chest tightness, nausea, vomiting, flatus, diarrhea, hypotension, prolonged QT interval, tetany Citrate toxicity, Hypocalcemia Decrease whole blood flow rate, increase WB:ACD ratio, switch to ACD/heparin anticoagulation, slow FFP infusion rate, administer calcium PO or IV (slow push or drip), add calcium to replacement fluid (continuous flow procedures only & not FFP or Cryo poor plasma) Burning eyes, periorbital Edema Ethylene oxide allergic reaction Discontinue procedure, perform setup with double prime, use oldest tubing kits Salwa Hindawi

Administer Benadryl IVP, epinephrine sub q, and/or solumedrol IV Hives, urticaria, wheezing, facial edema, SOB, hypotension, tachycardia Allergic reaction Administer Benadryl IVP, epinephrine sub q, and/or solumedrol IV Back pain, hematuria, tachycardia, hypotension, hemolysis, SOB Acute transfusion Reaction Discontinue blood component and order transfusion reaction work-up Flushing, hypotension ACE inhibitor reaction Change albumin lot number, switch to FFP or colloid starch replacement, hold or discontinue ACE inhibitor, delay therapeutic apheresis for 24-48 hours after ACE inhibitor administration The procedure should be paused when a reaction occurs and the physician should be notified. All medical interventions should be prescribed by a physician. The physician will determine if the procedure should be restarted or aborted. SOB = shortness of breath; WB = whole blood; ACD = acid citrate dextrose; FFP = fresh frozen plasma; ACE = angiotensin-converting enzyme. Salwa Hindawi

Swedish registry Since 1996 adverse events (AE) in therapeutic apheresis (TA) More than 14,000 procedures were registered during the observation period . No fatalities occurred AEs were most frequent in patients with Good pasture's syndrome (12.5%), TTP/HUS (10.5%) and Guillain Barre syndrome(11.0). Transf Apheresis Sci 2001, Aug;25(1):33-41 Salwa Hindawi

Conclusion Donation & Therapeutic Apheresis is safe and easy effective methods to be used when needed. A well-trained and experienced team can overcome the technical difficulties in order to complete the procedures without complications. Policy and procedure of Donors Apheresis And Therapeutic Apheresis should be in place. Salwa Hindawi

References Henstis, D.W. Risks and safety practices in haemapheresis procedures. Arch Pathology Lab. Med. 113:273-278, 1989. 2. Strauss, RG et al. Clinical Applications of therapeutic apheresis: Report of the clinical applications committee. J Clin Apheresis 6,4, 1993. 3. Meyer D, et al: Red cell collections by apheresis technology transfusion 33:819-824, 1993. Salwa Hindawi

4. Denise M. Harmening, Modern Blood Banking & transfusion Practices, 4th edition 1999. 5. Guidelines for the Blood Transfusion Services in the United Kingdom 4th Edition 2000. 6. AABB Annual Meeting, Oct 26-29 Orlando, FL USA 2002. 7. AABB annual Meeting, Nov SanDiago, USA 2003. 8. Apheresis Principles and Practice, 2nd Edition, Bruce C. McLeod 2003. 9. AABB Technical Manual 14th Edition, 2005. Salwa Hindawi

Thanks Salwa Hindawi