1. بسم الله الرحمن الرحيم
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2. 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, April 2006
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3. Early History The word apheresis means, "to take away from"
Blood letting, Egyptian and Greek
Leeches, blood sucking worms.
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4. 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.
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5. 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)
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6. What is Aphereis?
Collection of a particular blood component from a Donor / patient and the remaining constituents are Returned to the donor or patient.
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7. Salwa Hindawi

8. Salwa Hindawi

9. Methods 1. Centrifugation (specific gravity) Intermittent flow IFC
Contineous flow CFc
Immunoadsorption
Apheresis by membrane filteration
3. Photopheresis
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10. Applications 1. Component collections Plateletpheresis Leucopheresis
Erythrocytapheresis
Plasmapheresis
Stem cell collection
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11. 2. Therapeutic Procedure
Therapeutic cytapheresis
Therapeutic plasmapheresis
(plasma exchange)
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12. 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
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13. 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.
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14. 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
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15. Important points to be considered
Technical difficulties:
Access
Anticoagulation
Volume shift
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16. Total blood volume according to body mass/ml rate
Newborn ml/kg
Premature ml/kg
Infant ml/kg
70ml/kg Adult
Extracorporeal volume (ECV) and TBV
ECV not more than 15% of TBV
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17. 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.
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18. 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.
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19. 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)
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20. 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
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21. Therapeutic Plasmapheresis
It is the removal and retention of the plasma with return of all cellular components to the patient.
Recommended plasma volumes be exchanged
One volume exchange(2-4 L)  unwanted plasma component to 30% of its initial value .
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22. 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)
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23. 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
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24. 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.
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25. 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
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26. 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.
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27. 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
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28. 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 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.
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29. 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
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30. 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.
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31. References Henstis, D.W. Risks and safety practices in haemapheresis
procedures. Arch Pathology Lab. Med. 113: , 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: , 1993.
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32. 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 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.
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33. Thanks
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