1. Clinical Applications of
Therapeutic Apheresis
Raul H. Morales-Borges, MD
Medical Director
Blood Services
American Red Cross of Puerto Rico

2. Origin of the Word “APHERESIS”
 Greek
 Means “Withdrawal
 Blood components are separated by
centrifugation accordingly to relative
density.

3. Density of blood components
 Plasma 1.025-1.029
 Platelets 1.040-1.045
 Lymphocytes 1.050-1.061
 Granulocytes 1.087-1.092
 Erythrocytes1.078-1.114

4. Blood Component Separation

5. Definition of TPE
•Removal of large volumes of patient plasma and
replacement of the plasma with appropriate
fluids.
Specialty areas:
•Renal and metabolic diseases
•Hematologic diseases
•Neurologic disorders

6. Therapeutic Apheresis (TA)
 Whole blood is removed from the patient
into an instrument that separates its
components via a centrifugation process.
 The goal is to selectively remove a
substancial proportion of one or more
components causing disease while
returning the remaining components to
the patient, with or without replacement of
the removed component.

7. TA Technologies
Membrane Centrifugation
 Prisma Gambro BCT
 Asahi Plasma Flow
 Cascade apheresis for
selective plasma
component removal
 Specialized devices

8. Apheresis in Clinical Practice
Sickle Cell Dis.
Malaria Thrombocytosis
RBC WBC PLT Plasma
Leukemias TTP
Cell Therapies Guillain Barre Syn.
Myasthenia Gravis
Goodpasture’s Syn.
Waldenstrom’s

9. Bloodletting and Plasmapheresis

10. “When it comes to bloodletting four
questions must be answered”
 Who?
 When?
 How much?
 Which Fluids?

11. Removed with
Plasma
•Immune complexes
•Immunoglobulins (IgG, IgM, IgA)
•Abnormal/increased amounts of plasma protein
•Cholesterol
•
•Plasma metabolic waste products
•Plasma protein bound poisons

12. Access
 Plamapheresis is an extracorporeal theapy
and as such is dependent on adequate
central vascular access.
 As plasmapheresis results in profound
immunosuppression, a tunnelled line is
preferred.
 Baxter/Edwards Bloodlines are used.
 Apheresis/dialysis-compatible catheter
vendors include MedComp, Quinton
Intruments, Vascath, Arrow, and Vaxcel.

13. A “perfect” apheresis catheter:
Dual lumen
Staggered ports
Large-bore lumens
Minimal length
Sufficient firmness
Biocompatibility
Infection resistance

14. How much?
 Volume of exchange
• 1-1.5 plasma volume
 Calculation depends on numerous factors
• Frequency of procedures
• Duration of therapy

15. Important Formulas
 Total Blood Volume= 0.065 x Kg
 Plasma Volume=(0.065 x Kg) x (1 –
Hct in decimal number)
 Red Cell Volume= Hct in decimal x
TBV

16. Efficiency of Plasmapheresis
 What is being Efficiency of Plasmapheresis
removed? 70
60
• IgG - mainly 50
40
1 plasma vol
1.5 plasma vol
extravascular Percent
30
2 plasma vol
20
• IgM – mainly 10
0
intravascular

17. Frequency of
Procedures
Disease specific:
IgM removal: Predominantly
intravascular Procedure may be
done every other day.
IgG removal: Predominantly
extravascular Procedure may be
done daily.

18. Exchange Fluids
 5% Albumin
• Best choice
• Dilute only with saline
 Combination of saline and albumin
 FFP
 Cryopoor plasma
 Cryoprecipitate (vWF mediates in
recurrent TTP; also used to avoid
fluid overload)

19. Replacement Fluid
Crystalloids: Contain no protein. Normal
saline 0.9%
Ex: in combination with albumin
replacement
Colloids: Contain protein 5% albumin
Ex: Guillian-Barré, myasthenia gravis
Fresh frozen plasma/cryo-poor plasma
Ex: TTP, HUS (thrombotic
microangiopathies)
6% hetastarch, pentastarch

20. Anticoagulant
•ACD-A:
Binds to Ca++.
Lowers pH of the blood. Inhibits platelet clumping.
Acts as an extracorporeal anticoagulant.
May cause hypocalcemia.
•Heparin:
Complexes with antithrombin and increases its
activity which inactivates thrombin and other factors
and prevents thrombus formation.*
Acts as a systemic anticoagulant.
There are individual sensitivities and elimination
rates.
Can cause heparin induced thrombocytopenia.
*Essentials of hemostasis and thrombosis drugs used in
management of thrombosis.

21. Diseases Treated with TA
Guillain-Barre Syndrome 11%
Guillain-Barre Syndrome 11%
Myasthenia Gravis 12%
Myasthenia Gravis 12%
CIDP 8%
CIDP 8%
Cryoglobulinemia 30%
Cryoglobulinemia 30%
Anti-GBM Disease 30%
Anti-GBM Disease 30%
Pauci-immune RPGN 13%
Pauci-immune RPGN 13%
SLE nephropathy 10%
SLE nephropathy 10%
Myeloma kidney 7%
Myeloma kidney 7%
Recurrent FSG 5%
Recurrent FSG 5%
Renal transplantation 5%
Renal transplantation 5%

22. American Society for Apheresis
(ASFA) Guidelines
 Indications by Category (there are 4
categories).
 There are 3 levels of evidence.
 There are 2 grade recommendations.

23. Category I: Apheresis is considered primary
or standard.
Category II: There is sufficient evidence to
suggest efficacy, usually in an adjunctive
role.
Category III: Insufficient data to determine
effectiveness. Isolated published studies
have indicated that it may be of benefit as a
“last-ditch” effort.
Category IV: Controlled trials have not
shown benefit.

24. Renal and metabolic diseases:
Antiglomerular basement
membrane antibody disease (cat.
I)
Rapidly progressive
glomerulonephritis (cat. II)
Familial hypercholesterolemia
(cat. II)
Cryoglobulinemia (cat. II)

25. Hematologic diseases:
ABO-mismatched marrow transplant
(cat. II)
Thrombotic thrombocytopenia purpura
(cat. I)
Myeloma, paraproteins, or hyperviscosity
(cat. II)
Coagulation factor inhibitors (cat. II)

26. Neurologic disorders:
Guillain-Barré syndrome (Acute
inflammatory demyelinating
polyradiculoneuropathy)(cat. I)
Chronic inflammatory demyelinating
Polyradiculoneuropathy (cat. I)
Myasthenia gravis (cat. I)
Cryoglobulinemia with polyneuropathy (cat.
II)

27. Modified McLeod’s Criteria for
Evaluation of Efficacy of
Therapeutic Apheresis
Evidence Mc Leod’s Explanation
Criteria
Mechanism Plaussible Clear
Pathogenesis Rationale
Correction Better Blood Meaningfully
Corrected
Clinical Effect Perkier Clinically
Patients Worthwhile

28. ASFA 2010 Indication Categories
for TA
 There are 68 diseases.
 There are many TA accordingly to the diseases.
Few of the procedures are:
• Total Plasma Exchange (TPE)
• RBC Exchange
• Extracorporeal Photopheresis (ECP)
• Immunoadsorption (IA)
• Thrombocytapheresis & Leukocytapheresis
• Selective removal methods
• Adoptive Cytapheresis
• Membrane differential filtration
• Cryofiltration apheresis

29. General Issues to be Considered
When Evaluating a New patient for
Initiation of TA
 Rationale
 Impact
 Technical Issues
 Therapeutic Plan
 Clinical and/or laboratory end-points
 Timing & Location

30. Risks / Side effects of TA
The overall rate is < 5%.
 Transfusion Reactions
 Nausea/Vomiting
 Hypotension, hypovolemia, fluid overload
 Vasovagal reactions
 Pallor, tachycardia, respiratory distress,
muscle spasm, chills, rigors
 Hematomas, venous sclerosis, thrombosis,
bleeding, infection
 Hypocalcemia from citrate

31. Use of Calcium in
Preventing Symptoms
 TUMS 1000 mg po 30 minutes prior
the procedure and halfway of the
procedure (As recommended by Medical
Directors Consensus from ARC)
 Or Use Calcium Gluconate as always.

32. Use of Magnesium
 IV Magnesium as per an article from
FDA, NIH, Walter Reed ARMY
Institute of Research (Salim Haddad et al:
Transfusion June 2005; 45: 934-944).

33. Metabolic Alkalosis due to TPE
 It’s common in patients with
decreased renal function.
 Secondary to large sodium citrate
load given during the procedure.
 Can be prevented when using 3%
albumin and cryoprecipitate rather
than FFP’s
Pearl RG, Rosenthal MH: American Journal of Medicine
1985 Sep; 79(3): 391-393.

34. Blood Component Collection by Apheresis
 Began in the 1970’s.
 Platelet donors are limited to 24
collections during a rolling 12-month
period.
 RBC’s donors are limited to donate 2
units every 16 weeks.
 Single whole blood or one PRBC’s
unit donor every 8 weeks.

35. Use in Hematopoietic Stem Cell
Transplatation as Mobilization &
Collection of PBHPC’s
 Last Standards & Rules by FDA on
11/24/2004 and effective on
05/25/2005.
 Goal: To achieve the Product CD34+
cell counts appropriate for infusion to
the recipient.

36. TTP – A Thrombotic Microangiopathy
 Microvascular Occlusive Disorder
 Platelet thrombi
 Thrombocytopenia
 Mechanical damage to erythrocytes
 70% of patients are women

37. TTP – hyaline thrombi in
glomerolus

38. TTP – Mortality Rate
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Before Plasma Exchange After Plasma Exchange

39. Pathophysiology of TTP
 Presence of Unusually Large von
Willebrand Factor Multimers
(ULvWFM)
 Absence or low levels of ADAMTS13
(vWF cleaving metalloprotease)
 Presence of auto-antibodies to
ADAMTS13

40. Plasma Exchange in TTP
FFP as exchange fluid
 Removal of auto-antibodies to vWF
multimers cleaving enzyme
 Infusion of vWF multimers cleaving
enzyme

41. Pathophysiology of TTP
Normal TTP
Cleaved von Willebrand Factor
multimers Platelet aggregate
vWF-Cleaving
Enzyme Auto-antibody to
vWF-Cleaving
Uncleaved unusually
Enzyme
large vWF multimers
Endothelial Cell
Endothelial Cell

42. Diagnosis
From Pentad to Triad
 Thrombocytopenia  Thrombocytopenia
 MAHA  MAHA
 CNS symptoms  LDH elevation
 Renal insufficiency
 Fever

43. Conditions Associated with TTP
 Primary (idiopathic)
 Secondary
• Systemic autoimmune • Drugs
disorders  Ticlopidine
 SLE  Clopidrogel
 Rheumatoid arthritis  Cyclosporine A
 Scleroderma  Tacrolimus
 Polyarteritis nodosa  Quinine
• Infectious diseases • Neoplastic diseases
 HIV infection • Surgeries
 Bacterial endocarditis  Cardiovascular
 Intestinal
• PBSC transplantation
• Pregnancy

44. Treatment of TTP
 Daily plasma exchange
 Exchange fluids
• FFP
• Cryopoor plasma
• Detergent treated plasma
 Treat until clinical symptoms improve and
laboratory values normalize
 Avoid platelet transfusions

45. Treatment of persistent TTP
 Plasma exchange
 Corticosteroids
 Vincristine
 Rituximab
 Splenectomy

46. Treatment of relapsing TTP
 Plasma exchange
 Treat beyond improvement
 Consider adding medications
 Splenectomy
 Look for other disease association

47. TTP/HUS (Hemolytic Uremic
Syndrome)
 HUS
• MAHA
• Renal failure
 Classic HUS
• Childhood, Escherichia coli 0157:H7 association
 Adult HUS
• Renal disease is more severe
• Difficult to differentiate from TTP
 Platelet – fibrin thrombi
 Normal ADAMTS 13 (vWF cleaving enzyme) levels
 No auto-antibody to ADAMTS
 Response to plasma exchange – equivocal results

48. Rapidly Progressive Glomerulonephritis
(RPGN); Crescentic Glomerulonephritis
 Subacute deterioration of renal
function
 Crescents in glomeruli
 Various etiologies

50. Rapidly Progressive Glomerulonephritis
(RPGN); Crescentic Glomerulonephritis
 Goodpasture’s syndrome (Anti-Glomerular
Basement Membrane Disease or Anti-GBM
Disease)
 Pauci immune RPGN (Wegener’s
Granulomatosis or microscopic
polyarteritis with antineutrophil
cytoplasmic antibodies (ANCA)
 RPGN with granular immune complex
deposits sometimes associated with
systemic vasculitis

51. Goodpasture’s syndrome
 Anti-GBM antibodies crossrective
with alveolar basement membrane

52. Goodpasture’s Syndrome
 Clinical presentation
• RPGN
• Pulmonary hemorrhage
• Anti-GBM antibodies
 Treatment
• Immunosuppressive drugs
 Cyclophosphamide
 Corticosteroids
 Azathioprine
• Plasmapheresis (ASFA Category I)
 Daily pheresis for 14 days with 5% albumin, 1-1 ½ plasma
volume
 Finish procedure with 1 liter of FFP in cases with pulmonary
hemorrhage and /or renal biopsy

53. Antineutrophil Cytoplasmic
Antibodies
• ANCA by immunofluorescence
methods
• c-ANCA = Wegener’s
disease (60% to 90%)
• p-ANCA = microscopic
polyangiitis (MPA)
(50% to 80%),
UC (40% to 80%), Crohn’s
(10% to 40%)
Hoffman GS. Arth Rheum. 1998;41(a):1521–1537.

54. Vasculitis

55. ANCA positive Pauci Immune
RPGN
 Clinical presentation
• RPGN with or without pulmonary hemorrhage
• Perinuclear (p-ANCA)-systemic microvasculitis
• Internuclear (c-ANCA)-Wegener’s
granulomatosis
 Treatment
• Immunosuppressive drugs
• Plasmapheresis (ASFA Category II) may
benefit patients with severe renal disease (Cr
9) and dialysis dependent patients

56. Immune Complex RPGN (MPGN)

57. Immune Complex RPGN
 Clinical presentation
• RPGN
• Membranoproliferative GN (MPGN)
 Associations
• Hepatitis C
• Cryoglobulinemia
 Treatment
• Antiviral drugs
• Corticosteroids
• Plasmapheresis (ASFA Category II)

58. Acute Inflammatory Demyelinating
Polyradiculoneuropathy (AIDP)
‘
Guillain-Barre Syndrome (GBS)
 Pathogenesis
• Anti-myelin (gangliosides) antibodies GM1, GM1b, GD1a
 Clinical presentation
• Ascending paralysis
• “albuminocytologic dissociation”
 High CSF protein
 No CSF pleocytosis
• 10-23% require assisted ventilation
• Nerve conduction studies show demyelination
• dysautonomia
 Treatment
• Supportive care
• IVIG 400mg/kg x 5 days
• Plasmapheresis (ASFA Category I)
 Start within 14 days of onset
 5-6 Q.O.D. procedures, 1-1 1/2 plasma volume exchange with 5% albumin

59. Anti-myelin Antibodies

60. GBS Clinical Course
GBS course
Symptom severity
Time

61. Myasthenia Gravis
Nerve
Acetylcholine (Ach)
AchR Anti-AchR Ab
Muscle

62. Myasthenia Gravis
 Clinical picture
• Variable degrees of weakness; improved by
rest
• Thymoma in 15% of patients
 Treatment
• Mestinon
• Prednisone
• Imuran or other immunomodulatory meds
• Plasmapheresis (ASFA Category I)
• IVIG 400 mg/kg x 5 days
• Thymectomy

63. Myasthenia Gravis
 Plasmapheresis
• Acute myasthenic crisis
• Respiratory insufficiency
• Failure to respond to medications
• Side effects of medications (prednisone)
• Before and after surgery (thymectomy)

64. Myasthenia Gravis
Before plasmapheresis After Plasmapheresis

65. Hyperviscosity Syndrome
 Causes
• Wadenstrom’s macroglobulinemia 50%
• Multiple myeloma 5%
 Clinical presentation
• Neurologic symptoms
• Bleeding diathesis
• Retinal hemorrhage and papilledema
• Hypervolemia
• Congestive heart failure
 Treatment
• Plasmapheresis (ASFA Category II)
• Chemotherapy

67. Systemic Lupus Erythematosus
(SLE)
 Systemic autoimmune disease with the
presence of autoantibodies and immune
complexes (anti-DNA, anti-DS-DNA)
 Multiple organ involvement including the
kidneys
 Controlled clinical trials failed to show
benefit from plasmapheresis in lupus
nephropathy
 Plasmapheresis (ASFA Category III)

68. Red Cell Exchange
 Sickle Cell Disease
 Malaria
 Babesiosis

69. Sickle Cell Disease
 Clinical picture
• Chronic genetic anemia
• Hgb S instead of Hgb A alters the erythrocytes and their
membranes (sickle red cells)
• Increased blood viscosity
• Microvascular occlusion
 Infarcts in brain, lungs, retina
 Pain crisis
 Priapism
 Acute chest syndrome
 Stroke
• Treatment
 Red cell transfusions
 Hydroxyurea
 Red cell exchange (ASFA Category I)
• Aims to maintain Hgb S <30

70. Malaria
 Cause
• Plasmodium falciparum, vivax, ovale, malariae
• Transmitted by female anopheline mosqito
• Infected RBC adhere to endothelial cells of capillaries and
postcapillary venules via surface knobs
• Microvascular obstruction of brain, kidneys,lungs
 Clinical picture
• Fever, malaise, headache
• Neurologic impairment
• Renal failure
• ARDS
 Traetment
• Chloroquine, quinine, quinidine
• Red cell exchange (ASFA Category III)
• Plasmapheresis for removal of cytokines to prevent or treat
lactic acidosis, hypoglycemia (NR)

71. White Cell Depletion
Leukapheresis
 Leukocytosis
• Acute Myelogenous Leukemia (AML)
• Chronic Myelogenous Leukemia (CML)
• Acute Lymphocytic Leukemia (ALL)
• Chronic Lymphocytic Leukemia (CLL)
 Clinical picture
• Hyperviscosity with microvascular occlusion
 CNS symptoms
 Hemorrhage
 Pulmonary insufficiency
 Treatment
• Combination chemotherapy (tumor cell lysis leads to metabolic
imbalance and ARDS)
• Leukapheresis (ASFA Category I)
 Ptreatment of leukocytosis
 Prevention of tumor cell lysis syndrome

72. Plateletpheresis
 Thrombocytosis (>1,000 x 10 /L) 9
• Essential
• Polycytemia vera
 Clinical picture
• Microvascular occlusion
 CNS symptoms
 Hemorrhage
 Pulmonary insufficiency
 Treatment
• Chemotherapy
• Plateletpheresis (ASFA Category I)

73. Rheumatoid Arthritis
 Chronic inflammatory autoimmune disease
• Arthritis
• Rheumatoid nodules
• Serum rheumatoid factor
 Treatment
• DMARD (Disease Modifying Anti Rheumatic
Drugs)
• Anti-TNF alpha monoclonal antibodies
• Apheresis
 Plasmapheresis (ASFA Category IV)
 Lymphoplasmapheresis (ASFA Category II)
 Prosorba column (ASFA Category II)

74. Protein A binds IgG

75. Protocols for Reducing anti-HLA
antibodies in positive CXM and
AMR
 IVIG alone
 Plasmapheresis and IVIG
 Plasmapheresis, IVIG and anti-CD20
antibody (splenectomy)
AmJTransplant 4(7):1033-1041, 2004

76. Protocols for Reducing anti-HLA
antibodies in positive CXM and AMR
30% rejection
IVIG 42 patients episodes
89% graft
survival at 2
years
Plasmapheres 62 patients 94.2% graft
is and IVIG survival at 3
years
AmJTransplant 4(7):1033-1041, 2004

77. LDL Apheresis
 Using Liposorber or HELP system
 For LDL > 300 mg/dl or LDL > 200
mg/dl plus CAD
 Can be used in severe
hypertriglyceridemia.

78. Extracorporeal photopheresis
 Immunomodulatory effect
 Cellex or TheraKos
 Using 8MSO 0.6 mg/kg
 For:
• CTCL
• Graft vs. Host Disease
• Solid organ transplant rejection
• Crohn’s Disease
• Scleroderma

79. Quality & Audit Management
 cGMP, cGTP, SOP’s, CFR
 FDA requirements & AABB standards
 OSHA, CMS, Joint Commission
 CAP
 CLIA
 Foundation for the Accreditation of
Cellular Therapy (FACT)

80. Summary
 Therapeutic Apheresis is an
outpatient or inpatient procedure
that usually takes two to three hours
and the blood components causing
illness are removed from circulation
saving lifes. The risks or side effects
are manageable or preventable. Its
under used. Future review of the
guidelines is recommended &
encouraged.

81. References
 Journal of Clinical Apheresis, Vol.15,
No.1/2, 2000, Special Issue, Clinical
Applications of Therapeutic Apheresis
 Journal of Clinical Apheresis 2000-2006
 APHERESIS, Principles and Practice, 2nd &
3rd Editions from 2003 & 2010 respectively,
Bruce C. McLeod Editor, AABB Press

82. Cont. References
 R Bambauer, R Latza, R Schiel: Therapeutic Apheresis in the Treatment of
Hemolytic Uremic Syndrome in View of Pathophysiological Aspects. Ther
Apher Dial 15(1): 10-19, 2011.
 ZM Szczepiorkowski et al: Guidelines on the use of therapeutic apheresis in
clinical practice-evidence based approach from the Apheresis Applications
Committee of the American Society for Apheresis. Jounal of Clinical
Apheresis 25: 83-177, 2010.
 SG Shelat: Practical Considerations for Planning a Therapeutic Apheresis
Procedure. The American Journal of Medicine 123(9): 777-784, 2010.
 Lamont Williams (AABBR Staff Writer): Plasma exchange in Organ
Transplantation. AABB News, 8-19, April 2010.
 K. El-Gharini & DJ. Unsworth: Therapeutic apheresis – pasmapheresis.
Clinical Medicine, 6(4): 343-347, July/August 2006.
 RB Striker, RG Miller & DD Kiprov: Role of plasmapheresis in acute
disseminated (postinfectious) encephalitis. J Clin Apher 7(4):173-179,
1992.

83. Dr. Raúl H. Morales Borges
Hematólogo/Oncólogo
 Cruz Roja  Ashford Medical
Americana de PR Center
• Servicios de Sangre • Suite # 107
• Ubicados en el • Condado, San Juan
Centro Medico de • Tel. 787-722-0412
PR • Fax 787-723-0554
• Tel. 787-759-8100 • Cel. 787-354-0758
• Ext. 3873
• ihoa@coqui.net
• Dir. 787-993-3873
• www.ihoapr.com
• Cel. 787-505-5814
• MoralesBorgesR@usa.redcross.org

84. Gracias