seminar on types of apheresis- donor and therapeutic

1. APHERESIS
BY EKTA
JAJODIA

2. DEFINITION
 Apheresis is derived from a greek word
meaning “to take away”
 Technique in which whole blood is
withdrawn – separated into its components –
desired component is retained and remaining
constituents are returned to donor

3. MECHANISM OF ACTION
 Large-bore intravenous catheter is connected to
spinning centrifuge bowl
 Whole blood collected from donor/ patient into
the centrifuge bowl
 More dense elements like RBCs settle to the
bottom – then WBC – Platelets – and plasma on
the top

6. METHODOLOGY
1. Centrifugation method – separation is by density
2. Membrane filtration technique
 Centrifugation method is most commonly used

7. TYPES OF CENTRIFUGATION
METHOD
1. Intermittent flow centrifugation (IFC) –
 Performed in cycles ( known as passes)
 Blood is collected from an individual
to prevent clotting , anticoagulant added to tubing

8. blood pumped into centrifuge bowl through inlet
port
bowl rotates and components separated according
to specific gravity
RBCs packed against outer rim of bowl(greatest
density)
followed by WBCs, platelets and plasma

9. separated components flow from bowl through outlet
port into separate collection bags
undesired components are diverted into reinfusion
bag and returned to the individual
reinfusion completes one cycle
Cycles are repeated until the desired quantity of
product is obtained (eg – plateletpheresis usually
takes 6-8 cycles to collect a therapeutic dose)

10.  IFC can be done –

a. With 1 venepuncture (one arm procedure) –
blood is withdrawn and reinfused through the
same needle
b. With 2 venepuncture (2 arm procedure) – one
for phlebotomy and 1 for reinfusion

11. 2. Continuous flow centrifugation(CFC) –
 It withdraws , process and return the blood to
individual simultaneously
 This is in contrast to IFC procedure , which
completes a cycle before beginning a new one
 Always done with 2 venepuncture sites
 ADV- low extracorporeal blood volume is used
– so useful in elderly and children

12. MEMBRANE FILTRATION
TECHNIQUE
 Blood that passes over membranes with specific
pore sizes allows passage of plasma through
membrane while cellular portion passes over it
 Limited to only plasma collection

13. GUIDELINES FOR THERAPEUTIC
HEMAPHERESIS BY AMERICAN
SOCIETY OF APHERESIS
1. CATEGORY 1 – Efficacy demonstrated
apheresis as primary therapy
a. Hyperviscosity
b. TTP
c. GBS
d. Cryoglobulinemia
e. Myasthenia gravis
f. CTCL

14. 2. CATEGORY 2 – sufficient evidence to support
efficacy but only on adjunctive basis
a. SLE
b. HUS
c. RPGN
d. Coagulation factor inhibitors
e. Cold agglutinin hemolytic anemia
3. CATEGORY 3 - inconclusive evidence for
efficacy
4. CATEGORY 4 – lack of efficacy in controlled
trials

15. APHERESIS PROCEDURAL
ELEMEMTS
1. Venous access
2. Replacement fluid
3. Normal constituents removed
4. Anticoagulation
5. Patient history and medication
6. Frequency and number of procedures
7. Complications

16. VENOUS ACCESS
 Requires large bore venous catheters to sustain
a flow rate of 50-100ml/min
 Location – Peripheral – anticubital
Central – femoral/subclavian/jugular

17. REPLACEMEMENT FLUID
 Required in therapeutic plasmapheresis
Must be FDA approved for use with blood
products – get mixed with RBCs before the return
phase
1.Crystalloids – 0.9% NS
2.Colloids – 5% Normal serum albumin (NSA)
FFP
HES(hydroxy ethyl starch)

18.  NS provides less oncotic pressure than plasma ,
so 2-3 times the volume removed should be
replaced
Mixtures of NSA and NS has also been used
 FFP is especially recommended in case of TTP

20. NORMAL CONSTITUENTS
REMOVED
 Coagulation factors – replaced in 2-3 days after
exchange
Measure PT/APTT every 2-3 days rather than
daily
 Platelets – 25-30% loss per procedure
 Endogenous synthesis replaces in 2-4 days

21. ANTICOAGULATION
1. Citrate based – a. ACD-A(acid citrate
dextrose- adenine) –MC used
b. Trisodium citrate – used
with leukapheresis
2. Heparin
3. Combination of ACD-A and heparin

22.  Citrate binds with ionised calcium and blocks
calcium-dependent clotting reactions
 S/E – hypocalcemia – so addition of calcium
with replacement solution can reduce incidence of
hypocalcemia
 Heparin prevents conversion of prothrombin to
thrombin
 S/E -Heparin results in systemic anticoagulation
 So, low amount of heparin + ACD-A is an
effective anticoagulant

24. PATIENT HISTORY AND
MEDICATION
 Certain medications like antibiotic and
anticoagulant are removed during aphereis – so
should be given immediately after procedure
 Should avoid ACE inhibitors upto 48hrs after
apheresis

25. I I
I

26.  ACE inh causes – vasodilatation
 Apheresis – causes activation of bradykinin in
extracorporeal circuit – potent vasodilator –
profound hypotension
 If ACE inh given – further hypotension

27.  Use of apheresis technique is divided into 2 –
1. Component collection
2. Therapeutic procedure
 2 types of apheresis-
1. Cytapheresis (leucapheresis, plateletpheresis
and erythrocytapheresis)
2. Plasmapheresis

28. PLATELETPHERESIS
COMPONENT COLLECTION
 Indication – Bleeding – secondary to
thrombocytopenia or platelet dysfunction
Platelet transfusion
By platelet concentrates
harvested from routine
whole blood
donations(RDP)
By apheresis – Platelet
yield is related to donor’s
initial Platelet count (SDP)

29.  Donor’s PC should be > 1.5 lakhs
 If it’s the 1st donation or if 4 wks have elapsed
since prior platelet donation – a PC is not reqd
If platelet donation done in <4wks – PC reqd
In apheresis product – Number of platelets (3 *
10^11 in about 300ml ) is equivalent to 6-10
random donor platelets
 In case of emergency can donate again after 3
days

30.  Must not have taken NSAIDs or Aspirin within
last 48 hrs
 Takes about 45-90 mins
 Approved for 5 days storage at 20-24°C with
continuous gentle agitation
 At the end of storage period – the pH should be ≥
6.2
 If RBC contamination in product is negligible
(<2ml) – compatibility testing not reqd

31. THERAPEUTIC PLATELETPHERESIS
Indications -
1. For management of patients with symptomatic
thrombocythemia
2. For those who cant tolerate drug therapy like
hydroxyurea and anagrelide
3. In polycythemia vera
With each procedure of TP – 50% reduction in PC

32.  In pregnancy with thrombocythemia – drug
therapy is C/I – so TP is the preferred treatment
for rapid lowering of PC to prevent placental
infarction and fetal death

33. LEUKAPHERESIS
COMPONENT COLLECTION
 Indication –
1. Severe neutropenia
2. Patients with infection unresponsive to
traditional therapy
 Sedimenting agents like HES allows better
separation of granulocytes from RBCs

34.  <2% of total granulocytes in body are present in
circulation – corticosteroids use in donor before
collection can increase number of circulating
granulocytes
 Use of recombinant G-CSF and GM-CSF in
donors – cause increase in collection of
granulocytes(upto 1* )
10^11
 Current standard dose is ≥1* 10^10

35.  Shelf life is 24hrs at 20-24°C but s/b transfused
as soon as possible
Due to large no. of lymphocytes present – must
be irradiated to prevent GVHD (function of
granulocytes is not affected by irradiation)
 If RBC contamination >2ml – ABO compability
testing reqd

36. THERAPEUTIC LEUCOCYTAPHERESIS
 Indication –
1. To deplete malignant leucocytes in both acute
and chronic leukemias – to prevent/treat
leucostatic syndrome wherein
pulmonary/cerebral dysfunction may develop
once TLC is >1 lakhs/cumm in AML or > 3
lakhs/cumm in CML
2. Leukemic phase of cutaneous T cell lymphoma
(sezary syndrome)

37. ERYTHROCYTAPHERESIS
COMPONENT COLLECTION
 done in 2 ways
2 units of RBCs
In such a case, donor must
wait for 16 weeks before
next RBC donation
1 unit of RBC collected
concurrently with
plasma/platelets

38.  Donor criteria –
For females – 5’5” height
≥ 150 pounds weight
hematocrit level of 40%
For males – 5’1” height
≥ 130 pounds weight
hematocrit - 40%

39. THERAPEUTIC ERYTHROCYTAPHERESIS
 Its an exchange procedure
 MC used in – 1. Sickle cell disease – during
severe crisis such as stroke, acute chest syndrome,
priapism and cholestasis
Exchanged with RBC containing ≥ 70% HbA
2. In parasitic infection – severe falciparum
malaria and babesiosis – to lower parasite load

40. PLASMAPHERESIS
COMPONENT COLLECTION
 Indication – To collect immune plasma from
donors with increased concentration of certain
plasma immunoglobins
 RBCs must be returned within 2 hrs of
phlebotomy
 RBC loss s/n/b > 25ml/week

41.  Amount of blood processed at one time s/n/b
>500ml – not >1000 ml in 48 hrs – and not >2000
ml in 7 day period

42. THERAPEUTIC PLASMAPHERESIS
 Purpose is to remove offending agent in plasma
causing clinical symptoms
 Replacement fluid must be given
 Factors removed by plasmapheresis –
1. Immune complexes (in SLE)
2. AutoAbs or alloAbs (F-VIII inh)

43. 4. Abs causing hyperviscosity (in Waldenstrom’s
macroglobulinemia
5. Protein bound toxins
6. Lipoproteins
7. Platelet aggregating factors (in TTP)

44. IMMUNOADSORPTION
 Method in which a specific ligand binds to
insoluble matrix in a column
Plasma is then perfused over the column
Selective removal of pathogenetic substance and
return of patient’s own plasma

45. ADSORBENT SUBSTANCE REMOVED APPLICATION
Charcoal Bile acids Cholestasis
A and B Ags Anti-A and Anti-B Transplantation
Anti-LDL LDL hypercholesterolemia
DNA ANA, Immune complexes SLE
Protein A(styphylococcal) IgG, Immune complexes ITP, HUS

46. PHOTOPHERESIS
 FDA approved for Cutaneous T-cell lymphoma
 Patient is treated with drug psoralen
It binds to DNA of all nucleated cells
Leucocytapheresis done and WBCs exposed to UV-A
light

47. this activates psoralen and prevents replication
These treated cells are then returned to patient
 Also indicated in – scleroderma, RA, Acute and
chronic GVHD

48. ADVERSE EFFECTS
1. Citrate toxicity
2. Vascular access complications – sepsis,
hematoma, phlebitis
3. Vasovagal reactions
4. Hypovolemia
5. Allergic reactions
6. Air embolism
7. Depletion of clotting factors
8. Transfusion transmitted infections

50. IMPORTANT POINTS TO REMEMBER
 In apheresis procedure, blood is withdrawn from
donor/patient – separated into components – one or
more components are retained – remaining
constituents combined and returned back to the
individual
 Apheresis by IFC – requires only one
venepuncture site

51.  Apheresis by CFC – requires 2 venepuncture
site – withdrawal and return of blood occurs
simultaneous
CFC has an advantage of lower extracorporeal
volume
 MC anticoagulant used is - ACD-A
 In therapeutic plasmapheresis – replacement
fluid used are – NS, NSA, HES and FFP

52. FFP especially in case of TTP
 Granulocyte concentrates should contain a
minimum of 1 * 10^10 granulocytes
 Plateletpheresis products should contain a
minimum of 3 * 10^11 platelets , an equivalent of 6-
10 random platelet concentrates

53. REFERENCES
1. Modern blood banking and tranfusion practices
– Denise M. Harmening
2. Recent advances in hematology
3. Various internet sources

54. THANK YOU