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بسم الله الرحمن الرحيم. 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. Early History.

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introduction to apheresis

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

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Early History

The word apheresis means, "to take away from"

Blood letting, Egyptian and Greek

Leeches, blood sucking worms.

Salwa Hindawi

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Late History

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

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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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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

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Applications

1. Component collections

  • Plateletpheresis
  • Leucopheresis
  • Erythrocytapheresis
  • Plasmapheresis
  • Stem cell collection

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2. Therapeutic Procedure
  • Therapeutic cytapheresis
  • Therapeutic plasmapheresis
  • (plasma exchange)

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donation criteria
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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donation interval
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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important points to be considered
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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important points to be considered15
Important points to be considered

Technical difficulties:

Access

Anticoagulation

Volume shift

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total blood volume according to body mass ml rate
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

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guidelines for therapeutic apheresis
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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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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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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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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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 .

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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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Category IV

Category III

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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adverse effects of apheresis
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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adverse effects of apheresis cont
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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Signs and Symptoms, Possible Causes, and Treatment of Adverse

Effects during Therapeutic Apheresis

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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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swedish registry
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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conclusion
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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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.

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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.

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Thanks

Salwa Hindawi

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