APHERESIS

METHODOLOGY
By: Rojas, Charity o Depending on the substance that is being
removed, different processes are employed in
apheresis. If separation by Dormsty is required,
Apheresis centrifugation is the most common method.
- Derived from Greek word: Other methods involve absorption onto beads
coated with an absorbent material and filtration.
Apo- meaning away and heresis, is the o The centrifugation method can be divided into
process which involves the removal of whole two basic categories:
blood, separating and collecting any of the
components, whilst returning remaining blood
component to maintain haemodynamic status. 1. Continuous flow centrifugation (CFC)
- Historically, required two venipunctures as the
Historical background continuous means the blood is collected, spin
In 1660, 1st experimental apheresis performed and returned simultaneously.
by Richard Lower in Oxford, England. - ---- use a single venipuncture.
Between 1902-1914, plasmapheresis - Main Advantage: the low extracorporeal volume
performed in France, Russia and USA. (calculated by volume of the apheresis chamber,
In 1960, Solomeg and Fahey used Manual the donors hematocrit and total blood volume of
Therapeutic Plasmapheresis to reduce elevated the donor) used in the procedure which may be
Ig levels in Hyperviscosity Syndrome. ------ in the elderly and for children.
- Nowadays, Automated cell separator machine is used
to collect and/or treat blood components in 2. Intemittent flow Centrigugation (IEC)
apheresis.
- --------

It involves removal of whole blood from a patient or

donor. Within an instrument that is essentially
designed as a centrifuge, the components of whole
blood are separated. One of the separated portions is
then withdrawn and the remaining components are PLATELETPHERESIS
retransfused into the patient or donor. (more accurately called thrombocytapheresis or
thrombapheresis, through these names are rarely
used) is the process of collecting thrombocytes,
The components which are separated and withdrawn
more commonly called platelets, a component of
include:
o Plasma (plasmapheresis) blood involved in blood clotting.
o Platelets (plateletpheresis) The term specifically refers to the method of
o Leukocytes (leukapheresis) collecting the platelets which is performed by a
device used in lood donation that separates the
platelets and returns other portions of the blood to
Whole blood is introduced into a chamber that is the donor.
spinning and the blood separate into components Platelet transfusion can be a life-saving procedure
(P plasma, PRP platelets rich plasma, WBC in preventing or treating serious complications
leukocytes, RBC, red blood cels) by gently along from bleeding and hemorrhage in patients who
the wall of the chamber. The components to be have disorders manifesting as thrombocytopenia
removed can be selected by moving the level of (low platelet count) or platelet dysfuntion.
the aspiration directed at the right. This process may alos be used therapeutically to
treat disorders resulting in extraordinarily high
platelet counts such as essential thrombocytosis.
 The maximum amount of plasma that can be used for systemic infections in patients with
retained should not exceed 500 mL if the donor neutropenia.
weigh less than 175 lbs or 600 mL if the donor The product generally has a 24-hour shelf life
weighs more than 175 lbs. from collection and is often transfused before
Routinely, the number of platelets in an apheresis infectious disease testing is completed. It is a
product is equivalent to 6-10 random platelet therapy of last resort and its use is controversial
concentrates. and rare.
AABB standards requires that 75% of CORTICOSTERIODS (prednisone and
plateletpheresis products tested contain a dexamethasone) increase the number of
minimum of 3x1011 platelets. granulocytes but may exacerbate medical
NO ASPIRIN CONTAINING MEDICATIONS or conditions like diabetes or hypertension.
NSAIDs withn 36 hours (these drugs inhibit the HEMATOPOIETIC GROWTH FACTORS (G-
cyclooxygenase enzyme at the prostaglandin CSF, GM-CSF) allows increase granulocyte
pathway. It prevent adequate platelet aggregation collection
and the release of platelet adenosine diphosphate. Granulocyte concentrate minimum of 1.0x1010
The procedure typically takes 45-90 minutes. The granulocytes in at least 75% of the unit tested
product is usually prepared in a closed system for Compatability testing required and stored in room
5 days storage. If the prosuct is prepared in an temperature without agitation.
open system, it must be transfused within 24 hours
Platelet stored at room temperature 920-24
degrees celcius should be maintained within
continuous gentle agitation. Compatibility testing
ERYTHROCYTAPHERESIS
not required.
An apheresis procedure by which erythrocytes
(red blood cell) are separated from whole blood.
It is an extracorporeal blood separation method
whereby whole blood is extracted from a donor or
LEUKAPHERESIS
patient, the red blood cells are separated and the
White blood cells are separated from a sample of
remaining blood is returned to circulation.
blood. It is a specific type of apheresis, the more
ADVANTAGES to automated RBC collection:
general term for separating out one particular o Standardized RBC mass collection (180-
constituent of blood and returning the remainder to
200 mL)
the circulation. o Use of a smaller needles for collection
It may be performed to decrease a very high white o Use of saline compensation, which reduce
blood cell count to obtain autologous (i.e. the the risk of hypovolemia
patient own blood cells for later transplant back o Reduced cost of testing, data, entry, and
into the patient or to obtain cells for research staffing.
purposes. o Eliminating secondary separation
It may also be performed to obtain the patients procedure
own blood cells for later transplant. White blood Collected either 2 standard units of RBC or 1 unit
cells may be removed to protect them from of RBC
damage before high-dose chemotherapy, then - if 2 units of RBC donor must wait 16 weeks
transfused back into the patient in the trement of before providing another donation.
advanced breast cancer. REQUIREMENTS:
Alternatively, only granulocytes, macrophages and Female at least 55, weighs at least 150 lbs,
monocytes can be removed, leaving the 40% hematocrit
lymphocyte count largely unchanged. This is used Male at least 51, weighs at least 130 lbs,
as a treatment for autoimmune diseases. 40% hematocrit
Leukapheresis, typically for granulocytes, is a
rarely performed blood donation process. The PLASMAPHERESIS
Is the removal, treatment and return of
product is collected by automated apheresis and is
(components of) blood plasma from blood
 circulation. It is thus an extracorporeal therapy (a PERIPHERAL BLOOD STEM CELL
medical procedure performed outside the body)
The method is also used to collect plasma, which
(PSBC)/HEMATOPOIETIC
is frozen to preserve it for eventual use in the PROGENITOR CELLS
manufacture of a variety of medications. Background
The procedure is used to treat a variety of
disorders, including those of the immune system, o First successful transplant late 1960s
o 30,000 40,000 transplants performed
such as Goodpasture syndrome, myasthenia
gravis, Guillain-Barre syndrome, lupus, and yearly worldwide
o -------
thrombotic thrombocytopenic purpura.
COMPLICATIONS OF PLASMAPHERESIS
THERAPY
Hematopoietic stem cell
o Insertion of a rather large intravenous
catheter can lead to bleeding, lung o Responsive in maintaining marrow
puncture (depending on the site of catheter function throughout the life of individual
insertion) and if the catheter is left in too o Stem cells are undifferentiated cells with
long, it ca get infected. the capacity for unlimited or prolonged
o When patient blood is outside of the body self-renewal and the ability to give rise to
passing through the plasmapheresis differentiated cells.
machine, the blood has a tendency to clot. Totipotent: give rise to entire
To reduce this tendency, citrate is infused organism
while the blood is running through the Pluripotent: give rise to most cells
circuit. Citrate binds to calcium in the o Give rise to any blood cells: RBC,
blood, calcium being essential for blood to platelet, WBC
clot. Citrate is very effective in preventing o ----
blood from clotting, however, its use can o ----
lead to life threatening low calcium levels.
This can be detected using the Chvosteks
sign or Troussesus sign. To prevent this THERAPEUTIC APHERESIS
complication, calcium is infused
The removal of a blood component from a patient
intravenously while the patient is
to remove defective cells or deplete a disease
undergoing the plasmapheresis. In
mediator.
addition, calcium supplementation by
The process removes whole blood and separates
mouth may also be given.
the blood components via centrifugation
The procedures are performed to attain a curative
Other complications include: state or maintain a palliative state in a number of
o Hypotension disease processes.
o Potential exposure to blood products, with
risk of transfusion reactions or transfusion
transmitted diseases Therapeutic cytapheresis
o Suppression of the patients immune Therapeutic plasmapheresis (plasma
system exchange)
o Bleeding or hematoma from needle Immunoadsorption (selective adsorption)
placement Photophoresis
The collected plasma is promptly frozen at lower PLASMAPHERESIS/PLASMA
than -20C (-4F) and is typically shipped to a EXHANGE
processing facility for fractionation. Plasmapheresis
o A procedure in which blood of patient or the
donor is passed through a medical device
which separates out plasma from the other
components of blood and the plasma is
 removed (i.e less than 15% of total plasma o Controlled trails have not shown
volume/ approx. 500 mL) without the use of benefits to be approved by institution
replacement solution. review board.
Plasma Exchange
o Therapeutic procedure in which blood of the IMMUNOADSORPTION
patient is passed through a medical device An extracorporeal treatment method for the
which separates out plasma from other therapeutic removal of autoantibodies and
components of blood, the plasma is removed immune complexes in autoimmune diseases or
and replaced with a replacement solution such antibody-mediated graft rejection.
as colloid solution (e,g. albumin and/or
plasma) or combination of crystalloid/colloid INDICATION Category
solution.
Chronic Local encephalitis II
(Frasmussen encephalitis)
INTENSITY OF TREATMENT CATEGORIES FOR Coagulation factor inhibition III
TPE Cryoglubulinemia II
Secondary to Hepatitis C virus
Level Schedule Duration Dilated cardioenyopathy III
Aggressive (A) Daily 3 treatments to New York Heart Association
indefinite Class II-IV
Routine 3x a week 5-7 treatments Familial Hypercholesterolemia
Prolonged (P) 1-2x a week 3-8 weeks Homozygous I
Chronic Every 1-4 weeks Indefinite Heterozygous II
Paranoplastic neurologic III
syndromes
EFFICIENCY OF TPE (THERAPEUTIC ---------- poly---- IgG/IgA or IgM III
PLASMA EXCHANGE) Rheumatoid arthritis, refractory II
Volume of exchange
o 1-1.5 plasma volume
Calculation depends on numerous factors Types & Clinical Applications
o Frequency of procedures Adsorbent Sub removed Application
o Duration of therapy Charcoal Bile acids Cholestatic pruritis
What is being removed? A, B antigen Anti-A, Anti-B Transplantation
o IgG mainly extravascular Anti-LDL Heparin LDL Hypercholesterolemia
DNA, ANA Immune SLE
o IgM mainly intravascular
complexes
Protein A IgG Immune ITP, cancer, HUS
complexes
TPE: Indication Categories
Category I
o Apheresis is standard and acceptable
as a primary therapy or first line PHOTOPHERESIS
adjunct therapy. This does not mean A technique for treating cutaneous T-cell
that it is mandatory. lymphoma in which a photoactive chemical is
Category II administered, and the blood is removed and
o Apheresis is accepted but as circulated through a source of ultraviolet
supportive to other treatment. radiation, then returned to the patient. It is
Category III believed to stimulate the immune sytem.
o Apheresis may be beneficial, however, Buffy coat is separated from whole blood,
there is insufficient evidence to chemically treated with Methozalen (Livadex)
establish the efficacy or risk or and exposed to ultraviolet light and returned to
benefit. the patient.
Category IV

INDICATION CATEGORY
 Cardiac allograft rejection protein components of the transfused blood or
Prophylaxis I potassium or citrate preservatives in the banked
Treatment of rejection II blood.
Cutaneous T-cell
lymphoma: mycosis IMMEDIATE DELAYED
fungoides: Sezary I IMMUNE
syndrome III
IHTR DHTR
Erythrodermic
FNHTR Alloimmunization
Norerythrodermic
Allergic reactions PTP
Graft-vs-host disease
Anaphylaxis and anaphylactoid TA-GVHD
Skin (chronic) II
reaction Immunosuppression
Skin (Acute) II
TRALI
---- (acute/chronic) III
Lung allograft rejection II NONIMMUNE
III Bacterial contamination Iron overload
III TACO Air embolism
IV Physical or Chemical
Damages
Depletion and dilution of
Complications of Apheresis coagulation factors and
Citrate toxicity platelets
Vascular access complications (hematoma,
sepsis, phlebitis, neuropathy)
LOCATIONS OF PREVENTABLE
Vasovagal reactions
TRANSFUSION-ASSOCIATED DEATHS, In order
Hypovolemia
of occurrence
Allergic reactions
Hemolysis 1. Laboratory
Air embolus o Leading causes of preventable laboratory
Depletion of clotting factoOR errors are the following:
Circulatory and respiratory distress o Improper specimen identification
Transfusion-transmitted disease o Improper patient identification
Lymphocyte loss o Antibody identification error
Depletion of protein and immunoglobulins o Crossmatch procedure error
2. Nursing service
3. Anesthesia service
4. Clinical staff

SUMMARY OF FREQUENT ERROR CAUSES

ASSOCIATED WITH TRANSFUSION
REACTIONS
TRANSFUSION REACTION 1. Patient misidentification
A systemic response by the body to the 2. Sample error
3. Wrong blood issued
administration of blood incompatible with that of 4. Transcription error
the recipient. 5. Administration error
The causes include rbc incompatibility, allergic 6. Technical error
sensitivity to the leukocytes, platelets, plasma 7. Storage error