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THERAPEUTIC
APHERESIS
Dr. Nwogoh Benedict
Department of Haematology and Blood Transfusion, UNIBEN/UBTH
Benin City
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OUTLINE
• Definition
• History
• Components of blood
• Types
• Method and Principle
• Indications
• Anticoagulants
• Care of the patient/Donor
• Complications
• Challenges
2
• Conclusion
8/13/2024
Apheresis Dr. Nwogoh Benedict
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DEFINITION
• The word “apheresis” originates from a Greek word which means
“to take away” or “to take out”.
• Apheresis is simply a procedure that involves the taking away of
blood from a healthy donor or patient, separating it into its
component parts during the donation process and the needed
component collected while the unused returned to the donor or
patient.
• The concept was originally applied to blood donation but over the
years has been expanded to therapeutics
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BLOOD COMPONENTS
• Cellular elements – 45%
• Plasma – 55%
• Mainly water – 92%
• Solutes – 8%
• Proteins: albumin, globulin, coagulation proteins etc
• Non-protein nitrogenous substances
• Hormones
• Respiratory gases
• Electrolytes etc
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FORMS OF APHERESIS
• Cellular elements: Cytapheresis
• Erythrocytapheresis
• Leukapheresis
• Thrombocytaphersis (Plateletaphersis)
• Plasmapheresis
• Removal of significant proportion of plasma with replacement using
a suitable solution.
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METHODS AND PRINCIPLE
• Basic methods in apheresis include
• Centrifugation
• Continuous centrifugation
• Intermittent or non-continuous centrifugation
• Non-centrifugation (membrane based)
• Filtration
• Sieving
• Adsorption technology
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CENTRIFUGATION
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SEPARATION OF BLOOD
COMPONENT BY CENTRIFUGATION
• Each blood component has its own specific gravity. This forms
the basis for the differential separation during centrifugation
Constituent Specific gravity
Plasma 1.025 – 1.028
Platelets 1.040
WBC
B lymphocytes 1.050 – 1.060
T – lymphocytes 1.050 – 1.061
Blast/promyelocytes 1.058 – 1.066
Monocytes 1.065 – 1.066
Myelocytes/basophils 1.070
Reticulocytes 1.078
Metamyelocytes 1.080
Band/segmented neutrophils 1.087 – 1.092
Erythrocytes 1.078 – 1.114
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SEPARATION BY SIEVING
• The filtration method separates plasma from cellular elements by
sieving.
• The technology is commonly limited to plasmapheresis and
plateletapheresis.
• The membrane
Componentpore size measures 6µm
Diameter in µm
Platelets 3
Erythrocytes 7
Lymphocytes 10
Granulocytes 13
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EXTRACORPOREAL
PHOTOPHERESIS
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APHERESIS EQUIPMENT
MANUFACTURERS
• Fenwal
• Fresenius
• Terumo BCT:
• Cobe spectra,
• Trima accel,
• Optima spectra
• Haemonetics
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CLINICAL APPLICATIONS OF
APHARESIS
Donor apharesis Patient apharesis
• Plasmapharesis • Collection of components
• FFP
• Platelet apharesis • Therapeutic apharesis
• Leukacytapharesis • Removal procedures
• Stem cells
• T- cells
• Exchange procedures
• Granulocytes
• Erythrocytapharesis
• Combinations
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CATEGORY DEFINITIONS FOR THERAPEUTIC APHERESIS
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GRADING RECOMMENDATIONS, STRENGTH AND QUALITY OF
EVIDENCE
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CLINICAL APPLICATION OF APHERESIS ASFA APPOVED
LIST
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THERAPEUTIC APHERESIS IN RBC
Disease DISEASES.
TA modality Category Replacement solution
Polycythaemia vera RBC apheresis I Human albumin –
electrolyte (HAE)
Secondary polycythaemia RBC apheresis III HAE
SCA RBC exchange I RBC units
Primary
Prophylaxis
ACS, stroke, TIA, etc.
End organ damage III
Rh incompatibility TPE III HAE
RBC alloimmunization in pregnancy TPE III
AIHA TPE
Warm III HAE
Cold II
Aplastic anaemia TPE III HAE
Pure RBC aplasia TPE III HAE
HSCT
ABO incompatibility TPE, II HAE
RBC exchange III
HLA
Apheresis desensitization
Dr. Nwogoh Benedict TPE III Group O RBC
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GVH disease
Skin (acute/chronic) ECP II
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THERAPEUTIC APHERESIS IN A
SELECTION OF THROMBOCYTE
Disease DISEASES
TA modality Category Replacement
solution
Idiopathic TPE III Human
thrombocytopenic albumin –
purpura electrolyte
(HAE)
Post transfusion purpura IA-Protein A III HAE
TTP TPE I HAE
Thrombocytosis TPE III HAE
Primary Plateletaphe II
resis
Secondary
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Plateletaphe III 8/13/2024 31
resis
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THERAPEUTIC APHERESIS IN
LEUKOCYTE DISEASES
Disease TA modality Categor Replacement
y solution
Hyperleukocytosis
Symptomatic Leukocytaph II Human albumin
eresis – electrolyte
(HAE)
Prophylactic or Leukocytaph III HAE
secondary eresis
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DISEASES ASSOCIATED WITH
ABNORMAL IMMUNOGLOBULIN
LEVELS
• Hyperviscosity from myeloma gammopathy
• Amyloidosis
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GENERAL ISSUES TO CONSIDER WHEN EVALUATING A NEW
PATIENT FOR THERAPEUTIC APHERESIS
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CARE OF THE PATIENT/DONOR
• Apheresis is an invasive procedure that can have significant physiologic
consequences. Apheresis centres should ideally have a quality management
system including policies and procedures, qualified apheresis physicians
and nurses, appropriately licensed machines with regular preventative
maintenance and a mechanism to report and investigate adverse events.
• Any patient requiring apheresis needs a medical history (including a
medication review), physical examination and laboratory investigations.
• The medical history should focus on the indication for apheresis (e.g.
diagnosis, current symptoms, appropriateness of request, concurrent
treatments), and health-care providers should use this information to assess
the patient’s ability to tolerate the procedure and identify potential
complications so they can be mitigated.
• The physical examination should include, at minimum, vital signs, height and
weight, peripheral venous access assessment and volume status.
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CARE OF THE PATIENT/DONOR
• Prior to the first apheresis treatment, laboratory tests should include: a complete blood
count; electrolytes and creatinine; calcium, magnesium, phosphate, and albumin. Additional
laboratory studies may also be necessary, depending on the indication for apheresis.
• Serologic testing and biochemical disease markers should be collected prior to apheresis to
avoid inaccurate results. Since apheresis patients are exposed to large amounts of blood
components and products, consider checking immunity against hepatitis B and offering
vaccination if non-immune.
• Informed consent for apheresis requires that the patient or substitute decision-maker is fully
aware of the risks and potential benefits of this treatment.
• Furthermore, many jurisdictions also require a separate consent for blood and blood
products.
• Co-morbidities, concurrent treatments and medications should be taken into account while
planning a course of apheresis. The treatment plan should be reviewed and adjusted
regularly based on progress and any arising complications.
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ANTICOAGULATION
• Citrate
• This is the most commonly used anticoagulant. Available as ACD
(acid, citrate and dextrose)
• Citrate is metabolized by the liver, muscle and kidney
• There are 2 formulations
• Solution A: 3% citrate (21.4mg/ml)
• Solution B: 2% citrate (12.9mg/ml)
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COMPLICATIONS
• 1. Vasovagal and hypovolemic reaction
• This can be worse in patients on ACE inhibitors.
• Advice patients to stop medication 24 – 48 hrs before procedure
• 2. Hypocalcaemia.
• 3. Catheter complications
• 4. Mechanical haemolysis
• 5 Air embolism (Acute SOB, chest pain, confusion, diaphoresis,
shock, syncope).
• 5. Transfusion reactions
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COMPLICATIONS
• 6. Thrombocytopenia: (30 – 50% reduction in platelet count may
occur.)
• 7. Coagulopathy.
• Usually transient.
• PT/APTT may be prolonged
• Rarely, it may replacement of clotting factors (FFP or
cryoprecipitate).
• 8. Electrolyte imbalance: Hypokalaemia, hypomagnesaemia
• 9. Hormonal imbalance: elevated parathormone
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HYPOCALCAEMIA
• Development of hypocalcaemia may depend on:
• Rate of return of citrated blood
• Recommended rate of 1mg/kg/min is harmless. Rate >1.7mg/kg/min
can cause severe hypocalcaemia.
• Length of the procedure
• Use of an anticoagulated replacement product eg FFP
• Clearance of citrate by the body (functional state of metabolizing
organs).
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FEATURES OF HYPOCALCAEMIA
Severity Features
Mild Circumoral paraesthesia, sneezing & chewing of the
mouth,
Moderate Paraesthesia extends to the hands and feet, chest chills
despite use of warmer, nausea and vomiting, abdominal
cramps, light headedness, hypotension and
restlessness.
Severe Muscle cramps, severe abdominal cramps, bladder or
bowel incontinence, fear o impending doom,
hypotension, loss of consciousness, blurriness o vision,
arrhythmia, neuronal instability: chevostek’s sign,
trousseau sign, seizure
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MANAGEMENT OF
HYPOCALCAEMIA
• Keep the donor/patient warm
• Adjust the blood to anticoagulant ratio
• Reduce the return rate
• Administer calcium
• If unabated, terminate the procedure.
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CASE REPORT
Purpuric Patches
Plasmapharesis Section
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CHALLENGES OF APPLICATION IN
RESOURCE-CONSTRAINED
SETTINGS
• Knowledge of its application in management of medical
conditions
• Availability of equipment and infrastructure
• Availability of the necessary expertize to use the machine.
• Appropriate technical skill for maintenance of equipment
• Power supply
• Supplies of kits
• Cost of procedure
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CLOTS IN THE KITS DUE TO
REPEATED POWER OUTAGE
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CONCLUSION
• The science of apheresis has evolved over the years.
• It is widely applied in blood donation and clinical therapeutics
involving a number of haematological and non haematological
diseases.
• A good quality management system is necessary to prevent and
effectively manage associated adverse reaction.
• The application of apheresis in our setting is still limited by a
number of challenges.
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THANK YOU
QUESTIONS AND ANSWERS
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REFERENCES
• Szczepiorkowsk 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. Journal of Clinical
Apheresis 25:83–177 (2010)
• Yenson Paul. Principles of Therapeutic Apharesis: A method to the Madness.
A presentation at Apharesis program of British Columbia.
• Schwartz J. Apharesis: Basic principles, Practical considerations and clinical
Applications. Review session, ASFA AGM, scotttsdale , Arizona
• Bambauer R, Latza R, Burgard D and Schiel R. Therapeutic Apheresis in
Blood Disorders. Accessed from Avidscence.com.
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• Connelly-Smith L, Dunbar NM. The 2019 guidelines from the
American Society for Apheresis: what's new?. Current Opinion in
Hematology. 2019 Nov 1;26(6):461-5.
• Arogundade FA, Sanusi AA, Oguntola SO, Omotoso BA,
Abdel‐Rahman EM, Akinsola A, Balogun RA. Benefits and
challenges of starting a new therapeutic apheresis service in a
resource‐constrained setting. Journal of Clinical Apheresis. 2014
Aug;29(4):194-8.
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