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    Physiology & Applications

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    Yuliyanti Yasin
    Therapeutic apheresis procedures involve separating out components of a patient's blood and removing or manipulating specific portions. Apheresis is commonly used to collect blood components from donors or to treat patients by reducing circulating amounts of harmful substances. The most common apheresis procedures are therapeutic plasma exchange, used to treat autoimmune diseases by removing antibodies and immune complexes, and plateletpheresis to collect platelets from donors. Apheresis requires specialized equipment to separate blood components through centrifugation based on differences in size and density. Procedures must carefully replace removed fluid volumes and consider factors like anticoagulation method and replacement solutions to safely perform therapeutic apheresis.

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    Physiology & Applications

    Uploaded by

    Yuliyanti Yasin
    133 views52 pages
    Therapeutic apheresis procedures involve separating out components of a patient's blood and removing or manipulating specific portions. Apheresis is commonly used to collect blood components from donors or to treat patients by reducing circulating amounts of harmful substances. The most common apheresis procedures are therapeutic plasma exchange, used to treat autoimmune diseases by removing antibodies and immune complexes, and plateletpheresis to collect platelets from donors. Apheresis requires specialized equipment to separate blood components through centrifugation based on differences in size and density. Procedures must carefully replace removed fluid volumes and consider factors like anticoagulation method and replacement solutions to safely perform therapeutic apheresis.

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    Therapeutic apheresis procedures involve separating out components of a patient's blood and removing or manipulating specific portions. Apheresis is commonly used to collect blood components from donors or to treat patients by reducing circulating amounts of harmful substances. The most common apheresis procedures are therapeutic plasma exchange, used to treat autoimmune diseases by removing antibodies and immune complexes, and plateletpheresis to collect platelets from donors. Apheresis requires specialized equipment to separate blood components through centrifugation based on differences in size and density. Procedures must carefully replace removed fluid volumes and consider factors like anticoagulation method and replacement solutions to safely perform therapeutic apheresis.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    133 views52 pages

    Physiology & Applications

    Uploaded by

    Yuliyanti Yasin
    Therapeutic apheresis procedures involve separating out components of a patient's blood and removing or manipulating specific portions. Apheresis is commonly used to collect blood components from donors or to treat patients by reducing circulating amounts of harmful substances. The most common apheresis procedures are therapeutic plasma exchange, used to treat autoimmune diseases by removing antibodies and immune complexes, and plateletpheresis to collect platelets from donors. Apheresis requires specialized equipment to separate blood components through centrifugation based on differences in size and density. Procedures must carefully replace removed fluid volumes and consider factors like anticoagulation method and replacement solutions to safely perform therapeutic apheresis.

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    of 52

    Physiology &

    Applications

    APHERESIS PROCEDURES

    Worldwide implemented nowadays.


    Most of Asian Countries also involved.
    The usage of this procedure varies between
    countries.

    APHERESIS

    Derived from Greek word Phaeresis which


    means taking away

    Apheresis constitutes a number of procedures in


    which donor/patient blood is processed to remove
    or manipulate a specific portion of blood.

    The remaining blood is returned back to the


    donor/patient

    Apheresis is aimed to:


    Collect a therapeutic dose of a particular
    component e.g. Plateletpheresis
    Therapeutically reduce the circulating amount
    of a particularly harmful component e.g. TPE
    Collect a particular blood cell/ precursor from
    a patient for re-infusion e.g. PBSC Collections

    SPECTRUM OF APHERESIS
    Therapeutic Apheresis

    Component Donation

    Platelet
    Red cell
    Plasma

    TPE
    Leukocytapheresis
    Thrombocytapheresis
    Erythrocytapheresis
    RBC exchange
    LDL apheresis
    Adsorptive cytapheresis
    Lymphocytapheresis
    ECP
    Rheopheresis

    Specific Procedure
    PBSC Collection

    APHERESIS EQUIPMENT

    SEPARATION IN THE SYSTEM

    Plasma

    Trombocytes
    Lymphocytes
    Monocytes
    Granulocytes

    Erytrocytes

    CENTRIFUGE CHANNEL

    CENTRIFUGE CHANNEL AND RPM

    PHTDI, April 2013

    10

    METHODS OF APHERESIS

    Conventional/ manual
    Automatic/ Cell Separator
    Machines
    - Intermittent flow separation
    - Continuous flow separation

    PRINCIPLE OF PROCEDURES

    SEPARATION BY CENTRIFUGATION

    Centrifugation
    Separation based on
    specific gravity
    Continuous flow

    Separation based on specific weight / size


    Spec Weight (g/mL)

    Size (m

    Plasma

    1.026

    Platelets

    1.040

    1-4

    Lymphocytes

    1.050-1.061

    6-10

    Monocytes

    1.077

    10-30

    Granulocytes

    1.080 -1.088

    10-15

    Erytrocytes

    1.093-1.100

    6-8

    DONOR APHERESIS

    14

    DONOR APHERESIS
    Plasmapheresis
    Cytaferese

    - Trombocytapheresis
    - Lymphocytapheresis
    - Stemcelapheresis
    - Monocytapheresis
    - Granulocytapheresis
    - Erytrocytapheresis

    Cell therapy

    Multicomponent apheresis
    15

    PLATELET PHERESIS

    Plateletpheresis : collection of platelets


    from a donor with return of donor RBCs

    Plateletpheresis is the most common


    application of apheresis

    2 T YPES OF PLATELET COMPONENTS :

    - random donor platelets or whole


    blood derived platelets (RDP)
    - single donor platelets or apheresis
    platelets (SDP)

    Plateletpheresis (SDP)
    2 to 5 x 10e11 platelet yield
    30% drop in donor platelet count
    replaced in 48 hours
    Low white cell contamination
    Minimal donor red cell loss
    Fewer donor reactions than whole
    blood donations.

    PHERESIS PLATELETS
    o

    Storage: at 20 C to 24 C under
    constant agitation. Maximum
    storage time = 5 days

    Therapeutic dose: between 2.0 5.0 x 1011


    Platelets = 4-8 whole blood collections.

    Pheresis Donation Vs Whole Blood Donatio


    Pheresis Donation

    Whole Blood Donation

    Blood Cell Separator

    No specialized equipment

    Ave 1.5 to 2 hours

    10 mins

    No shows, rejections,
    deferrals very costly

    More uniform work flow

    Hospital/blood center

    Mobile collection

    By appointment

    Walk-ins

    Lab & medical access

    Autonomous operation

    RISKS OF PLATELET TRANSFUSION


    Contamination of Platelets
    The risk of platelet sepsis is greater
    with a transfusion of pooled platelet
    concentrates from multiple donors
    than from a single donor .

    RISKS OF PLATELET TRANSFUSION


    Platelet transfusion can transmit viral
    or bacterial disease.
    Contaminating red cells in the product
    may transmit malaria.
    Graft-versus-host disease (preventable
    by irradiation)

    Cytomegalovirus (preventable by
    serological screening)
    Alloimmunization caused by
    contaminating white cells.

    RISK OF PLATELET TRANSFUSION


    Leukocyte removed could possibly prevent all
    these problems, but this is not established.

    Febrile reactions are common and are reduced


    but not totally eliminated by Leukocyte
    removal
    Platelet themselves may cause fever.

    Advantages of Single Donor Platelets Over


    Pooled Platelet Concentrate Transfusions

    One donor exposure only


    For special feature collections
    (HLA-matched, CMV-negative)
    Lower reaction rate
    Lower risk of alloimmunization and
    transmission of viruses
    Increased donor productivity

    Advantages of Single Donor Platelets Over


    Pooled Platelet Concentrate Transfusions

    One Pretransfusion Test

    Lower Cost than Manual Collection


    Prompt Transfusion Possible
    Less Unit Handling
    Compliance with Quality System
    Standards

    THERAPEUTIC APHERESIS

    PATIENT APHERESIS
    (REDUCTION OF CELLS)
    Cytaferese

    - Trombocytes
    - Lymphoblasts
    - Myeloblasts
    - Erytrocytes

    28

    PATIENT APHERESIS (EXCHANGE)

    Plasma exchange
    RBC exchange

    29

    FUNCTION OF THERAPY
    Theurapetic Plasma
    Exchange

    Plasma
    Platelet
    Depletion
    WBC
    Depletion

    Platelet
    White Blood Cell

    RBC

    3
    0

    Limfosit
    Monosit
    Granulosit
    RBC Exchange

    MNC Collection
    Granulocyte
    Collection

    Therapeutic Plasma Exchange (TPE)

    A therapeutic procedure in which blood of the patient


    is passed through a medical device which separates
    out plasma from other components of blood, the
    plasma is removed and replaced with a replacement
    solution such as colloid solution (e.g., albumin and/or
    plasma) or combination of crystalloid/colloid
    solution.

    Schwartz et al. Journal of Clinical Apheresis.2013

    THERAPEUTIC PLASMA EXCHANGE


    (TPE)
    The most common use of TPE is for the
    treatment of autoimmune or immune mediated
    diseases or disorders
    TPE removes:
    Monoclonal antibodies
    Paraproteins
    Autoimmune antibodies
    Antigen-antibody complexes

    Red Cells

    Clean
    Plasma

    Plasma

    THERAPEUTIC PLASMA EXCHANGE


    (TPE)

    ABNORMAL SUBSTANCES REMOVED


    FROM THE CIRCULATION BY TPE
    1. Paraproteins (Waldenstorms Macroglobulinemia)
    2. Autoantibodies (Myasthenia Gravis, Goodpastures syn.)
    3. Lipids (LDL in familial hypercholesterolemia; phynatic acid
    in refsums disease)
    4. Toxins or drugs (that are bound to albumin)
    5. Circulating immune complexes (CIC)
    6. Soluble mediators of inflammatory response (activated
    complement component, vasoactive substances)

    3
    4

    PROCEDURAL ELEMENTS
    & PRACTICAL CONSIDERATIONS

    3
    5

    Venous access
    Replacement fluid
    Normal/abnormal constituents removed
    Anticoagulation
    Patient history and medications
    Frequency and number of procedures
    Complications

    VENOUS ACCESS
    Require large bore venous catheters to sustain the flow rates
    required (50-100 ml/min)
    Type of catheters: 17 gauge
    Location:
    Peripheral: antecubital fossa
    central: femoral/subclavian/jugular
    Arteriovenous shunt/fistula
    Number of lines: continuous flow devices : separate lines

    3
    6

    REPLACEMENT FLUID
    Must be FDA approved to use with blood products [ get mixed
    with RBC before the return phase]
    Replacement solutions:
    Crystalloidsnormal saline 0.9%
    Colloids5% albumin; plasma

    Function of the replacement fluid is to


    maintain intravascular volume (primary)
    restoration of important plasma proteins
    maintenance of colloid osmotic pressure
    maintenance of electrolyte balance
    3
    7

    REPLACEMENT FLUID
    TTP/HUS

    FFP
    Cryodepleted FFP
    Mixtures : Albumin /FFP
    Albumin /FFP

    Neurological
    GBS, MG, Stiff-man CIDP

    5% Human Albumin
    Albumin/Saline (70% /30%)

    Renal
    (RPGN, FSGS)

    5% Human Albumin
    Albumin/Saline (70% /30%)

    Post Transplant

    5% Human Albumin
    Albumin/Saline (70% /30%)
    Consider adding FFP at the end if post op

    3
    8

    COMPARISON OF REPLACEMENT FLUIDS


    Replacement fluid

    Advantage

    disadvantage

    Crystalloid

    Low cost
    Hypoallergenic
    No infectious risk

    Hypo-oncotic
    No coagulation factors
    No immunoglobulins
    2-3 volumes required

    Albumin

    Iso-oncotic
    No infectious risk

    Higher cost
    No coagulation factors
    No immunoglobulins

    Plasma

    Immunoglobulins
    Coagulation factors
    Iso-oncotic

    Infectious risk
    Citrate
    Allergic reactions
    ABO compatibility

    3
    9

    REPLACEMENT FLUID AND BALANCE


    3 choices of fluid balance (FB):
    100% FB isovolemic volume replaced=volume removed
    <100% FB hypovolemic (dry) -volume replaced <
    volume removed
    >100% FB hypervolemic (wet) -volume replaced >
    volume removed

    4
    0

    NORMAL/ABNORMAL CONSTITUENTS
    REMOVED TPE
    TPE:
    One volume exchange removes about 63%-65% of most plasma
    constituents
    A single two-volume exchange removes about 86% of plasma
    constituents
    Increasing the volume beyond 1-1 .5 volumes has very little
    impact on removal of plasma constituents

    4
    1

    VOLUME OF PATIENT PLASMA


    EXCHANGED (PEX)
    Little advantage beyond 1 .0-1 .5 volumes
    1 pv = 63%
    2 pv = 86%
    3 pv = 95%

    Removal of IgG and IgM by plasma exchange:


    Measure
    IgG
    IgM
    Intravascular amount
    45%
    76%
    total body removal

    1 .0 PEX vol.
    28%
    48%

    1 .5 PEX vol.
    35%
    59%

    2.0 PEX vol.


    39%
    65%

    4
    2

    ANTICOAGULATION
    Anticoagulation citrate
    Dextrose (ACD):
    Found in human cells, plant
    cells, and citrus fruits
    Chelates positively charged
    calcium ions (ionized
    calcium) and blocks calciumdependent clotting factor
    reactions
    Works extracorporeally
    Metabolized in the liver
    almost immediately upon
    return
    Side ef fects: hypocalcemia.
    small pts, large vol. of citrated
    blood, liver dysfunction

    4
    3

    Heparin:
    Prevents conversion of
    fibrinogen to fibrin and
    prothrombin to thrombin
    Systemic anticoagulation
    Metabolized slowly 1 -2 hours
    Individual sensitivity and
    elimination rates

    PATIENT HISTORY AND MEDICATIONS


    Does patient have a disease which is amenable to treatment
    by the requested apheresis procedure
    Does the patient/donor capable of sustaining the fluid shif ts
    associated with apheresis
    Certain medications, most notably antibiotics and
    anticoagulant can be removed by apheresis -should be given
    immediately af ter the procedure
    Angiotensin-converting enzymes (ACE) inhibitors

    4
    4

    FREQUENCY AND NUMBER OF


    PROCEDURES
    Depends on: Disease being treated, Patient signs and
    symptoms, Lab values
    Substance

    Volume Treated
    (ml/kg)

    Treatment Interval
    (hours)

    Number of
    Treatment

    Autoantibodies

    40-60

    24-48

    4-6

    Immune
    complexes

    40-60

    24-48

    Treat to response

    Paraproteins

    40-60

    24

    Treat to response

    Cryproteins

    40-60

    24-48

    Treat to response

    Toxins

    40-60

    24-71

    Treat to response

    TTP/HUS

    40

    24

    To remission

    4
    5

    TPE SUCCESS FACTORS AND


    FREQUENCY
    Extravascular space

    Plasma

    Capillary

    The success of a TPE


    procedure is dependent
    on the:
    Distribution of disease
    mediator
    Volume of plasma
    removed

    COMPLICATIONS
    Hypotension
    Vasovagal syncope
    Hypocalcaemia
    Allergic reaction
    Other side effects
    Vascular access: hematoma, phlebitis, infection
    Air embolism
    Loss of blood components: bleeding
    Thrombocytopenia (30% decrease)
    Hypofibrinogenemia (50% decrease)

    INDICATIONS FOR TA

    J CLIN APHERESIS

    J CLIN APHERESIS

    J CLIN APHERESIS

    Thank you

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