Apheresis

Apheresis

1. APHERESIS SUNIL KUMAR.P Department of Clinical pathology St.John’s Medical College Bangalore 10/13/2018 1 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

2. Derived from Greek, “to carry away ” • Hemapheresis is the removal of whole blood from donor/patient, separation into components, retaining the desired/unwanted component and return of remaining constituents to the donor/patient. 10/13/2018 2 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

3. INDICATIONS OF HAEMAPHERESIS To collect the components for transfusion purposes Platelets - Plateletpheresis Leucocytes - Leucapheresis Plasma - Plasmapheresis Peripheral blood stem cells To remove pathological component Therapeutic Apheresis 10/13/2018 3 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

4. Donation Criteria Donors for apheresis procedure must meet the criteria applicable as the donors for normal donation. ABO and Rh typing, Testing for transfusion and transmitted diseases Antibody screening A drug history should be obtained; donors who have taken aspirin or aspirin containing medications within 3 days of donation should be temporarily deferred 10/13/2018 4 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

5. Donation Interval The interval between platelet donations should be at least 72 hours , with no more than two donations in a week,4 times in a month and 25 donations in a year. Platelet count should be more than 1.5 lakhs Plasmapheresis donors may donate as often as every 48 hours but not more than twice in a 7-day period. Serum protein concentration should be more than 6 gm/dl. Written informed consent must be obtained from the donor & patient 10/13/2018 5 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

6. Methodology Manual Method Apheresis Machines 1 . Centrifugation (specific gravity) Intermittent flow IFC Continous flow CFC Immunoadsorption Apheresis by membrane filteration 10/13/2018 6 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

7. MANUAL METHOD Blood collected into plastic bag which containing anticoagulant preservative solution Bag centrifuged to get desired component, which is separated into a satellite bag Remainder is infused through the same vein. Process is repeated 10/13/2018 7 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

8. DISADVANTAGES The amount of components harvested is less than the automated machines. Time consuming. Volume of blood taken out from the body is more. 10/13/2018 8 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

9. APHERESIS MACHINES The machines are broadly of two types Intermittent flow centrifugation(IFC) Haemonetic Model S-30,V-50,MCS Dideco Progress Continous flow centrifugation(CFC) Cobe Spectra Dideco Viva Fresenuis 10/13/2018 9 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

10. SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE 10/13/2018 10

11. SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE 10/13/2018 11

12. Apheresis - Mechanism of Action • Large-bore intravenous catheter connected to a spinning centrifuge bowl •Whole blood is drawn from donor/patient into the centrifuge bowl •The more dense elements, namely the red cells, settle to the bottom with less dense elements such as white cells and platelets overlying the red cell layer and finally, plasma at the very top. 10/13/2018 12 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

13. INTERMITTENT FLOW CENTRIFUGATION Require the use of a disposable unit consist of sterile tubings and a bowl. Blood is drawn from an individual and mixed with the anticoagulant with the help of a pump and pumbed into centrifuge bowl through inlet port The blood gets separated in bowl into various components by differential centrifugation. 10/13/2018 13 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

14. The separated components flow from the bowl through outlet port, with the desired component being harvested into a separate collection bag. The centrifuge stops and pump gets reversed This completes one cycle . 10/13/2018 14 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

15. Haemonetics centrifuge bowl. IFC Procedure. 10/13/2018 15 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

16. ADVANTAGE Single venous access. DISADVANTAGE Time taken is more. Extracorporeal volume is more. 10/13/2018 16 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

17. CONTINOUS FLOW CENTRIFUGATION Blood is withdrawn from an individual with the assistance of a pump, mixed with the anticoagulant Blood is collected in a chamber/belt Separation of the components is achieved through centrifugation Desired component is diverted into a collection bag and remainder is reinfused into individual through second venous access. 10/13/2018 17 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

18. ADVANTAGES Time required is less Less extracorporeal volume DISADVANTAGES Two access required. 10/13/2018 18 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

19. PLATELETPHERESIS Removal of platelet from donor and return of red cell, white cell and plasma Routine procedure takes 90 min-2 hours Stored for 5 days on platelet agitator at 22 degrees. INDICATIONS Thrombocytopenia Aplastic Anemia Bone marrow Transplant. 10/13/2018 19 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

20. LEUCAPHERESIS Removal of leucocytes with return of red cells, platelets and plasma. Required for treating sepsis. Granulocyte concentrate must contain minimum of 1x10 10 granulocytes . Shelf life is 24 hours. Granulocyte collection yield by apheresis procedure can be increased by Giving steroids Addition of red cell aggregating agents Eg.HES 10/13/2018 20 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

21. CORTICOSTEROIDS Corticosteroids are believed to increase the vascular pool of granulocyte by stimulation o bone marrow to increase cellular output to blood. Eg ., Dexamethasone, prednisolone 10/13/2018 21 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

22. NEOCYTAPHERESIS PRINCIPLE OF SEPARATION Young, larger and less dense red cells are expressed earlier than older cells. In patients requiring repeated transfusions The administration of relative young cells will improve management by Decreasing frequency of transfusion Decrease the rate of iron loading. Expensive, time consuming. 10/13/2018 22 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

23. PLASMAPHERESIS/PLASMA EXCHANGE It is the procedure in which the whole blood is withdrawn from donor/patient, anticoagulated and separated into components with return of separated cellular components to donor/patient If relatively small volume of plasma are removed and replaced by saline, the term Plasmapheresis is used. If more plasma is moved, it become necessary to infuse plasma or plasma protein fraction to replace the lost plasma proteins, this is called Plasma Exchange 10/13/2018 23 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

24. INDICATIONS FOR PLASMAPHERESIS Removal of antibodies Allo antibodies HDN Anti Rh antibodies in pregnant women Neonatal thrombocytopenia Auto antibodies Myasthenia gravis Acute polyneuritis Removal of immune complexes SLE RA 10/13/2018 24 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

25. Hyper viscosity syndrome Multiple Myeloma Waldenstorm’s Macroglobulinemia Removal of toxins Hepatic failure Renal failure Replacement of deficient plasma component TTP HUS 10/13/2018 25 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

26. APPLICATION OF PLASMAPHERESIS Plasmapheresis of normal donors for preparation of plasma fraction Therapeutic plasmapheresis - to remove some particular constituent from patients plasma REPLACEMENT FLUIDS FOR PLASMA EXCHANGE Crystalloid Albumin Plasma protein fraction (PPF) FFP 10/13/2018 26 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

27. COMPLICATIONS OF PLASMA EXCHANGE Reactions to replacement fluids Vaso - Vagal reactions Pyrogenic reactions Hypothermia Hypocalcemia Thrombocytopenia Anaemia Hypogammaglobulinemia 10/13/2018 27 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

28. THERAPEUTIC LEUKAPHERESIS Has been tried in patients of CML, but general opinion is that apheresis is ineffective probably due to rapid production rate of cells in comparison to the number of cells removed through apheresis . Leukapheresis is most effective in Chronic lymphosarcoma cell leukemia Prolymphocytic leukemia Hairy cell leukemia Eosinophilic syndrome Sezary cell syndrome 10/13/2018 28 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

29. HAEMATOPOEITIC STEM CELL Two types Autologous Allogenic Donor or patient treatment with growth factor to mobilise peripheral blood stem cells CD 34 cell count done on product to ensure good quality product 10/13/2018 29 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

30. THERAPEUTIC THROMBOPHERESIS Done in cases with essential thrombocythemia RED CELL PHERESIS Done in patients with sickle cell disease especially during sickle cell crisis Severe parasitic load 10/13/2018 30 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

31. ADVANTAGES OF APHERESIS Less HLA sensitization. Less chances of TTD. More effective than usual component donation. 10/13/2018 31 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

32. ADVERSE EFFECT OF APHERESIS IN DONORS Citrate toxicity Donor may feel numbness or tingling sensation around the mouth. Problem solved by Giving exogenous calcium Decreasing the rate of infusion of returned component Adverse effect of HES may occur Febrile allergic rections Head ache, Mild hypertension Oedema of extrimities 10/13/2018 32 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE

33. COMPLICATIONS Hypocalcemia Air embolism Hypo fibrinogenemia Hypotension Vaso vagal reactions Haematoma , infection in the site of venous access Allergic reactions 10/13/2018 33 SUIL KUMAR P . ST.JOHN'S MEDICAL COLLEGE , BANGALORE