Apheresis Procedures

Definition

From greek Apheresis, i.e. separation

of plasma through membran filter or

centrifuge

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Plasmapheresis
Preparative Plasmapheresis
Therapeutic Plasmapheresis

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Blood Cells

selective

Plasma Fractions

semi-selective

Conserved Plasma

non-selective

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Overview

Plasmapheresis

Preparative Plasmapheresis

Conserved Plasma

Plasma Fractions

Therapeutic Plasmapheresis

Blood cells

non-selective

semi-selective

selective

Plasma Protein Concentrate

Coagulation Factors

Leucocyte Concentrates

Therapeutic Plasma Exchange

Cascade Filtration

Enzym Adsorption (Bioreaction)

Fresh-frozen-Plasma (FFP)

Human Albumine

Erythrocyte Concentrate

Activated Charcoal Adsorption

Cryo Filtration

Immuno Adsorption

Thrombocyte Concentrate

Ion Exchange Adsorption

Immuno Adsorption

Phenylalanin

Tryptophan

Protein A

LDL-Apheresis

Heparin Prezipitation

Dextransulfat Adsorption

Immuno Adsorption

Thermo Filtration (?)

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Therapeutic Plasmapheresis
non-selective

semi-selective

Ion Exchange Adsorption

Activated charcoal Adsorption
Plasma Exchange

selective
Cascade Filtration

Enzym Adsorption (Bioreaction)

Cryo-Filtration

Immuno-Adsorption

Immuno-Adsorption

Protein A

Phenylalanin
Tryptophan

LDL-Apheresis
Heparin Prezipitation
Dextransulfat Adsorption
Immuno-Adsorption
Thermo-Filtration (?)

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Cryo-Filtration
Dextransulfat Adsorption
Cascade Filtration
Therapeutic Heparin Precipitation
Immuno-Adsorption
Plasma Exchange

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Membrane Filter Separation

Filtration Rate <1/3 of Blood Flow Rate
TMP <100 mmHg

Hemocompatibility
Sterilisation:
ETO
Steam
Gamma

Secondary Membrane

Pore Size 0.2-0.6 m

Surface 0.13-0.6 m

Material:
Polypropylen
Polysulfon
Cellulosediacetat

Cut-off 3 MioDa
Sieving Coefficient >0.8

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Thrombocytes 2-3.5 m

Albumine 69 kDa
IgG 150 kDa
IgA 160 kDa
IgM 900 kDa

Fibrinogen 340 kDa

LDL 2000-4500 kDa

0.02 m

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Membrane Pores 0.2-0.6 m

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Sieving Coefficient

Concentration ratio of a certain component in

parated plasma to the Concentration in plasma before seperation

Plasma Component
Total Protein
Albumine
IgG
IgA
IgM
Fibrinogen
Cholesterol

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Sieving Coefficient
0.9
0.95
0.9
0.85
0.8
0.95
0.8

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optimal plasma separation

1. plasma/blood flow 1/3
2. low TMP

3. high blood flow

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TPE - Therapeutic Plasma Exchange

Heater
PV

PPL

BLD

SAC

Heparin

V
V

PA

Plasma Filter

SAD

Advantages

Disadvantages

rel. simple technic

bride spectrum of
indication
rel. low
costs

non-selective
substitution
complications
no chronic
application

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Pl.

Balance

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Blood Access

Vessel Access
periferal vein
arterio-venous fistula
central-venous access

V. jugularis
interna
V.
subclavia
V.

cubitalis

V.
femoralis
Cimino Fistula

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Anticoagulation

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Coagulation Cascade
Defect

Injury

Tissue

Endothel
Exogen System

Endogen System
XII

XI

IX

XIIa

XIa

IXa
VIII
Ca (IV)
TF3

Tissue Factor (III) +

Ca2+ (IV) + VII

Citrate

2+

TF3
+

Thrombocytes
XIII

Thrombin

Xa + V + Ca2+
(IV)
Prothrombin (II)

Heparin

AT III
Fibrin Monmers

Fibrinogen (I)

XIIIa
Fibrin

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Substitution
Clinical
Requirement
isovolemic, isotonic, isooncotic
allergen and pyrogen free, sterile

containing coagulation
factors and
immunoglobulins

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Substitution
Remarcs

1. Plasma Expander

Dextrane, Hydroxyethylstarch (HES), Gelatine Preparation. Short

Half Life Time

2. Conserved Plasma
Protein
3. Fresh Frozen Plasma
(FFP)
4. Human Albumine
Solution

Contain Elytes, Albumine, Globulins. Expensive, Incompatibility

Reactions

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AB0-Compatibility,
Indikation for TTP und Goodpasture-Syndrom,

Allergic Reactions, Viral Infections, Hypocalcemia

Albumine +Hemofiltration Solutions with Lactate or Bicarbonate,
Low Rate of Side Effects

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Hemofiltration Solution
Na+
mmol/l

K+
mmol/l

Ca2+
mmol/l

Mg2+
mmol/l

Clmmol/l

Lactate
mmol/l

Glucose
g/l

Osmol.
mmol/l

135-150

0-4

1.6-2.0

0.50-0.75

100-113

35-45

0-2.0

285-312

Na+
mmol/l

K+
mmol/l

Ca2+
mmol/l

Mg2+
mmol/l

Clmmol/l

Bicarbon.
mmol/l

Glucose
g/l

Osmol.
mmol/l

140

0-4

1.5

0.5

109-113

35

1.0

290-300

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Human Albumine Electrolyte Solution

3%
3.5%
4%
4.5%
5%
5.5%
6%
Solution Solution Solution Solution Solution Solution Solution
HF-Solution (ml)

850

825

800

775

750

725

700

Human Albumine 20% (ml)

150

175

200

225

250

275

300

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Albumine Solution

HF Solution

Albumine

i.g. 2 Liters 4%-Solution = 400 ml Albumine 20% + 1600 ml HF Solution

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Exchange Volume

Plasma Volume - 2 PV
Ratio
1:1
Therapy Time 1 3 h
acute: 1x
day for 3 days lang, then every 2 days
Frequency
chronic: 1-4 monthly

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Dilution Kinetics

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Intracellular Space = 40%

Extracellular Space = 20%

Interstitial Space = 16%

Intravascular Space = 4%

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Distribution Volume

Plasma Component Molekular Weight

Dalton

Intrav. Distribution Half Life Time

%
Days

Normal value
g/l

Albumine

69 000

40

19

35-50

IgG

150 000

50

20-23

8-18

IgA

160 000

50

5-6

0.9-4.5

IgM

900 000

80

5-6

0.6-2.8

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Complications

technical

medical

Access Problems

Hypotension

Plasma Filter Clotting

Allergy

Blood Leak

Fever

Hemolysis

Hypocalcemia
Arrhythmia
Edema

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Indications

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Remind
1. Plasmapheresis is often a symptomatic
therapy
2. Plasmapheresis can cause a ReboundEffect by resynthesis and
redistribution of pathogens
3. Therefore plasmapheresis is regulary
accompanied by an immunosuppressive or cytostatic therapy

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Cascade Filtration
Heater
PV

PPL

BLD

Heparin

V
V

PA

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Cascade Filter

SAC

Plasma Filter

SAD

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Cascade Filtration

(DeadEnd-Procedure)

Heater
PV

PPL

BLD

Heparin

V
V

PA

Cascade Filter

SAC

Plasma Filter

SAD

Retinate Pump

Retinate Bag

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Cascade Filtration

(Recirculation-Procedure)

Heater
PV

PPL

BLD

Heparin

V
V

Cascade Filter

SAC

Plasma Filter

SAD

PA

Recirculation
Pump

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Thermofiltration
PV

PPL

BLD

SAC

PA

Cascade Filter

Heparin

Plasma Filter

SAD

Heater

Retinate Pump

Retinate Bag

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PAP Plasmaadsorption single

column
Heater
PV

PPL

BLD

Heparin

V
V

PA

Particle Filter

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Dr. M. Susca

Plasma Adsorber

SAC

Plasma Filter

SAD

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PAP Plasmaadsorption double

Heater
column
PV

PPL

Regeneration
Solution

BLD

SAC

Heparin

V
V

PA

Plasma Filter

SAD

Plasma
Adsorber

Particle Filter

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