Apheresis

 Greek work meaning “take out”

 The process of removal of whole blood from a
donor or patient, separating out specific portions,
and returning the other portions to the
donor/patient
 Can be done for
. Donor apheresis

 Harvesting specific components for transfusion

(plasma, platelet, red cells) .
Therapeutic apheresis
 Removal of specific pathologic substances
 Cytapheresis
 To harvest specific cellular components such as
platelets, granulocytes or red cells.
 Plasmapheresis
 To harvest plasma only and return back the
cellular components to the donor/patient
 Therapeutic Plasma Exchange
 Therapeutic Apheresis

 . Therapeutic Apheresis is an Umbrella term

covering multiple procedures in three
categories:

 . Removing a blood component

 . Removing and replacing a component
 . Blood component alteration
 Donor Apheresis

. Platelets
. Plasma
. Red blood cells
. Red blood cells and plasma
. Granulocytes
. Allogeneic progenitor cells
Sedimented blood sample

100 –
90 –
80 – Plasma
Plasma
70 – Areas of
Platelets predominance
60 –
WBC Lymphocytes predominance
50 –
Leukocytes Platelet Rich layer Monocyte predominance
40 –
Granulocyte predominance
30 – Neocytes
Erythrocytes
20 – Erythrocytes

10 –
 Principle of apheresis

Anticoagulant Remaining blood

added components recombined
and returned

Plasma
Platelets
Whole blood Lymphocytes Whole blood
Granulocytes
(vein) (vein)
Erythrocytes

Blood components separated by centrifugation

and selectively removed
 Apheresis techniques
 Centrifugation
Intermittent-flow centrifugation (IFC)
Continuous-flow centrifugation (CFC)
 Photopheresis
 Membrane filtration
Hollow-fibre filter with Pore diameter: 0.2 to 0.6 um
Double-lumen vein catheter / AV-fistula
Continuous-flow 50-200 ml/min
Plasma removal 20-50 ml/min
 Immunoadsorption
 Membrane Separation:
Key Parameters

 Trans-membrane Pressure
. Difference between the pressures at both sides of the membrane
(blood/plasma).
. Usually must be kept below 50 mmHg to avoid RBC hemolysisand/or pore
blocking.

Hematocrit
. As blood is flowing along the fiber, plasma is being continuously removed
and the HCT increases.
. Plasma removal must be limited to avoid exceeding a critical HCT and
blood viscosity that could cause membrane blocking.

Shear Rate
. Flow below which blood cells adhere to the membrane
. Blood flows need to be faster the shear rate to avoid blocking of the pores.
 Centrifugal Separation

.Based on the different specific gravity of the

blood components.

. In some instruments, also based on the cellular size

(Elutriation).

. All apheresis devices need to be able to control the

Separation Factor.
 Separation Factor (SF)

.Is a combination of centrifugal

acceleration (g)
and centrifugation time (dwelling time)
. Or also
. The “centrifugal experience” that
determines the
degree of cell separation and sedimentation
. A.K.A. Packing Factor (same concept,
different components)
Separation factor
Sedimentation Velocity: Stoke’s
Law

 Sv = 2 w2 R r2 (r-ro)9µ
Cellular Sv is proportional to:
 Centrifugal Acceleration (w2 R ) or g
 Square of the radius (r) of the cell
 Difference between plasma and cell
densities (r-ro)
 Inverse of fluid viscosity (µ)
 Centrifugal Separation

 . Is a function of Sv and time.

In other words, depends on:
 . The inlet flow, which determines the dwelling
time.
 . Design of the separation chamber, mostly the
 centrifugation radius (R).
 . Angular speed of the centrifuge or RPM (ω)
 . Plasma viscosity (μ)
 . Cellular density and size, (ρ) y (r).
Intermittent-flow centrifugation
 Procedures are performed in cycles
 More extracorporeal volume
 Smaller and more mobile
 One-arm procedure
 Longer time

PB/BN/MME
 Continuous-flow centrifugation
 Withdraw, process and return blood
simultaneously
 Two venipuncture sites
 Less extracorporeal volume
 Less time required
Cell Separators
 Types of Apheresis
 Donor apheresis
Erythrocytes
Platelets
Plasma
Progenitor (stem) cells
 Therapeutic apheresis
Plasma exchange (TPE)
 Cytaphersis
Erythrocytapheresis
Leucapheresis
Thrombocytapheresis
Extracorporeal photopheresis
 Donor Criteria
 Criteria for whole blood donation
 Adequately trained operator
 A physician familiar with all aspects of apheresis must be
available during the procedure
 Routine premedication of the donors to increase the
component yield is not recommended
 Volume of extracorporeal blood ≤15% of the donor’s
estimated blood volume
 History of thrombosis, Protein C or S deficiency, factor V
Leiden
 Plasmapheresis
 Not more than 500ml per procedure in the
absence of volume replacement

 Not more than once in two weeks (15 days)

 Not more than 12 litres (1000ml / mth) per year

 Protein analysis annually; total protein not less

than 60 g/l
 Donor Criteria
 Thrombocytapheresis (Plateletpheresis)
 Platelet count ≥ 150 x 109/l (preferably >250 x 109/l)
 Usually not more than twice in a weeks
 48 hours must elapse between rwo procedures

 Red cell apheresis

 Interval between two single units is 3 months
 2 units red cell apheresis(2UD); HB ≥ 14 g/dl, Body
weight ≥ 70 Kg
 Interval between 2UD and WBD or another 2UD ≥ 6
months
 Interval between WBD and 2 UD ≥ 3 months
 Donor Criteria
 Total net volume of combined donation in one procedure
should not exceed 500 ml

 Interval between one

plasmapheresis/thrombocytapheresis and WBD/single RC
donation (combined or not with plasma and/or platelet
collection) ≥ 48 hours

 Interval between a WBD/single RC donation/failed return

of red cells during apheresis and next plasmapheresis
/throbocytapheresis ≥ 1 month
 Complications of Donor Apheresis
 Vascular effects; venous spasm, collapse,
hematoma, neuropathy
 Citrate toxicity; circumoral paraesthesia,
vibratory sensations, nausea, vomiting,
Diarrhoea, tetany
 Syncope, seizures, vasovagal effects
 Hemolysis
 Infections; sepsis, phlebitis,
 Chills
 Therapeutic Plasma Exchange
 Removal of antibodies
Alloantibodies: anti-HPA-1a, anti-D, anti-P, anti-HLA, anti A / B
Autoantibodies: anti-AchR, anti-GBM, platelet aab, myelin aab,
ANCAs

 Removal of immune complexes /

macromolecules
 Removal of monoclonal proteins
 Removal of excess plasma constituent
 Replacement of a specific plasma component
 Patient assessment
 Physical examination
 Diagnosis?
 Which Category?
 Cost bearing?
 Investigation-
CBC , Coagulation, Hct, Total proteins
Serum Calcium, Blood Group
 Category I - Indications
 Guillain-Barre Syndrome
 Chronic inflammatory demyelinating
polyneuropathy
 Myasthenia Gravis
 Homozygous familial hypercholesterolemia
Heterozygous refractory to medicines
 Goodpasture syndrome
 Thrombotic thrombocytopenic purpura
 Post-transfusion Purpura
 Phytanic acid storage disease
 Category II - Indications
 Cryoglobulinemia
 Hyperviscosity syndrome (Waldenstrøm)
 Rapidly progressive glomerulonephritis (ANCA-
Pos)
 Coagulation factors inhibitors (factor VIII)
 Myelomatosis with renal involvement
 Idiopathic thrombocytopenic purpura
 Acute vascular rejection after heart transplant
 Reumatoid Arthritis
 ABO-mismatched marrow transplant (recipient)
 TPE; Indications category III
 Hemolytic uremic syndrome
 Recurrent focal glomerulosclerosis
 Heart transplant rejection
 Acute hepatic failure
 Raynaud’s phenomenon
 Vasculitis
 Scleroderma
 SLE
 HDN
 Platelet alloimmunization and refractoriness
 Multiple sclerosis
 Paraneoplastic neurologic syndrome
 TPE; Indications category IV
 AIDS
 Amyotrophic lateral sclerosis
 Systemic amyloidosis
 Acute rejection of renal transplant
 Psoriasis
 Schizophrenia
 Lupus nephritis
 Vascular access
Peripheral vein, Catheter, AV fistulae
 Anticoagulants
Citrate; 0.8 mL/min/L TBV
Heparin

 Priming
0.9 % saline
Blood (ECV:≥10%, anemic & hemodynamically unstable patients)
 Replacement fluid
4% albumin
FFP
Combination (0.9% saline, 4% albumin, plasma)
 Complications of TPE
 Vascular access complications
 Fall in Plasma protein levels
(Ig, C3, ALP, SGOT)
 Coagulation factors
(Antithrombin III)
 Citrate toxicity
 Allergic reaction
 Fall in blood pressure
 Increased risk for infections
 TRALI
 Mortality?
 Citrate Toxicity
 Metabolism in mitochondria (Liver, Kidney, muscle)
 Ca++

Normal value; Ca++: 1.05 to 1.3 mmol/L (total calcium: 2.25 to 2.75 mmol/L)

 Mg++ K+ pH HCO3
 Causes
Citrate given too quickly
Citrate given faster than it can be metabolised
Citrate accumulation due to duration of the procedure
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