Apheresis Joshua Daniel NEW

8/2/2019 Apheresis Joshua Daniel NEW

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1. Removal of whole blood from a donor or a patient

2. Separation into blood components

3. Retention of desired component

4. Return of the remaining elements to the donor or patient

5. Can be used to collect a component intended fortransfusion or remove a pathologic component


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Centrifugation

Types of separation

Membrane Filtration

Continuous Process

Types of Machines

Intermittent Process


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Inlet Pump Plasma Pump

Desired

component

Return to Patient

ACD


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Plasma

Packedred cells

Buffycoat

Granulocytes1.085*

Monocytes1.065*

Lymphocytes1.071*

Platelets1.048*


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APHERESIS

DONORAPHERESIS

THERAPUTICPLASMA

EXCHANGE


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Red cell pheresis

Plateletpheresis

Plasmapheresis

Granulocytopheresis

Stem cell pheresis


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Collecting only packed red cells from the donor

Up to 2 units of red cells can be collected from a

single donor

Interval between 2 units donation is 6 months

Desired Hb% 14 gms, weight > 60 Kgs

Useful in corporate setups where finding donors isdifficult


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Plateletpheresis is the process of collecting onlyplatelets

Random donor Platelets > 5.5 x 1010

plateletsin 50 - 70 ml of plasma

Single Donor platelet 3 x 1011 platelets in

~300 ml of plasma


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High quality product with better post transfusion plateletincrements

Leuko-Reduced product

Reduced donor exposure therefore reduced TTIs and

Alloimmunization

Less time consuming and can be harvested from a singledonor

Donor can donate 2 times a week

Single unit transfusion increases post transfusion 30 40thousand


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Severe neutropenia (ANC


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Patients with bone marrow failure where neutrophilrecovery is not anticipated to recur spontaneously and

no further active treatment is planned

Sepsis in the absence of either neutropenia or knownneutrophil dysfunction

Pyrexia of unknown origin (PUO)


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Granulocytes are transfused daily untilthe patient's infection clears or until the

neutrophil count exceeds 500/l

Dosage: 1x 1010


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Process of harvesting circulating blood stem cellsto use in bone marrow transplantation.

Can also be collected and separated from thebone marrow

Stem cell marker is CD 34

Minimum dosage 2x106 per kg body weight of thepatient


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Aplastic anemia Sickle cell anemia, thalassemia

Fanconis anemia, Pure red cell aplasia

Congenital immune deficiency syndromes Glycogen and lipid storage disorders

PNH, Radiation injury

Leukemia's Lymphomas


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Erythrocytopheresis

Thrombocytopheresis

Leukopheresis

Plasmapheresis

o LDL Pheresis

o Immuno Adsorption

o Photopheresis


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RBC PlasmaWBC PLT

Sickle Cell Dis.

Malaria

Leukemias

Cell Therapies

Thrombocytosis

Guillain Barrie Synd.

Myasthenia Gravis

Good pastures Synd.Acute liver failure

Drugs overdose

Poisoning


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Extracorporeal blood purification techniquedesigned to remove large molecular weight

substances from the plasma.

Examples: pathogenic auto antibodies,immune complexes, cryoglobulins, myelomalight chains, endotoxin, and cholesterolcontaining lipoproteins.


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The substance to be removed should be

Sufficiently large(mol wt greater than 15,000)which cannot be easily removed by less expensivepurification techniques like hemofiltration or high-fluxhemodialysis.

Must have asufficiently long half-life, so thatextracorporeal removal is much more rapid thanendogenous clearance pathways.

Must be acutely toxic and resistant toconventional therapy, so that the rapid eliminationfrom the extracellular fluid by TPE is indicated.


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Plasma Volume Exchange Percent Removed

0 0%

0.5 39.3%

1.0 63.2%

1.5 77.7%

2.0 86.5%

2.5 91.8%

3.0 95.0%


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Category I: Standard acceptable first line therapy

Category II: Generally accepted in a supportive role

Category III: Not clearly indicated based oninsufficient evidence.

Category IV: Demonstrated to have a lack of efficacyClinical applications should be undertaken onlyunder an approved research protocol.


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Neurological:

Guillain Barre synd Myasthenia Gravis

CIDP Paraprotein associated

poly neuropathy

Hematological: TTP

Sickle cell crisis ABO mismatch Marrow

transplant

Others:

Cutaneous T cellLymphoma

Leukocytosis Thrombocytosis

Good pasteur synd Hypercholestrolemia

Phytanic acid storagedisease

Amanita phalloidespoisoning

Cryoglobinemia


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Neurological: Multiple sclerosis Eaton lambert synd Acute CNS inflamatory

demyelinating disease

Pediatric autoimmuneneropsychiatry disorder

Hematological: ITP

Maternal-fetal Rhincompatability Coagulation factors

inhibitors Hyperviscosity synd

Renal & Others:

RPGN

Acute renal failure dueto cast nephropathy Graves disease Digitalis toxicity

Pemphigus vulgaris Bullous pemphigoid Toxic epidermonecrolysis


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Neurological:

Stiff man syndrome

Multiple sclerosis

Paraneoplastic synd

Polymyositis

Hematological:

Posttransfusion

Purpura Aplastic anemia

Autoimmune

hemolytic anemia

Renal & others: Hepatic failure

Recurrent focalglomrulosclerosis

HUS

Renal transplantrejection

Heart transplantrejection

Drugs over dose

Poisoning


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Examples: AIDS, amyotrophic lateralsclerosis, lupus nephritis, psoriasis, renaltransplant rejection, schizophrenia,

rheumatoid arthritis


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Acute progressive paralyzing illness affecting both

motor and sensory peripheral nerves .Etiopathology: Ab to Basic Myelin protein whichcauses destruction of myelin (Demyelination).

Clinical features: Rapidly progressive symmetricalmuscle weakness, and paresthesias, respiratory andoropharyngeal muscles may involve in more severecases requiring mechanical ventilation

Autonomic dysfunction (BP & HR) seen in 25% ofpatients.

long-term neurologic deficits in 75%.

Mortality 5%.


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Most effective when initiated within 7 days of diseaseonset.

Can accelerate motor recovery, decrease time on theventilator, and speed attainment of other clinical

milestones.

Median time to wean from mechanical ventilation andthe time to walk without assistance are comparable or

sometimes better than IV IGPatients with axonal involvement reported greaterpotential benefit than IVIG


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Nerve

Muscle

Anti-AchRAbAcetylcholine (Ach)

AchR

Auto-Ab directed against the acetylcholine receptors

on the motor end plate prevents the normal functioningof the receptors by increasing the receptor turnover,blocking the binding of acetylcholine, and fixingcomplement with degradation of the receptor.


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1) Acetylcholine esterase inhibitors :Increases the amount

of acetycholine at the motor end plate eg., pyridostigmine,neostigmine

2) Immuno-suppressive medications : Decreases theantibody production eg., cortico-steroids or azathioprine.

3) IVIg give beneficial effects.

4)TPE: is specially useful during1) crisis and 2) Before

thymectomy for early recovery from surgery 3) Managementof severe disease refractory cases unresponsive toconventional therapy 4) Rapid resolution of clinical signs,5) Lower incidence of complications


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Causes: Hepatitis ( viral, autoimmune)Drug toxicity ( Acetaminophen)

Ingestion of hepatotoxins

Wilsons diseaseFulminant liver failure:

Mortality rate is 50 90 % caused by acute

metabolic disturbances, hepaticencephalopathy, severe coagulopathy


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Removes albumin bound and large mol.wt toxins like aromaticamino acids, endotoxins, indols, mercaptan , phenol

Most studies show improved cerebral & hepatic blood flow,mean arterial pressure, cerebral perfusion pressure andcerebral metabolic rate

Improves laboratory parameters cholinesterase activity &galactose activity

Restores coagulation factors and removes activated clottingfactors, tissue plasminogen activator, FDP

In some patients, liver regenerates during TPE


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Mushroom ( Amanita phyllode)

Paraquat

Anti digoxin antibodies

Vincristine

Eltroxin

Cysplatin.

Carbamazepine

Tricyclic anti-depressants

Methanol

Ethanol

Heavy metal ( mercury )

Verapamil

Diltiazem,


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Drug removal is most dependent on percentage ofprotein binding and volume of distribution. Drugs witha high percentage of protein binding and a relatively

modest volume of distribution will have the greatestlikelihood of being removed by TPE


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Not significantly removed:

Prednisolone

Minimal removal:Cyclophosphamide

AzathioprineAminoglycosidesTobramycinDigoxinVancomycin

Post treatment supplement needed:Phenytoin

Acetylsalicylic acidPropranololThyroxine


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THANK YOU

Apheresis Joshua Daniel NEW

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