Apheresis

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Apheresis

Apheresis (ἀφαίρεσις (aphairesis, "a taking away")) is a medical


Apheresis
technology in which the blood of a person is passed through an apparatus
that separates out one particular constituent and returns the remainder to
the circulation. It is thus anextracorporeal therapy.

Contents
Method
Continuous flow centrifugation
Intermittent flow centrifugation
Centrifugation variables
Types
Donation
Therapy
Evidence-based guidelines for therapeutic apheresis
Fluid replacement during apheresis Whole blood enters the centrifuge (1) and
See also separates into plasma (2), leukocytes (3),
References and erythrocytes (4). Selected components
External links are then drawn off (5).
MeSH D016238

Method
Depending on the substance that is being removed, different processes are employed in apheresis. If separation by density is required,
centrifugation is the most common method. Other methods involve absorption onto beads coated with an absorbent material and
filtration.

The centrifugation method can be divided into two basic categories:

Continuous flow centrifugation


Continuous flow centrifugation (CFC) historically required twovenipunctures as the "continuous" means the blood is collected, spun,
and returned simultaneously. Newer systems can use a single venipuncture. The main advantage of this system is the low
extracorporeal volume (calculated by volume of the apheresis chamber, the donor's hematocrit, and total blood volume of the donor)
used in the procedure, which may be advantageous in the elderly and for children.

Intermittent flow centrifugation


Intermittent flow centrifugation works in cycles, taking blood, spinning/processing it and then giving back the unused parts to the
donor in a bolus. The main advantage is a single venipuncture site. To stop the blood from coagulating, anticoagulant is automatically
mixed with the blood as it is pumped from the body into the apheresis machine.

Centrifugation variables
The centrifugation process itself has four variables that can be controlled to selectively remove desired components. The first is spin
speed and bowl diameter, the second is "sit time" in centrifuge, the third is solutes added, and the fourth is not as easily controllable:
plasma volume and cellular content of the donor. The end product in most cases is the classic sedimented blood sample with the
RBC's at the bottom, the buffy coat of platelets and WBC's (lymphocytes/granulocytes, PMN's, basophils, eosinophils/monocytes) in
the middle and the plasma on top.

Types
There are numerous types of
apheresis.

Donation
Blood taken from a healthy donor
can be separated into its
component parts during blood
donation, where the needed
Disinfect, insert the cannula, pull out the cannula, dress the wound. The blue
component is collected and the pressure cuff is controlled by the platelet apheresis machine in newer models.
"unused" components are returned
to the donor. Fluid replacement is
usually not needed in this type of collection. There are lar
ge categories of component collections:

Plasmapheresis – blood plasma. Plasmapheresis is useful in collecting FFP (fresh frozen plasma) of a particular
ABO group. Commercial uses aside from FFP for this procedure include immunoglobulin products, plasma
derivatives, and collection of rare WBC and RBC antibodies.
Erythrocytapheresis – red blood cells. Erythrocytapheresis is the separation oferythrocytes from whole blood. It is
most commonly accomplished using the method of centrifugal sedimentation. This process is used for red blood cell
diseases such as sickle cell crises or severe malaria. The automated red blood cell collection procedure for donating
erythrocytes is referred to as 'Double Reds' or 'Double Red Cell Apheresis.' [1]

Plateletpheresis (thrombapheresis, thrombocytapheresis) –blood platelets. Plateletpheresis is the collection of


platelets by apheresis while returning the RBCs, WBCs, and component plasma. The yield is normally the equivalent
of between six and ten random platelet concentrates. Quality control demands the platelets from apheresis be equal
to or greater than 3.0 × 1011 in number and have a pH of equal to or greater than 6.2 in 90% of the products tested
and must be used within five days.
Leukapheresis – leukocytes (white blood cells). Leukopheresis is the removal ofPMNs, basophils, eosinophils for
transfusion into patients whose PMNs are inef fective or where traditional therapy has failed. There is limited data to
suggest the benefit of granulocyte infusion. The complications of this procedure are the dif ficulty in collection and
short shelf life (24 hours at 20 to 24 °C). Since the "buf
fy coat" layer sits directly atop the RBC layer , HES, a
sedimenting agent, is employed to improve yield while minimizing RBC collection. Quality control demands the
resultant concentrate be 1.0 × 1010 granulocytes in 75% of the units tested and that the product be irradiated to
avoid graft-versus-host disease (inactivate lymphocytes). Irradiation does not fect af PMN function. Since there is
usually a small amount of RBCs collected, ABO compatibility should be employed when feasible.
Stem cell harvesting – circulatingbone marrow cells are harvested to use inbone marrow transplantation.

Donor safety

Single use kits – Apheresis is done using single-use kits, so there is no risk of infection from blood-contaminated
tubing or centrifuge.
Immune system effects – "the immediate decreases in blood lymphocyte counts and serum immunoglobulin
concentrations are of slight to moderate degree and are without known adverse fects.ef Less information is available
regarding long-term alterations of the immune system"[2]

Kit problems
Two apheresis kit recalls were:
Baxter Healthcare Corporation (2005), in which "pinhole leaks were observed at the two-omega end of the umbilicus
(multilumen tubing), causing a blood leak."[3]
Fenwal Incorporated (2007), in which there were "two instances where the anticoagulant citrate dextrose (ACD) and
saline lines were reversed in the assembly process. The reversed line connections may not be visually apparent in
, including death, to the donor."[4]
the monitor box, and could result in excessive ACD infusion and severe injury

Plasticizer exposure
Apheresis uses plastics and tubing, which come into contact with the blood. The plastics are made of PVC in addition to additives
such as a plasticizer, often DEHP. DEHP leaches from the plastic into the blood, and people have begun to study the possible effects
of this leached DEHP on donors as well as transfusion recipients.

"current risk or preventive limit values for DEHP such as the RfD of the US EP A (20 μg/kg/day) and the TDI of the
European Union (20–48 μg/kg/day) can be exceeded on the day of the plateletpheresis. . . . Especially women in
their reproductive age need to be protected from DEHP exposures exceeding the above mentioned preventive limit
values."[5]
"Commercial plateletpheresis disposables release considerable amounts of DEHP during the apheresis procedure,
but the total dose of DEHP retained by the donor is within the normal range of DEHP exposure of the general
population."[6]
The Baxter company manufactured blood bags withoutDEHP, but there was little demand for the product in the
marketplace[7]
"Mean DEHP doses for both plateletpheresis techniques (18.1 and 32.3 μg/kg/day) were close to or exceeded the
reference dose (RfD) of the US EPA and tolerable daily intake (TDI) value of the EU on the day of the apheresis.
Therefore, margins of safety might be insufficient to protect especially young men and women in their reproductive
age from effects on reproductivity. At present, discontinuous-flow devices should be preferred to avert conceivable
health risks from plateletpheresis donors. Strategies to avoid DEHP exposure of donors during apheresis need to be
developed."[8]

Therapy
The various apheresis techniques
may be used whenever the
removed constituent is causing
severe symptoms of disease.
Generally, apheresis has to be
performed fairly often, and is an
The assembly (A-D), operation (E) and disassembly (F) of the platelet apheresis
invasive process. It is therefore
machine which can be configured to separate other components as well.
only employed if other means to
control a particular disease have
failed, or the symptoms are of such a nature that waiting for medication to become effective would cause suffering or risk of
complications.

Plasma exchange – removal of the liquid portion of blood to remove harmful substances. The plasma is replaced
with a replacement solution.
LDL apheresis – removal of low density lipoprotein in patients with familial hypercholesterolemia.
Photopheresis – used to treat graft-versus-host disease, cutaneous T-cell lymphoma, and rejection in heart
transplantation.
Immunoadsorbtion with Staphylococcal protein A-agarose column – removal of allo- and autoantibodies (in
autoimmune diseases, transplant rejection, hemophilia) by directing plasma through protein A-agarose columns.
Protein A is a cell wall component produced by several strains of Staphylococcus aureus which binds to the Fc
region of IgG.
Leukocytapheresis – removal of malignant white blood cells in people with leukemia and very high white blood cell
counts causing symptoms.
Erythrocytapheresis – removal of erythrocytes (red blood cells) in people withiron overload as a result of Hereditary
haemochromatosis or transfusional iron overload
Thrombocytapheresis – removal of platelets in people with symptoms from extreme elevations in platelet count such
as those with essential thrombocythemiaor polycythemia vera.
Evidence-based guidelines for therapeutic apheresis
In 2010, the American Society for Apheresis published the 5th Special Edition(1)[9] of evidence based guidelines for the practice of
Apheresis Medicine. These guidelines are based upon a systematic review of available scientific literature. Clinical utility for a given
disease is denoted by assignment of an ASFA Category (I – IV). The quality and strength of evidence are denoted by standard
GRADE recommendations. ASFA Categories are definedas follows:

Category I for disorders where therapeutic apheresis is accepted as a first line treatment,
Category II for disorders where therapeutic apheresis is accepted as a second-line treatment,
Category III for disorders where the optimal role of therapeutic apheresis is not clearly established and
Category IV for disorders where therapeutic apheresis is considered ineffective or harmful.

Fluid replacement during apheresis


When an apheresis system is used for therapy, the system is removing relatively small amounts of fluid (not more than 10.5 mL/kg
body weight). That fluid must be replaced to keep correct intravascular volume. The fluid replaced is different at different
institutions. If a crystalloid like normal saline (NS) is used, the infusion amount should be triple what is removed as the 3:1 ratio of
normal saline for plasma is needed to keep up oncotic pressure. Some institutions use normal serum albumin, but it is costly and can
be difficult to find. Some advocate using fresh frozen plasma (FFP) or a similar blood product, but there are dangers including citrate
toxicity (from the anticoagulant),ABO incompatibility, infection, and cellular antigens.

See also
Leukoreduction
Plasmapheresis
Venipuncture

References
1. dtm double red cell (http://www.cc.nih.gov/dtm/dtm_double_red_cell.htm) Archived (https://web.archive.org/web/200
70705090407/http://www.cc.nih.gov/dtm/dtm_double_red_cell.htm) July 5, 2007, at the Wayback Machine.
2. Strauss, Ronald G. (1984). "Apheresis donor safety – changes in humoral and cellular immunity".
Journal of Clinical
Apheresis. 2 (1): 68–80. doi:10.1002/jca.2920020112(https://doi.org/10.1002%2Fjca.2920020112). PMID 6536660
(https://www.ncbi.nlm.nih.gov/pubmed/6536660).
3. "Archived copy"
(https://web.archive.org/web/20090117033956/http://www .fda.gov/cber/recalls/baxaphe013105.htm). Archived from
the original (http://www.fda.gov/CbER/recalls/baxaphe013105.htm) on 2009-01-17. Retrieved 2008-12-20. "Recall of
Amicus Apheresis Kits, Baxter Healthcare Corporation", US FDA, Jan 31 2005
4. "Recall of CS3000 Apheresis Kits", US Food and Drug Administration, June 21, 2007
(http://www.fda.gov/BiologicsBl
oodVaccines/SafetyAvailability/Recalls/ucm053390.htm)
5. Koch, Holger M.; Bolt, Hermann M.; Preuss, Ralf; Eckstein, Reinhold; Weisbach, Volker; Angerer, Jürgen (2005).
"Intravenous exposure to di(2-ethylhexyl)phthalate (DEHP): Metabolites of DEHP in urine after a voluntary platelet
donation". Archives of Toxicology. 79 (12): 689–93. doi:10.1007/s00204-005-0004-x(https://doi.org/10.1007%2Fs00
204-005-0004-x). PMID 16059725 (https://www.ncbi.nlm.nih.gov/pubmed/16059725).
6. Buchta, Christoph; Bittner, Claudia; Höcker, Paul; Macher, Maria; Schmid, Rainer; Seger, Christoph; Dettke, Markus
(2003). "Donor exposure to the plasticizer di(2-ethylhexyl)phthalate during plateletpheresis".
Transfusion. 43 (8):
1115–20. doi:10.1046/j.1537-2995.2003.00479.x(https://doi.org/10.1046%2Fj.1537-2995.2003.00479.x) .
PMID 12869118 (https://www.ncbi.nlm.nih.gov/pubmed/12869118).
7. "SO FAR, PHTHALATE ALTERNATIVES HAVEN'T INSPIRED MUCH DEMAND"(http://www.highbeam.com/doc/1G
1-56958320.html), Plastics News, October 25, 1999, T
oloken, Steve
8. Koch, Holger M.; Angerer, Jürgen; Drexler, Hans; Eckstein, Reinhold; Weisbach, Volker (2005). "Di(2-
ethylhexyl)phthalate (DEHP) exposure of voluntary plasma and platelet donors".International Journal of Hygiene
and Environmental Health. 208 (6): 489–98. doi:10.1016/j.ijheh.2005.07.001(https://doi.org/10.1016%2Fj.ijheh.200
5.07.001). PMID 16325559 (https://www.ncbi.nlm.nih.gov/pubmed/16325559).
9. Szczepiorkowski, Zbigniew M.; Winters, Jeffrey L.; Bandarenko, Nicholas; Kim, Haewon C.; Linenberger , Michael L.;
Marques, Marisa B.; Sarode, Ravindra; Schwartz, Joseph; et al. (2010). "Guidelines on the use of therapeutic
apheresis in clinical practice-Evidence-based approach from the apheresis applications committee of the American
Society for Apheresis".Journal of Clinical Apheresis. 25 (3): 83–177. doi:10.1002/jca.20240 (https://doi.org/10.100
2%2Fjca.20240). PMID 20568098 (https://www.ncbi.nlm.nih.gov/pubmed/20568098).

External links
NIH
American Society for Apheresis
Apheresis in Blood Platelet Donation
WebPath Apheresis page.
WebPath Blood Donation and Processing
Donating Platelet Apheresis: Facts and the F
AQ

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