Apheresis:

physiology & application

TEGUH TRIYONO
Dept. of Clinical Pathology
Faculty of Medicine, Gadjah Mada University
RSUP dr. Sardjito
Yogyakarta, Indonesia
 APHERESIS PROCEDURES

• Worldwide implemented nowadays.

• Most of Asian Countries also involved.
• The usage of this procedure varies
between countries.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 APHERESIS

§ Derived from Greek word “Phaeresis” which

means “taking away”

§ Apheresis constitutes a number of procedures in

which donor/patient blood is processed to
remove or manipulate a specific portion of blood.

§ The remaining blood is returned back to the

donor/patient

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 APHERESIS IS AIMED TO:

§ Collect a therapeutic dose of a particular

component e.g. Plateletpheresis

§ Therapeutically reduce the circulating amount of a

particularly harmful component e.g. TPE

§ Collect a particular blood cell/ precursor from a

patient for re-infusion e.g. PBSC Collections

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 SPECTRUM OF APHERESIS
Therapeutic Apheresis Component Donation
§ TPE
§ Platelet
§ Leukocytapheresis
§ Thrombocytapheresis § Red cell
§ Erythrocytapheresis § Plasma
§ RBC exchange
§ LDL apheresis
§ Adsorptive cytapheresis
§ Lymphocytapheresis Specific Procedure
§ ECP
§ PBSC Collection
§ Rheopheresis

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

APHERESIS EQUIPMENT

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
SEPARATION IN THE SYSTEM

Plasma
Trombocytes
Lymphocytes
Monocytes
} Granulocytes

Erytrocytes

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
CENTRIFUGE CHANNEL

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CENTRIFUGE CHANNEL AND ‘RPM’

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
METHODS OF APHERESIS

§ Conventional/ manual
§ Automatic/ Cell Separator Machines
§ Intermittent flow separation
§ Continuous flow separation

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

PRINCIPLE OF PROCEDURES
SEPARATION BY CENTRIFUGATION

§ Centrifugation
§ Separation based on
specific gravity
§ Continuous flow

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Separation based on specific
weight / size
Spec Weight (g/mL) Size (µm
• Plasma 1.026
• Platelets 1.040 1-4
• Lymphocytes 1.050-1.061 6-10
• Monocytes 1.077 10-30
• Granulocytes 1.080 -1.088 10-15
• Erytrocytes 1.093-1.100 6-8
 DONOR APHERESIS

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
 DONOR APHERESIS

§ Plasmapheresis
§ Cytaferese
- Trombocytapheresis
- Lymphocytapheresis
- Stemcelapheresis
- Monocytapheresis Cell therapy
- Granulocytapheresis
- Erytrocytapheresis
§ Multicomponent apheresis
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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
 PLATELET PHERESIS

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 n Plateletpheresis : collection of platelets
from a donor with return of donor RBCs

n Plateletpheresis is the most common

application of apheresis

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 2 TYPES OF PLATELET COMPONENTS :

§ random donor platelets or whole

blood derived platelets (RDP)
§ single donor platelets or apheresis
platelets (SDP)

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 PLATELETPHERESIS (SDP)

v 2 to 5 x 10e11 platelet yield

v 30% drop in donor platelet count replaced in
48 hours
v Low white cell contamination
v Minimal donor red cell loss
v Fewer donor reactions than whole blood
donations.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 PHERESIS PLATELETS

o o
at 20 C to 24 C under
constant agitation. Maximum
storage time = 5 days

between 2.0 – 5.0 x 1011

Platelets = 4-8 whole blood collections.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Pheresis Donation Vs
Whole Blood Donation
Pheresis Donation Whole Blood Donation
q Blood Cell Separator q No specialized equipment
q Ave 1.5 to 2 hours q 10 mins
q No shows, rejections, q More uniform work flow
deferrals very costly
q Hospital/blood center q Mobile collection
q By appointment q Walk-ins
q Lab & medical access q Autonomous operation

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Risks Of Platelet Transfusion

The risk of platelet sepsis is greater with

a transfusion of pooled platelet
concentrates from multiple donors than
from a single donor.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Risks Of Platelet Transfusion
§ Platelet transfusion can transmit viral or bacterial
disease.
§ Contaminating red cells in the product may transmit
malaria.
§ Graft-versus-host disease (preventable by irradiation)
§ Cytomegalovirus (preventable by serological screening)
§ Alloimmunization caused by contaminating white cells.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Risks Of Platelet Transfusion

q Leukocyte removed could possibly prevent

all these problems, but this is not established.
q Febrile reactions are common and are
reduced but not totally eliminated by
Leukocyte removal
q Platelet themselves may cause fever.

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Advantages of Single Donor
Platelets Over Pooled Platelet
Concentrate Transfusions

One donor exposure only

For special feature collections (HLA-
matched, CMV-negative)
Lower reaction rate
Lower risk of alloimmunization and
transmission of viruses
Increased donor productivity

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Advantages of Single Donor
Platelets Over Pooled Platelet
Concentrate Transfusions

One Pretransfusion Test

Lower Cost than Manual Collection
Prompt Transfusion Possible
Less Unit Handling
Compliance with Quality System
Standards

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 THERAPEUTIC APHERESIS

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Patient Apheresis
(reduction of cells)
§ Cytaferese
• Trombocytes
• Lymphoblasts
• Myeloblasts
• Erytrocytes

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
 Patient Apheresis (exchange)

• Plasma exchange

• RBC exchange

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Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)
 Function of Therapy

Theurapetic Plasma
Exchange
Plasma

Platelet Limfosit
Platelet MNC Collection
Depletion
Monosit
WBC White Blood Cell
Granulocyte
Depletion Granulosit
Collection

RBC
RBC Exchange

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 Therapeutic Plasma Exchange (TPE)

A therapeutic procedure in which blood of the patient is

passed through a medical device which separates out
plasma from other components of blood, the plasma is
removed and replaced with a replacement solution such
as colloid solution (e.g., albumin and/or plasma) or
combination of crystalloid/colloid solution.

Schwartz et al. Journal

Dr. dr. Teguh Triyono,ofM.Kes
ClinicalSp.PK
Apheresis.2013
(K)
 Therapeutic Plasma Exchange (TPE)
• The most common use of TPE is for the treatment of
autoimmune or immune mediated diseases or
disorders
• TPE removes:
• Monoclonal antibodies
• Paraproteins
• Autoimmune antibodies
• Antigen-antibody complexes

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Therapeutic Plasma Exchange (TPE)

te
as
W

Plasma
Clean
Plasma
Red Cells

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

Abnormal Substances Removed
From the Circulation by TPE

1. Paraproteins (Waldenstorm’s Macroglobulinemia)

2. Autoantibodies (Myasthenia Gravis, Goodpasture’s syn.)
3. Lipids (LDL in familial hypercholesterolemia; phynatic acid in
refsum’s disease)
4. Toxins or drugs (that are bound to albumin)
5. Circulating immune complexes (CIC)
6. Soluble mediators of inflammatory response (activated
complement component, vasoactive substances)

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 Procedural Elements
& Practical Considerations

• Venous access
• Replacement fluid
• Normal/abnormal constituents removed
• Anticoagulation
• Patient history and medications
• Frequency and number of procedures
• Complications

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 VENOUS ACCESS

• Require large bore venous catheters to sustain the flow

rates required (50-100 ml/min)
• Type of catheters: 17 gauge
• Location:
Peripheral: antecubital fossa
central: femoral/subclavian/jugular
Arteriovenous shunt/fistula
• Number of lines: continuous flow devices : separate lines

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6 dr. Teguh Triyono, M.Kes Sp.PK (K)
 REPLACEMENT FLUID

• Must be FDA approved to use with blood products [get mixed with
RBC before the return phase]
• Replacement solutions:
Crystalloids–normal saline 0.9%
Colloids–5% albumin; plasma
• Function of the replacement fluid is to
maintain intravascular volume (primary)
restoration of important plasma proteins
maintenance of colloid osmotic pressure
maintenance of electrolyte balance

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7 dr. Teguh Triyono, M.Kes Sp.PK (K)
 REPLACEMENT FLUID

TTP/HUS FFP
Cryodepleted FFP
Mixtures : Albumin /FFP
Albumin /FFP

Neurological 5% Human Albumin

GBS, MG, Stiff-man CIDP Albumin/Saline (70% /30%)

Renal 5% Human Albumin

(RPGN, FSGS) Albumin/Saline (70% /30%)

Post Transplant 5% Human Albumin

Albumin/Saline (70% /30%)
Consider adding FFP at the end if post op

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8 dr. Teguh Triyono, M.Kes Sp.PK (K)
 Comparison of Replacement Fluids
Replacement fluid Advantage disadvantage
Crystalloid Low cost Hypo-oncotic
Hypoallergenic No coagulation factors
No infectious risk No immunoglobulins
2-3 volumes required
Albumin Iso-oncotic Higher cost
No infectious risk No coagulation factors
No immunoglobulins
Plasma Immunoglobulins Infectious risk
Coagulation factors Citrate
Iso-oncotic Allergic reactions
ABO compatibility

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9 dr. Teguh Triyono, M.Kes Sp.PK (K)
 Replacement Fluid and Balance

3 choices of fluid balance (FB):

100% FB –isovolemic –volume replaced=volume
removed
<100% FB –hypovolemic (“dry”) -volume replaced <
volume removed
>100% FB –hypervolemic (“wet”) -volume replaced >
volume removed

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 Normal/abnormal
Constituents Removed TPE
• TPE:
• One volume exchange removes about 63%-65% of most
plasma constituents
• A single two-volume exchange removes about 86% of
plasma constituents
à Increasing the volume beyond 1-1.5 volumes has very
little impact on removal of plasma constituents

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 Volume of Patient Plasma
Exchanged (PEX)
Little advantage beyond 1.0-1.5 volumes
• 1 pv = 63%↓
• 2 pv = 86%↓
• 3 pv = 95%↓

Removal of IgG and IgM by plasma exchange:

Measure IgG IgM
Intravascular amount 45% 76 %
“total body” removal
• 1.0 PEX vol. 28% 48%
• 1.5 PEX vol. 35% 59%
• 2.0 PEX vol. 39% 65%
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2 dr. Teguh Triyono, M.Kes Sp.PK (K)
 ANTICOAGULATION
• Side effects: hypocalcemia.
• ↑ small pts, large vol. of
• Found in human cells, plant citrated blood, liver
cells, and citrus fruits dysfunction
• Chelates positively charged
calcium ions (ionized calcium) • Prevents conversion of
and blocks calcium- fibrinogen to fibrin and
dependent clotting factor prothrombin to thrombin
reactions
• Systemic anticoagulation
• Works extracorporeally
• Metabolized slowly 1-2 hours
• Metabolized in the liver
almost immediately upon • Individual sensitivity and
return elimination rates

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Patient History and Medications

• Does patient have a disease which is amenable to treatment

by the requested apheresis procedure
• Does the patient/donor capable of sustaining the fluid shifts
associated with apheresis
• Certain medications, most notably antibiotics and
anticoagulant can be removed by apheresis -should be
given immediately after the procedure
• Angiotensin-converting enzymes (ACE) inhibitors

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 Frequency and Number of
Procedures
• Depends on: Disease being treated, Patient signs and
symptoms, Lab values
Substance Volume Treated Treatment Interval Number of
(ml/kg) (hours) Treatment
Autoantibodies 40-60 24-48 4-6

Immune complexes 40-60 24-48 Treat to response

Paraproteins 40-60 24 Treat to response

Cryproteins 40-60 24-48 Treat to response

Toxins 40-60 24-71 Treat to response

TTP/HUS 40 24 To remission
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 TPE – Success Factors and
Frequency

• Depends on: Disease being treated, Patient signs and

symptoms, Lab values

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6 dr. Teguh Triyono, M.Kes Sp.PK (K)
TPE – Success Factors and
Frequency
Extravascular space
• The success of a TPE
procedure is dependent
Plasma on the:
Capillary
• Distribution of disease
mediator
• Volume of plasma
removed

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Complications
• Hypotension
• Vasovagal syncope
• Hypocalcaemia
• Allergic reaction
• Other side effects
Vascular access: hematoma, phlebitis, infection
Air embolism
Loss of blood components: → bleeding
Thrombocytopenia (30% decrease)
Hypofibrinogenemia (50% decrease)

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 Indications for TA

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 J Clin Apheresis

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 J Clin Apheresis

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

 J Clin Apheresis

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)

TERIMA KASIH
 PLATELET PHERESIS

Dr. dr. Teguh Triyono, M.Kes Sp.PK (K)