This document discusses apheresis, which involves separating blood into its components. There are different methods of apheresis including intermittent flow centrifugation, continuous flow centrifugation, and membrane filtration. Apheresis can be used to collect various blood components from donors like platelets, plasma, red cells, and leukocytes. It has therapeutic applications like therapeutic plateletpheresis to treat high platelet counts and therapeutic plasmapheresis to remove pathological substances from the plasma like immune complexes. The document outlines the principles, methods, components that can be collected, and indications of apheresis.

1. APHERESIS
Presenter: Dr Aysha Femy
Moderator: Dr Ramadas Nayak.
Date of Presentation: 08.07.2019

2. OBJECTIVES
 Define apheresis
 Different methods of apheresis.
 Components that can be collected using apheresis
technology.
 Indications for therapeutic apheresis
 Newer concepts in apheresis
 Possible adverse effects of apheresis.

3. APHERESIS
 Greek word - “to take away”
 Whole blood is withdrawn
 Separated into its components
 Desired component is retained
 Remaining constituents are returned to donor

4. APHERESIS
 Any one of the components of blood can be
removed .
 The process of removing the plasma from red cells-
Plasmapheresis.
 Platelets –Plateletpheresis
 Red cells – Erythrocytapheresis
 Leukocytes -Leukapheresis.

5. APHERESIS
 Apheresis - non-therapeutic or therapeutic.
 Done manually or using automated equipment
 The separation of blood components is based on
the specific gravity or weight of each individual
blood constituent

6. APHERESIS
The advantages of single-donor components are:
 Reduced multiple donors exposure
 Reduced risk of alloimmunization
 Reduced incidence of transfusion-transmitted
diseases

7. APHERESIS- PRINCIPLE
 Tube of anticoagulated blood
-centrifuged
 Heavier RBCs -bottom
 Lighter plasma portion- top.
 Between these two -smaller
layer composed of WBCs &
platelets.

8. PRINCIPLE
Blood is removed from an
individual, mixed with an
anticoagulant
Transported directly to the
separation device
Once the components have
been separated, any
component can be withdrawn.
The remaining portions of the
blood are then mixed
Returned to the donor or
patient

10. PHYSIOLOGY OF APHERESIS

11. ANTICOAGULATION
 Citrate- used as the primary anticoagulant in
apheresis procedures
 Citrate is mixed with the blood immediately as it is
removed from the donor’s (or patient’s) vein
 Effectively anticoagulates the blood before it enters
the apheresis machine

12. APHERESIS
 Normal situations, infused citrate- actively metabolized
 Also diluted throughout the intra- & extracellular fluids
 As citrate-calcium complex is metabolized- bound Ca2+
ions released back into the bloodstream.
 PTH released -helps to maintain adequate circulating
Ca2+.
 Some individuals may have transient hypocalcemia

13. CELLULAR LOSS
 The goal of apheresis- intentionally remove a specific
cellular component
 A platelet donor- Acute platelet count of 20% - 29%
 Typically, hematocrit of 7% & platelet count of 22%
occurs after each granulocyte donation.
 Varying numbers of RBCs -lost during each donor
apheresis procedure

14. FLUID SHIFTS
 Changes in intravascular volume -secondary to
removal of blood.
 During donor apheresis procedures, the total
volume of components collected may be more
 Hence, if additional fluid is not infused, the donor
may experience hypotension.
 The sympathetic nervous system attempts to
compensate for this

15. METHODOLOGY
 Apheresis, performed using automated technology
 Separation - performed by centrifugation.
 Computerized control panel- allows the operator to
select the desired component
 Optical sensors detect specific plasma-cell/ cell-cell
interfaces & divert the specific component
 Disposable equipment- sterile single-use tubing sets,
bags & collection chambers.

16. METHODOLOGY
 Donor/ patient remains attached to instrument for the
duration of 45- 120 minutes.
 Depending on goal of the individual procedure -the
appropriate instrument is selected.
 Some instruments suitable only for donor apheresis;
others can be used for donor or therapeutic apheresis.
 Manipulate certain variables on an apheresis instrument
- commercial or therapeutic purposes.

17. METHODOLOGY
The variables that are considered during an apheresis
procedure:
 Centrifuge speed and diameter
 Duration of dwell time of the blood in the centrifuge
 Type of solutions added, such as anticoagulants or
sedimenting agents
 Cellular content or plasma volume of the patient or
donor

18. METHODS OF CENTRIFUGATION
INTERMITTENT FLOW CENTRIFUGATION (IFC)
CONTINUOUS FLOW CENTRIFUGATION (CFC).

19. INTERMITTENT FLOW CENTRIFUGATION
 Blood is processed in batches or cycles
 Whole blood is drawn - assistance of a pump.
 Anticoagulant is mixed with the blood
 The bowl rotates at a fixed speed
 Separates the components according to their
specific gravities.

20. INTERMITTENT FLOW CENTRIFUGATION
 The RBCs-packed against the
outer rim
 Followed by the WBCs,
platelets, and plasma.
 Once separated, the pump is
reversed
 Desired components pumped
through the outlet port

21. INTERMITTENT FLOW CENTRIFUGATION
 Undesired component pumped to reinfusion bag -returned
 Cycles repeated until desired quantity of product-obtained
 IFC procedure performed as a single-needle procedure - one
venipuncture
 If both arms are used ,the amount of time can be reduced.
 Currently available systems- versatile, portable, fully automated,
capable of efficient component collections.

22. The Haemonetics MCS Plus LN9000

23. CONTINUOUS FLOW CENTRIFUGATION
Here, the processes of
 Blood withdrawal
 Processing
 Reinfusion are performed simultaneously in a
ongoing manner.

24. CONTINUOUS FLOW CENTRIFUGATION
 Blood is drawn & returned continuously during a procedure-
2 venipuncture sites necessary.
 Dual-lumen central venous catheter
 Blood drawn from the phlebotomy site with the assistance of
a pump, mixed with anticoagulant
 Separation of the components - centrifugation
 Specific component is diverted, retained.
 The remainder of the blood is reinfused.

25. Baxter/Fenwal Amicus

26. The COBE Spectra
apheresis system

27. The Spectra Optia

28. The Fresenius
AS-104.

29. The IFC and CFC machines - advantages and
disadvantages

30. MEMBRANE FILTRATION
 Technology- used to separate blood components.
 Composed of bundles of hollow fibers or flat plate membranes
with specific pore sizes.
 As whole blood flows over the fibers or membrane, plasma passes
through the pores and collected
 Remainder of the components returned to the donor.
 This technology lends itself well to the collection of plasma

31. MEMBRANE FILTRATION
Filtration has several advantages over centrifugation
 Collection of a cell-free product
 Has the ability to selectively remove specific plasma
proteins by varying the pore size.
 The Fenwal Autopheresis-C instrument combines
centrifugation & membrane filtration technology

32. COMPONENT COLLECTION
 A healthy donor undergoes an automated procedure to
obtain a specific blood component that will be transfused to
a patient.
 In general, most of the requirements for whole blood
donation must be met
 However, apheresis donors must meet additional
requirements

33. GENERAL REQUIREMENTS FOR APHERESIS
 A qualified, licensed physician.
 Equipment should be good, reliable, in proper
working condition.
 Well-trained and motivated staff
 Operator must know all aspects of its operation and
trouble shootings.

34. GENERAL REQUIREMENTS FOR APHERESIS
 Operator -friendly & be able relieve the anxiety of
the donor/patient.
 There must be a manual readily available to nursing
and technical personnel
 Records for lab findings and data for each
apheresis procedure should be kept

35. GENERAL CRITERIA FOR SELECTING
APHERESIS-DONOR
 Donor must meet the same criteria as a whole blood
donation
 Donor should be preferably repeat donor - might have
given blood 1-2 times earlier.
 Written consent of the donor is taken after explaining the
procedure in detail
 Venous access*
 Tests for hemoglobin, ABO group, Rh type, and
screening for unexpected antibody are done.

36. GENERAL CRITERIA FOR SELECTING
APHERESIS-DONOR
More stringent regulations for donors who participate in serial
apheresis program
 Interval between 2 procedures should be at least 48 hrs-
loss of red cells should not exceed 25 ml per week
 If donor’s RBCS could not be reinfused during a procedure/
donates a unit of whole blood- 12 wks should elapse
 Careful monitoring of weight, blood cells count, serum protein
levels and quantitation of immunoglobulins is required.

37. COMPONENT COLLECTION
 Written, informed consent must be obtained.
 The apheresis procedure, tests to be performed, possible
risks and benefits explained.
 No specific medical benefit to the donor
 Special risks associated -side effects of the anticoagulant ,
hypovolemia, and fainting.
 The donor must be given the opportunity to accept or reject
the apheresis procedure.

38. PLATELETPHERESIS
 A portion of the donor’s platelet & some plasma is removed
 With return of donor’s RBCs, WBCs & remaining plasma
 Procedure : 1 to 1.5 hours.
 The product can be stored for 5 days.
 Platelets can be prepared without or with extra plasma in a
separate bag
 Number of platelets in an apheresis product ~ 6 to 8 random
platelet concentrates.

39. SPECIFIC CRITERIA FOR THE SELECTION OF
DONOR FOR PLATELETPHARESIS
Aspirin
within 36
hours
Interval
between
procedure
- 48 hrs.
Not more
than 2
times in a
week
Not more
than 24
times in a
year

40. SPECIFIC CRITERIA - PLATELETPHARESIS
•Prior the first procedure
•If interval between plateletpheresis
procedures is- 4 weeks.
A platelet
count is not
required
• If plateletpheresis is performed more
frequently than every 4 weeks
Platelet count
must be
>150,000/µl
• If extra plasma is collected & if the
procedure is performed > once every 4
week- total serum protein < 6.0 g/dl
• if there has been an unexplained
weight loss.
Procedure
should not be
done

41. LEUKAPHERESIS
 Occasionally granulocytes are needed –in neonates
& adults with neutropenia and sepsis- not
responding to antibiotics.
 To collect adequate number of granulocytes -
usually 1.0 - 3.0 x 1010, apheresis technique is
applied.

42. LEUKAPHERESIS
 Collection of adequate dose of granulocytes needs
administration of drugs or infusion of certain drugs.
 The donor is stimulated pre-donation with steroids.
 A protocol using 20 mg of oral prednisone at 17, 12, and
2hours before donation gives better granulocytes yield.

43. LEUKAPHERESIS
 Hydroxlethyl starch (HES), infused during the collection
procedure
 To increase RBC sedimentation
 To facilitate the separation and collection of granulocytes.
 G-CSF effectively increase granulocyte yield.
 Red cells should be compatible with the recipient’s plasma
 If >2 ml red cells present -should be cross matched.
 Ideally D-negative recipient should receive granulocyte
concentration from D-negative donor.

44. ERYTHROCYTAPHERESIS
 Recent advancement in apheresis involves the
collection of RBCs by automated apheresis.
 Many the automated apheresis machines have been
improved and allow the collection of either two may
occur.
 In such cases the serial plasmapheresis is deferred for
12 weeks.
 Red cells loss must not be more than 25 ml per week.

45. PLASMAPHERESIS
 Plasmapheresis -based on the principles of
separation of plasma by centrifugation & membrane
filtration techniques.
 There are several automated machines designed
for plasmapheresis
 These machines require special sterile disposable
tubing and containers.
 The anticoagulant is added in a controlled way.

46. ADVANTAGES OF AUTOMATED PLASMAPHERESIS
o The speed of collection is considerably faster than in manual
plasmapheresis
• 500-600 ml plasma can be collected within 30 minutes.
o Donors prefer automated procedure to manual plasmapheresis
o Total extracorporeal volume at any time, particularly with
filtration plasapheresis, is less than that in double manual
plasmpheresis
o Single venous access

47. DISADVANTAGES OF AUTOMATED PLASMAPHERESIS
 More expensive than the manual procedure.
 Plasma separated from cell separators may contain platelets
which are smaller than the average ,if not removed, detract
the quality of plasma intended for fractionation.
 Membrane filters have potential problems such as leakage or
damage to cells.
 The complement may activate.

48. CARE OF PLASMAPHERESIS DONORS
 The criteria for the acceptability of plasmapheresis donors are
slightly stringent
 Donors are informed about the procedure in detail
 Written consent is taken.
 Age should be between 18- 50 years
 Weight should be 60 Kg or more.
 Donor should have given whole blood 1 -2 times earlier.
 Total blood count & serum proteins should be with in normal
limited.

49. NON-THERAPEUTIC PLASMAPHERESIS
 Increase plasma inventory of FFP for transfusion
 Collect plasma from IgA negative donor for transfusion.
 Obtain plasma to prepare immunoglobulins to Rh, tetanus
or HBsAg etc.
 To collect plasma for preparing albumin, plasma protein
factor (PPF) and other plasma components.
 To prepare coagulation factors like Factor VIII, Factor IX
complex etc.

50. THERAPEUTIC APHERESIS

51. THERAPEUTIC PLATELETPHERESIS
 Treat patients who have abnormally elevated platelet
count with related symptoms
 Myeloproliferative disorders like polcythemia vera.
 Patients >1lkh/µL may develop thrombotic or
hemorrhagic complications.
 During apheresis , plt count can be decreased- 1/3rd -
1/2 the initial value.
 The procedure can be repeated as frequently as
necessary

52. THERAPEUTIC LEUKAPHERESIS
 Used to treat patients of leukemia, particularly with impending
leukostasis
 Indicated if the leukocyte count is more than 1lkh/ul.
 The efficacy- unproved.
 The white cell count rises over weeks, and leukoreduction can
be effected with the chemotherapy.

53. THERAPEUTIC EYTHROCYTAPHERESIS
 Erythrocytapheresis- an exchange procedure.
 A predetermined quantity of blood is removed from
the patient & replaced by homologous blood.
 Useful to treat complications in sickle cell disease.
 Also useful in patients with sever parasitic infection
from malaria.

54. THERAPEUTIC PLASMAPHERESIS (PLASMA
EXCHANGE)
 Not a cure for the underlying disease, rather a way to
provide short term relief.
 Actually a plasma exchange rather than apheresis.
 The pathological substances in plasma are removed and
replaced with a fluid.
 The replacement fluid may be plasma, albumin, saline.
 The plasma- constantly replaced with the fluid

55. • Immune complexes (e.g.SLE)
• Alloantibodies (Antibody-mediated transplant rejection)
• Autoantibodies (GB syndrome, Goodpasture’s syndrome)
• Immunoglobulins causing hyperviscosity (Waldenström’s
macroglobulinemia)
• Protein-bound toxins or drugs (Mushroom poisoning, barbiturate poisoning)
• Lipoproteins (familial hypercholesterolemia, hypertriglyceridemia)
Factors Removed by Therapeutic Plasmapheresis

56. EFFICACY OF THERAPEUTIC APHERESIS AS
TREATMENT MODALITY

57. FLUIDS USED IN APHERESIS
 All apheresis procedures use anticoagulant
 Most commonly used anticoagulant is ACD.
 Normal saline used to prime the system and to help in
maintaining fluid volume.
 In therapeutic plasmapheresis procedure large volume of
patient’s plasma is retained
 Replaced with fluids to maintain adequate intravascular
volume and oncotic pressure

58. Replacement Fluid Advantages Disadvantages
Crystalloid - Normal
Saline
•Least
•Hypo-allerge
•No risk of hepatitis &
HIV expensivenic
•2-3 volumes required
•Hypo-oncotic
•No coagulation factors
Albumin in 5 %
solution (NSA)
•Mild hyper-oncotic
•Used in 1:1 ratio of
the plasma removed
•No risk of hepatitis &
HIV
•High cost
•No coagulation factors
•No immunoglobulins
Plasma protein
Fractions
Less expensive than
albumin
Induction of
hypotensive reactions

59. ADVANCEMENTS IN APHERESIS

60. NEOCYTAPHERESIS
 Individuals who require continuous RBC therapy.
 Each ml of RBCs contains ~ 1 mg of iron- hemosidrosis,
 Another approach is to transfuse younger red cells (neocytes).
 Selective removal of the donor’s neocytes or younger red cells
found in the upper portion the layer of red cells after
centrifugation or neocytapheresis.
 Half-life of young red cells (neocytes)- 90 - 100 days while that of
mature RBCs is 60 days.

61. NEOCYTAPHERESIS
USES
 Reduces blood requirement
 Increases transfusion intervals
 Reduces iron overload.
But neocytes therapy did not get wider acceptance --
neocytapheresis is time consuming and expensive.

62. HEMATOPOIETIC PROGENITOR CELLS
 HPCs- referred to as peripheral blood stem cells , can
be collected by apheresis from an autologous or
allogeneic donor
 The procedure, much like donor leukapheresis
 Procedure lasts 4 to 6 hours
 Hematopoietic growth factors,GCSF, commonly used
prior to the collection
 Measurement of CD34+ cells in the peripheral blood
prior to collection is typically performed

63. HEMATOPOIETIC PROGENITOR CELLS
Advantages over traditional bone marrow collection.:
 Anesthesia is avoided
 Procedures can be performed safely in the outpatient
setting.
For the autologous HPC donor:
 Shorter period of cytopenia
 Decreased transfusion requirements
 Fewer infectious complications
 Decreased length of hospitalization.

64. IMMUNOADSORPTION/SELECTIVE ABSORPTION
Therapeutic plasma exchange- treat a no of immunological
disorders
 Immunoadsorption - Specific ligand is bound to an insoluble
matrix in a column or filter.
 Plasma - separated from anticoagulated whole blood by
centrifugation or filtration

65. IMMUNOADSORPTION/SELECTIVE ABSORPTION
 The sequestered plasma, then perfused through
the column or filter, with selective removal of the
pathogenic substance
 Subsequently -reinfusion of the patient’s plasma &
cellular components.
 The removal is usually mediated by an antigen–
antibody or chemical reaction.

66. IMMUNOADSORPTION/SELECTIVE ABSORPTION
 Initially licensed to treat patients with either refractory
idiopathic thrombocytopenic purpura (ITP) or RA
 Used off-label to treat a variety of other disease processes.
 Several adverse reactions:
 Fever, chills
 Hypo- and hypertension
 Allergic reactions
 Death.

67. IMMUNOADSORPTION/SELECTIVE ABSORPTION
 Familial hypercholesterolemia - LDL-apheresis
 Numerous adsorptive matrices have been developed
with varying clinical usefulness.
 Charcoal for removal of bile acids
 Polymyxin B for removal of endotoxin
 Cellulose acetate for removal of granulocytes or
monocytes

68. PHOTOPHERESIS
 Photopheresis utilizes leukapheresis to collect the buffy
coat layer from whole blood.
 Cells are treated with 8-methoxypsoralen (8-MOP),
exposed to UVA light
 Reinfused into the patient.
 The combination of 8-MOP and UVA irradiation results in
crosslinking of leukocyte DNA, ultimately leading to
apoptosis

69. PHOTOPHERESIS- USES
 Approved by FDA for Rx of
cutaneous T-cell lymphoma.
 Been used successfully to treat
acute and chronic GVHD
 Solid organ transplant rejection
 Selected immunologically
mediated diseases.

70. ADVERSE EFFECTS

71. ADVERSE EFFECTS
• Citrate toxicity
• Vascular access complications (hematoma, sepsis,
phlebitis, neuropathy)
• Vasovagal reactions
• Hypovolemia
• Allergic reactions
• Hemolysis

72. ADVERSE EFFECTS
• Air embolus
• Depletion of clotting factors
• Circulatory and respiratory distress
• Transfusion-transmitted diseases
• Lymphocyte loss
• Depletion of proteins and immunoglobulins

73. APHERESIS AT YMC!!!!

76. SUMMARY

77. SUMMARY
 In an apheresis procedure, blood is withdrawn from a donor or
patient and separated into its components.
 One or more of the components is retained,the remaining
constituents- recombined, returned
 The process of removing plasma from the blood is termed
plasmapheresis; removing platelets is termed plateletpheresis
or thrombocytopheresis
 Removing RBCs is termed erythrocytapheresis; removing
leukocytes is known as leukapheresis.

78.  Apheresis equipment that uses IFC requires only one
venipuncture, in which the blood is drawn and reinfused
through the same needle.
 Once the desired component is separated, the remaining
components are reinfused to the donor- one cycle is complete.
 Apheresis procedures performed on patients usually require
many cycles to reach an acceptable therapeutic endpoint.

79. SUMMARY
 CFC- withdraw, process, and return the blood to the individual
simultaneously.
 Two venipuncture sites are necessary.
 The process of phlebotomy, separation, and reinfusion is
uninterrupted
 Membrane filtration technology- membranes with specific
pore sizes, allowing plasma to pass through the membrane
while the cellular portion passes over it.
 The most common anticoagulant used in apheresis -ACD

80.  Therapeutic apheresis is used to remove a pathological
substance, to supply an essential or missing substance
to alter the antigen–antibody ratio, or to remove immune
complexes.
 The American Society for Apheresis (ASFA) has
developed categories to define the effectiveness of
therapeutic apheresis in treating a particular condition or
disease.

81. SUMMARY
 In therapeutic plasmapheresis procedures, the
replacement fluids used to maintain appropriate
intravascular volume and oncotic pressure include
normal saline, FFP, cryo-reduced plasma, and 5%
human serum albumin.
 Complications of apheresis include vascular access
issues, alteration of pharmacodynamics of medications,
citrate toxicity, fluid imbalance, allergic reactions,
equipment malfunction (hemolysis), and infection.

82. REFERENCES
 Schwartz, J., Padmanabhan, A et al. Guidelines on the Use of
Therapeutic Apheresis in Clinical Practice-Evidence-Based
Approach from the Writing Committee of the American Society
for Apheresis: The Seventh Special Issue. Journal of Clinical
Apheresis, 2016; 31(3), 149–338.
 McCullough J. Transfusion medicine. 4th ed. Chichester:
wiley; 2017.521-60.
 Denise M. Harmening, Modern blood banking & transfusion
practices, 350-370; 6th edition, 2012.

83. REFERENCES
 Julius U, Tselmin S, Bornstein S. LIPOPROTEIN APHERESIS:
YESTERDAY, TODAY, TOMORROW. REVIEW. Russian Journal of
Cardiology. 2018;(8):74-78.
 Garraud O. Therapeutic plasma exchange, 2019 and beyond.
Transfusion and Apheresis Science. 2019;58(3):226-227.
 Dr. R.N. Makroo, Practice of Safe Blood Transfusion, Compendium
of Transfusion Medicine, 332-45; 2nd edition, 2009.
 Saran R.k, Transfusion medicine technical manual,229-43; 2nd
ed;2003