Therapeutic apheresis in kidney transplantation: Emerging trends

INTRODUCTION

The use of therapeutic apheresis (TA) either as stand-alone or adjunctive treatment in kidney transplantation has increased over the years to become a leading indication. This study shows recent trends in indications for TA related to kidney transplantation, adverse events, and patient outcome in this cohort.

METHODS

This is a retrospective cohort review of adults who received TA for kidney transplant-related indications from January 1, 2017, to December 31, 2022, at the University of Virginia Medical Centre, Charlottesville, VA, USA. Data extracted include basic demographics, indication for apheresis, number of procedures, procedure characteristics, procedure-related adverse events (complications), and serum ionized calcium and serum creatinine. Data were analyzed using statistical package for social sciences (SPSS 2022 IBM Inc).

RESULTS

Data from a total of 131 patients who received 860 TA procedures were analyzed. Indications for TA were antibody-mediated rejection (65.5%), recurrent focal segmental glomerulosclerosis (15%), thrombotic microangiopathy (5%), desensitization for ABO incompatibility (4.5%) and for HLA-incompatibility (4.5%), and recurrent IgA nephropathy (1%). Some adverse events were encountered in 16.7% of the procedures and include hypocalcemia (7%), vascular access malfunction (0.7%), hypotension (1.2%), arrhythmia (0.6%), and depletion coagulopathy (0.6%). The overall case mortality rate was 8.4% over the 6-year period. There was one death recorded on machine during TA resulting in a procedure-mortality rate of 0.12%.

CONCLUSION

Antibody-mediated rejection was the most common indication for TA related to kidney transplantation. Adverse events were minor and patient survival over the time was within usual limits.

Apheresis practice variation during the COVID-19 pandemic: Results of a survey

BACKGROUND

The COVID-19 pandemic affected healthcare delivery across all specialties including apheresis. To describe the changes in apheresis service practices that occurred during the pandemic, the American Society for Apheresis (ASFA) Apheresis Medicine Attending Physician Subcommittee conducted a survey study.

STUDY DESIGN AND METHODS

A 32-question survey was designed and distributed to 400 ASFA physician members on September 7, 2022. Attending physicians responded to questions about whether and how apheresis service practices changed during the COVID-19 pandemic compared with the time period prior to the pandemic in terms of: (1) procedure types and volumes, (2) patient consultation workflow, and (3) the use of telemedicine. Descriptive analyses were reported as number and frequency of responses.

RESULTS

The survey response rate was 13.8% (55/400). Of these respondents, 96.4% (53/55) were attending physicians. The majority of respondents (42/53, 79.2%) indicated that the types of procedures performed during COVID-19 compared to pre-pandemic did not change. Most frequently for apheresis procedure volume, respondents reported: no change in their monthly inpatient volume (21/47, 44.7%) and a decrease in their monthly outpatient volume (28/46, 60.9%). Prior to COVID-19, 75.0% (30/40) of respondents performed consultations at bedside for inpatients and 67.4% (29/43) performed consultations at bedside for outpatients. Bedside consultations decreased in both settings during the pandemic but were still most frequently performed by attending physicians. At the same time, the use of telemedicine increased for 15.4% of survey respondents during COVID-19.

CONCLUSION

Some, but not all, respondents observed or made changes to their apheresis service during the COVID-19 pandemic. A subset of changes, such as increased utilization of telemedicine, may persist.

Trends in category and grade for therapeutic plasma exchange in the latest guideline on therapeutic apheresis by the American Society for Apheresis: Hurdles in pursuing evidence-based medicine

BACKGROUND AND OBJECTIVES

The Writing Committee of American Society for Apheresis released the ninth edition of guidelines for therapeutic apheresis in 2023. Categories have been a part of the guidelines since the first edition, and the grading system was introduced in the fifth edition, with updates in every new edition. In this study, we investigated the category and grade change trends through the latest five editions, focusing on therapeutic plasma exchange, to suggest future directions as part of evidence-based medicine.

MATERIALS AND METHODS

Categories and grades for therapeutic plasma exchange (TPE) were collected and analysed from the fifth through ninth editions. We aligned classification changes to the ninth edition's clinical context and compared its categories and grades with those introduced in the guideline.

RESULTS

Among 166 total indications in the ninth edition, 118 included TPE procedure, either as a sole treatment or as one of the therapeutic apheresis techniques. The total number of indications changed, but Category III remained predominant throughout the editions. Similarly, Grade 2C consistently emerged as the most prevalent grade. Notably, 24 cases had grade changes. Of the 16 cases with evidence quality changes, the quality weakened in six and improved in 10. Evidence levels were not improved throughout the study period for 102 clinical conditions.

CONCLUSION

To address gaps in evidence quality, international collaboration is imperative to establish comprehensive large-scale studies or randomized controlled trials. This will refine the use of therapeutic apheresis, including TPE, to foster evidence-based advancements in clinical practice.

Effective peripheral blood stem cell collection in a 4.6-kg child

BACKGROUND

Due to unique technical challenges, effective peripheral blood stem cell collections (PBSCs) have not been consistently reported in patients weighing less than 5 kg. We describe three PBSCs performed in a 4.6-kg child undergoing myeloablative chemotherapy for high-grade glioma.

STUDY DESIGN AND METHODS

A multidisciplinary group representing the clinical and apheresis teams adapted a PBSC protocol to accommodate the patient's size and collection targets. Special considerations included timing of the collection relative to chemotherapy, vascular access, strategies for monitoring adverse events during collection, and contingencies.

RESULTS AND DISCUSSION

The patient underwent three PBSC procedures over 2 days due to suboptimal collection after the first two procedures. For procedure 1, a conservative inlet: anticoagulant (AC) ratio and AC infusion rate of 15 and 0.6 mL/min/L total blood volume (TBV) resulted in premature discontinuation due to clotting. A ratio of 8 and AC infusion rate of 1.5-1.7 mL/min/L TBV with subsequent titration to higher levels were adopted for the second and third procedures. These changes resulted in greater acid-citrate-dextrose exposure, that was managed by continuous calcium chloride infusion. There was no hypocalcemia, hypotension, or distress during any procedure. A total of 15 × 106 CD34+ cells/kg were collected. This retrospective review illustrates that PBSC can be safely undertaken in children weighing less than 5 kg.

Evaluating the efficiency and safety of large-volume leukapheresis using the Spectra Optia continuous mononuclear cell collection protocol for peripheral blood stem cell collection from healthy donors: A retrospective study

BACKGROUND

Large-volume leukapheresis (LVL) refers to processing of more than three volumes of blood in a single session for peripheral blood stem cell collection. Recently, continuous mononuclear cell collection (cMNC) protocol has been developed using the Spectra Optia system, which is a widely used apheresis device. LVL using the novel protocol has been investigated in patients. However, the efficiency and safety of LVL in healthy donors using this protocol has not been characterized. Therefore, this study aimed to evaluate the efficiency and tolerability of CD34+ collection of LVL with the cMNC protocol in healthy donors.

STUDY DESIGN AND METHODS

We retrospectively collected data on LVL (>3 total blood volume) and normal-volume leukapheresis (NVL) performed in healthy donors between October 2019 and December 2021. All procedures were performed using the cMNC protocol.

RESULTS

Although pre-apheresis CD34+ cell count was lesser in LVL (23.5 vs. 58.0/μL, p < .001), CD34+ collection efficiency was comparable between LVL and NVL (61.2% vs. 61.4%, p = .966). Platelet loss was significantly higher in LVL compared to NVL (38.0% vs. 29.4%, p < .001), with no correlation between attrition of platelet and processing blood volume. Moreover, the incidence of citrate toxicity during procedures was comparable between the two groups (31.6% vs. 21.4%, p = .322). All LVL procedures could be completed without any adverse events.

CONCLUSION

Allogeneic LVL procedure using Spectra Optia cMNC protocol was well tolerated by the donors and resulted in efficient collection of CD34+ cells, which was comparable to that of NVL.

Therapeutic Plasma Exchange in Catastrophic Antiphospholipid Syndrome (CAPS): A Rare Case Report and Literature Review

BACKGROUND/AIM

Catastrophic antiphospholipid syndrome (CAPS) may be the first manifestation ("de novo") of antiphospholipid syndrome (APS) or a complication in the clinical course of patients known to have this syndrome. Approximately 40% of patients had an associated autoimmune disease, mainly, systemic lupus erythematosus (SLE). The trigger can be one of the following: infections, surgical interventions, neoplasms, pregnancy, discontinuation of anticoagulant treatment, and others. CAPS is a medical emergency in which early identification and prompt initiation of aggressive therapy is extremely important. According to the Guidelines for the use of Therapeutic Apheresis in Clinical Practice developed by the American Society for Apheresis (ASFA), last updated in April 2023, in CAPS, the indication for therapeutic plasma exchange (TPE) is category I, grade 2C.

CASE REPORT

We present a case of probable CAPS secondary to systemic lupus erythematosus (SLE) in an elderly patient in whom clinical and biological improvement was achieved through a multidisciplinary approach and prompt initiation of TPE. Because TPE is considered first-line therapy in CAPS, we initiated the procedure as soon as the attending rheumatologist raised this suspicion. Four plasmapheresis sessions were performed in the Intensive Care Unit. We used TPE by membrane filtration. Following the therapeutic intervention with TPE, corticotherapy (Solumedrol in puls-therapy), cyclophosphamide and anticoagulant treatment, the evolution was favourable, with clinical and biological improvement.

CONCLUSION

The prompt initiation of TPE, because of the suspicion of CAPS, increases the chances of a favourable evolution.

Plasma exchange-A useful adjunct therapy to red cell exchange in patients with sickle cell disease and multiorgan dysfunction

BACKGROUND

Urgent red cell exchange (RBCx) is indicated for many complications of sickle cell disease (SCD), including acute chest syndrome, stroke, and hepatic/splenic sequestration. Many who receive RBCx remain hospitalized and develop further complications, including multiple organ dysfunction syndrome (MODS), a leading cause of death in intensive care units. Therapeutic plasma exchange (TPE) has been advocated as an effective treatment of MODS, but its role in SCD compared with RBCx alone is not well studied.

METHODS

We identified all ICU encounters from 2013 to 2019 involving RBCx procedures for MODS or SCD crisis that progressed to MODS, a total of 12 encounters. Data regarding hospital length of stay (LOS), survival, number of TPE procedures following RBCx, and procedure characteristics were collected. Surrogate laboratory markers of end-organ damage and disease severity scores were recorded at the time of admission, post-RBCx, post-TPE, and at discharge.

RESULTS

Eight encounters involved RBCx followed by TPE (TPE group) while four involved RBCx alone (RBCx group). The TPE group had a higher SOFA score at ICU admission (9.5 vs. 7.0), greater predicted mortality, and a statistical trend toward higher disease severity scores following RBCx relative to the RBCx group (p = 0.10). The TPE group showed a significantly greater decrease in SOFA score between RBCx and discharge (p = 0.04). No significant difference in mortality or hospital LOS was observed between the groups.

CONCLUSION

The findings suggest TPE may be considered as an adjunct treatment for patients with acute complications of SCD that progress to MODS, especially in cases where there is no significant improvement following RBCx.

Complications of red cell exchange for anemia management in patients with transfusion-dependent thalassemia

BACKGROUND

In the Rare Blood Disorders clinic at the University of Alberta in Edmonton, red cell exchange (RCE) was utilized in transfusion-dependent thalassemia (TDT) patients with severe iron overload despite oral chelation and no access to iron infusion pumps for parenteral chelation. It was hypothesized that RCE would be less iron loading compared to simple transfusion. The purpose of this study is to document observations of the potential risks and benefits of RCE in TDT patients.

STUDY DESIGN AND METHODS

TDT patients treated with RCE were identified and consented for enrolment according to local research ethics standards. Seven patients were enrolled in the study. Charts were retrospectively reviewed from the time of initiation of RCE to the time of the most recent RCE or clinic follow-up. Outcomes were documented and analyzed by descriptive analysis.

RESULTS

The average age was 30 years. 85.7% were male. 100% were on oral chelation therapy and had hyperferritinemia at baseline. Outcomes included hepatic iron overload (5 of 7), cardiac dysfunction (3 of 7), worsening splenomegaly or extramedullary hematopoiesis (5 of 7), syncopal events during RCE (2 of 7), and new antibodies (1 of 7). Iron overload improved after escalated oral chelation, not in relation to RCE initiation.

DISCUSSION

We hypothesize complications were higher than expected due to inadequate hematocrit increment and lack of suppression of ineffective erythropoiesis. With no observed benefit in iron status, and high complication rates, we did not find evidence to recommend RCE in patients with TDT. This case series is a hypothesis-generating study on transfusion techniques in TDT.

Efficient granulocyte collection method using high concentrations of medium molecular weight hydroxyethyl starch

BACKGROUND

Granulocyte transfusion therapy is a rational therapeutic option for patients with prolonged, severe neutropenia. Although high molecular weight hydroxyethyl starch (hHES) facilitates the separation of red blood cells during granulocyte collection, renal dysfunction has been noted as a potential side effect. HES130/0.4 (Voluven®) is a medium molecular weight HES (mHES) with superior safety profiles compared to hHES. Although HES130/0.4 is reportedly effective in the collection of granulocytes, we lack studies comparing the efficiency of granulocyte collection using HES130/0.4 and hHES.

STUDY DESIGN AND METHODS

We retrospectively collected the data from 60 consecutive apheresis procedures performed on 40 healthy donors at the Okayama University Hospital between July 2013 and December 2021. All procedures were performed using the Spectra Optia system. Based on the HES130/0.4 concentration in the separation chamber, granulocyte collection methods using HES130/0.4 were classified into m0.46, m0.44, m0.37, and m0.8 groups. We used HES130/0.4 and hHES groups to compare the various sample collection methods.

RESULTS

The median granulocyte collection efficiency (CE) was approximately 24.0% and 28.1% in the m0.8 and hHES groups, respectively, which were significantly higher than those in the m0.46, m0.44, and m0.37 groups. One month following granulocyte collection with HES130/0.4, no significant changes were observed in serum creatinine levels compared to those before the donation.

CONCLUSION

Therefore, we propose a granulocyte collection approach employing HES130/0.4, which is comparable to the use of hHES in terms of the granulocyte CE. A high concentration of HES130/0.4 in the separation chamber was considered crucial for granulocyte collection.

Durable remission of thrombotic thrombocytopenic purpura in the setting of pembrolizumab therapy

BACKGROUND

There is a small but growing number of thrombotic thrombocytopenic purpura (TTP) cases attributed to immune checkpoint inhibitor therapy, with nivolumab and ipilimumab therapy being the most frequently described in the literature.

STUDY DESIGN AND METHODS

This report evaluates the course of a patient with a history of metastatic adenocarcinoma of the lung who developed TTP following treatment with the PD-1 inhibitor Pembrolizumab. The patient was treated with six sessions of therapeutic plasma exchange and appeared to be in remission. Exacerbation occurred 4 days later, and seven more sessions of plasma exchange were performed along with four total doses of Rituximab, and a steroid taper with monitoring of platelet counts and ADAMTS13 activity.

RESULTS

His platelet count recovered to a peak of 318,000 UL with an ADAMTS13 activity of 77% at the time of discharge. The patient has been following up regularly for outpatient testing with no TTP relapse as of the completion of this report.

DISCUSSION

This is one of a few cases of Pembrolizumab-associated TTP reported in the literature with successful complete remission following treatment. Plasma exchange in this setting may be an especially beneficial therapeutic intervention because of the removal of both the anti-ADAMTS13 antibody as well as the immune system upregulating anti-PDL1 monoclonal antibody with replacement of ADAMTS13 from donor plasma. Longer duration of plasma exchange and monitoring for normalization of ADAMTS13 levels in addition to platelet count before cessation of treatment may improve durable remission rates in this entity.

Single center experience of therapeutic plasma exchange in a resource-constrained setting: A study of trends in scope and complications

BACKGROUND

Therapeutic apheresis procedures are becoming an increasingly integral part of modern medical practice, be it as a part of therapy or pre-conditioning regimes for solid organ transplants. In our center, we follow the American Society for Apheresis (ASFA) guidelines for categorizing these procedures. However, lack of a centralized registry for therapeutic apheresis in India, lack of consolidated data as well as a resource-constrained setting prevent it from being utilized to its full potential.

STUDY DESIGN AND METHODS

This study was a retrospective analysis of therapeutic plasma exchange (TPE) procedures performed from January 2015 to October 2022 in the Department of Transfusion Medicine at a large tertiary care hospital in North India. All consecutive TPE procedures were included. Overall and specialty-wise scoring for all patients was performed. Mean scores were calculated.

RESULTS

A total of 1434 procedures were performed during the study duration of 7 years. These procedures were performed for 284 different patients. Majority of the procedures were referred from nephrology (895 of 1434, 62.4%), followed by neurology, gastroenterology, and liver transplant teams, hematology, critical care, rheumatology, pediatrics, and internal medicine. Complete response, partial response, and no-response were observed in 1077 (75.1%), 201 (14%), and 156 (10.9%) procedures respectively. Only 14 procedures reported adverse effects.

DISCUSSION

Increasing effectiveness of TPE in a number of procedures and a variety of indications has broadened its scope, while the small number of adverse events, when supervised by trained Transfusion Medicine physicians has made TPE a more viable and safer alternative to other treatment modalities.

A novel low-density lipoprotein/fibrinogen apheresis method for chronic limb-threatening ischemia in patients with poor options for revascularization: A multicenter, single-arm clinical trial

INTRODUCTION

Low-density lipoprotein (LDL) apheresis is a treatment option for patients with unhealed chronic limb-threatening ischemia (CLTI) after revascularization. The newly developed AS-25 is a direct hemoperfusion-type apheresis device that differs from conventional LDL apheresis therapy and is designed to specifically adsorb both LDL-C and fibrinogen. We evaluate the efficacy and safety of AS-25.

METHODS

This study included 61 patients whose ulcers failed to heal after revascularization or were ineligible for revascularization. Of these, 50 were undergoing hemodialysis. The primary endpoint was the healing rate of a target lesion of interest (ulcer), using historical data as control.

RESULTS

The ulcer healing rate of 45.9% was significantly higher than the historical data. No significant safety concerns were observed.

CONCLUSIONS

AS-25 was effective in healing ulcers and preventing major amputation even in CLTI refractory patients on hemodialysis, thus showing potential clinical applicability and high significance.

CLINICAL TRIAL REGISTRATION

UMIN study ID UMIN000020336.

How do we operate a large monthly red blood cell exchange program

BACKGROUND

Red blood cell (RBC) exchange for sickle cell disease presents unique difficulties due to RBC phenotyping, complex antibody work-ups, large number of RBC units required, and vascular access considerations, any of which can delay the procedure. Multidisciplinary coordination and systemic processes ensure that monthly appointments remain on schedule.

STUDY DESIGN AND METHODS

A high-volume chronic RBC exchange program is described, highlighting the importance of multidisciplinary coordination and process improvement strategies involving initial referral, vascular access, order sets, and allocation of antigen-negative or phenotypically matched RBCs.

RESULTS

Approximately 50 outpatient RBC exchanges are performed each month with an 82% kept-appointment rate. Specific factors for program success include open communication across services and improvements to referrals and standardized order sets.

CONCLUSION

A combination of multidisciplinary coordination and process improvement can ensure the success of a high volume RBC exchange program. Frequent communication of upcoming appointments between the referring hematologists, the hemapheresis clinic, transfusion service, and interventional radiology is critical. Advance notice to the immunohematology reference lab of upcoming appointments is needed to allow enough time for allocating antigen-negative RBCs. Order sets can be leveraged to standardize and streamline RBC exchanges. Lastly, numerous mechanisms help patients compensate for the cognitive sequelae of stroke.

Safety and performance of the Spectra Optia apheresis system for white blood cell depletion in patients with elevated white blood cell counts

BACKGROUND

For the past 30 years, white blood cell depletion (WBCD) or leukocytapheresis has been conducted to rapidly reduce excessive circulating white blood cell (WBC) concentrations in patients at risk for or with symptoms of leukostasis due to hyperleukocytosis. The goal of leukocytapheresis is to prevent or treat acute complications from leukostasis, thereby enabling patients to receive potentially curative chemotherapy.

METHODS

This report details the results from a retrospective and a prospective clinical study conducted in the European Union and the People's Republic of China, which assessed the use of the Spectra Optia Apheresis System for leukocytapheresis in patients with hyperleukocytosis. The primary objective of both studies was to the assess the safety and performance of the WBCD procedure in patients with elevated WBC counts.

RESULTS

Data were collected from 72 participants completing 87 WBCD procedures. The mean percent change in participant WBC counts post-procedure was 50.3 ± 21.2% and the collection efficiency (CE1) of the WBCD procedures was 53.7 ± 19.8%. Sixty-one participants (95.3%) experienced a total of 279 adverse events (AEs) with the majority of the AEs related to post-procedure changes in laboratory values, which is an anticipated AE in this patient population.

CONCLUSION

The data collected within these studies indicate that the WBCD procedure is safe and well tolerated in patients with hyperleukocytosis as evaluated by percent decrease in WBC count, CE1, and AE incidence.

How do I initiate and maintain a mobile apheresis service in the era of cellular therapy

BACKGROUND

Mobile delivery of apheresis services is an increasingly important component of health care equity, as patients should not have to transfer care providers or travel far distances to receive critical therapeutic apheresis procedures or cell therapy-based treatments. Therefore, the availability of such services should be expanded.

STUDY DESIGN AND METHODS

In this "How Do I" article, we provide a detailed overview of the elements necessary to initiate and maintain a successful mobile apheresis service, including challenges and potential solutions.

RESULTS

Safe and efficient operation of a mobile apheresis service must consider acquisition of physical assets, such as apheresis sites, personnel, equipment and supplies, communication devices, and transportation vehicles, and optimize organizational aspects, such as staff responsibilities, service partnerships, logistics management, case scheduling and triage, and billing. In the era of cellular therapy, additional critical considerations include regulatory compliance and facility accreditation.

DISCUSSION

To our knowledge, no previous publication provides the extensive details described herein to set up and maintain a successful mobile apheresis service, and thus will be very helpful to those facilities wishing to initiate or expand mobile apheresis services.

Fatal Babesiosis in an Immunocompetent Patient

Human babesiosis is an emerging infectious disease with a progressively rising number of cases in the Northeast over the last few decades. We report a case of fatal babesiosis in a 48-year-old male without significant risk factors for a severe presentation. Clinicians should be aware that even in patients without the classic risk factors of asplenia, advanced age, and immunocompromised status for severe presentations of babesiosis, a deadly case can present. There is a need for further research regarding optimal treatment options for severe babesiosis considering the questionable efficacy of red blood cell exchange (RCE) transfusion in patients who do not improve on the current first-line antimicrobials.

Low hematocrit reduces the efficiency of CD34+ cell collection when using the Spectra Optia continuous mononuclear cell collection procedure

BACKGROUND

CD34⁺ cell collection efficiency (CE) is the determining factor when calculating processed blood volume (PBV) for leukapheresis (LP). However, the factors affecting CE in the continuous mononuclear cell collection (cMNC) protocol performed by the Spectra Optia apheresis system are not well established.

STUDY DESIGN AND METHODS

We retrospectively collected the data from 147 consecutive apheresis procedures across 106 healthy donors and 27 patients completed between July 2016 and December 2020 at the Okayama University Hospital. All procedures were performed using the Optia cMNC protocol.

RESULTS

The median CD34⁺ CE2 was significantly higher in the donor samples (64.3%) than in the patient samples (46.8%) (p < .0001). WBC counts, hematocrit, and platelet counts were all significantly higher in the donors than in the patients, and there was a moderate positive correlation between CD34⁺ CE2 and hematocrit (r = .47, p < .0001), with the equation of the line being y = 1.23x + 12.23. In contrast, there was only a very weak correlation between CD34⁺ CE2 and WBC or platelet count. In addition, low hematocrit correlated with an increased time to interface formation.

CONCLUSION

These data revealed the negative impact of low hematocrit on the efficiency of CD34⁺ cell collection when using the Optia cMNC protocol and suggest that hematocrit values should also be considered when determining PBV.

Targeting C-Reactive Protein by Selective Apheresis in Humans: Pros and Cons

C-reactive protein (CRP), the prototype human acute phase protein, may be causally involved in various human diseases. As CRP has appeared much earlier in evolution than antibodies and nonetheless partly utilizes the same biological structures, it is likely that CRP has been the first antibody-like molecule in the evolution of the immune system. Like antibodies, CRP may cause autoimmune reactions in a variety of human pathologies. Consequently, therapeutic targeting of CRP may be of utmost interest in human medicine. Over the past two decades, however, pharmacological targeting of CRP has turned out to be extremely difficult. Currently, the easiest, most effective and clinically safest method to target CRP in humans may be the specific extracorporeal removal of CRP by selective apheresis. The latter has recently shown promising therapeutic effects, especially in acute myocardial infarction and COVID-19 pneumonia. This review summarizes the pros and cons of applying this novel technology to patients suffering from various diseases, with a focus on its use in cardiovascular medicine.

Therapeutic plasma exchange for the management of a type III hypersensitivity reaction and suspected immune-mediated vasculitis assumed to be caused by human albumin administration in a dog

OBJECTIVE

To describe the successful treatment of a life-threatening type III hypersensitivity reaction suspected to have been related to human serum albumin (HSA) administration in a dog with therapeutic plasma exchange (TPE).

CASE SUMMARY

A 3-year-old neutered male mixed breed dog was suspected to have developed immune-mediated vasculitis 2 weeks after the administration of HSA (740 mg/kg) for the management of hypoalbuminemia resulting from septic peritonitis. The dog was presented with fever, edema, hypoalbuminemia (26 g/L [2.6 g/dL]; reference interval, 30-44 g/L [3.0-4.4 g/dL]), and coagulopathy. The dog was treated with fresh frozen plasma (FFP) and glucocorticoids but remained hypoalbuminemic (18 g/L [1.8 g/dL]) and developed acute kidney injury (AKI). Over 4 days, 3 TPE treatments were performed, with a total of 2.7 plasma volumes exchanged. Replacement fluids consisted of a combination of FFP, hydroxyethyl starch 6%, and 0.9% saline solution. Following TPE treatments, serum albumin concentration increased (from 18 g/L [1.8 g/dL] to 25 g/L [2.5 g/dL]), serum creatinine concentration decreased (from 340 μmol/L [3.9 mg/dL] to 87 μmol/L [0.98 mg/dL]), and clotting times normalized (activated partial thromboplastin time decreased from 33 seconds to 14.5 seconds). There was a gradual but consistent clinical improvement of the edema and overall demeanor of the dog. No significant adverse effects were noted during the TPE treatments, and the dog was discharged after 8 days of hospitalization. Following discharge, the dog had complete clinical resolution of edema and AKI. NEW/UNIQUE INFORMATION: This is the first report describing successful use of TPE for the management of an immune-mediated reaction (type III hypersensitivity) following HSA administration.

Therapeutic Plateletpheresis in Patients With Thrombocytosis: Gender, Hemoglobin Before Apheresis Significantly Affect Collection Efficiency

Background: Thrombocytosis is a common symptom in myeloproliferative neoplasms (MPN), and excessive proliferation may deteriorate into thrombosis, bleeding, myelofibrosis, and may ultimately convert to acute leukemia. This study aimed to investigate the collection efficiency of plateletpheresis (CEPP) and factors influencing its efficacy in patients with thrombocytosis.

Materials and Methods: From September 2010 to December 2016, 81 patients from two institutions in China with myeloproliferative neoplasms and thrombocytosis accompanied by severe symptoms were treated with plateletpheresis by Fresenius COM. TEC machine.

Results: After apheresis, the median CEPP was 20.71% (IQR: 9.99–36.69%) and median PLT reduction rate was 25.87% (IQR: 21.78–36.23%). Further analysis showed that no significant difference was observed between PLT count with 800–1,000 × 10⁹/L and > 1,000 × 10⁹/L. The PLT counts significantly decreased (P < 0.001) after plateletpheresis, the red blood cell (RBC), white blood cell (WBC), hemoglobin (HGB), and hematocrit (HCT) levels showed no significant differences before- or after- plateletpheresis. Multivariate analysis showed that female sex (P = 0.009) and HGB (P = 0.010) before apheresis were associated with CEPP. Female (P = 0.022), HCT (P = 0.001) and blood volume (P = 0.015) were associated with the PLT reduction rate. Furthermore, symptoms were relieved after apheresis in patients whose PLT count was 800–1,000 × 10⁹/L accompanied with symptoms.

Conclusions: It is reasonable to perform plateletpheresis when the PLT count is over 800 × 10⁹/L and patients are complicated by clinical symptoms such as dizziness, headache, somnolence, and stupor. Plateletpheresis is effective in removing PLTs especially in females with high HGB.

Therapeutic apheresis and non-blood donor related apheresis current practices at various blood centres of healthcare organisations of India: A brief online survey

OBJECTIVES

To determine the variability in therapeutic apheresis (TA) and non-blood donor related apheresis practices, and the extent of expertise and knowledge of blood centre staff.

BACKGROUND

Apheresis activity that was earlier limited to therapeutic plasma exchange (TPE) and donor apheresis at few centres in India has seen remarkable surge involving many centres practising TA and non-blood donor related apheresis. The decentralised transfusion medicine practice in country has resulted in wide variability of knowledge and practice of TA. An online survey was conducted to achieve study objectives.

STUDY DESIGN AND METHODS

A 22 questionnaire survey was sent to the 215 blood centres through e-mail link focussing on three aspects; basic information of the participating centres, details of TA procedures and education and training levels of the staff.

RESULTS

Majority (71.9%) of centres were teaching institutions among analysed 57 centres. TPE (85.9%) and therapeutic cytapheresis (71.9%) were the most common TA procedures. The clinical haematology (68.4%) followed by neurology (64.9%) were the specialities utilising TA. The 64.9% centres used continuous flow cell separator and central venous access (52%) was preferred vascular access. A combination of normal saline, fresh frozen plasma and 5% albumin replacement fluid was first choice. Doctors involved in TA were trained in apheresis during their MD/DNB degree, but no structured training program existed for other category of staff.

CONCLUSION

There was a wide variability in TA practice in India and a dedicated training program for all categories of staff was emphasised by majority of participants.

A new step in understanding stem cell mobilization in patients with Fanconi anemia: A bridge to gene therapy

BACKGROUND

Fanconi anemia (FA) is an inherited disorder characterized clinically by congenital abnormalities, progressive bone marrow failure (BMF), and a predisposition to malignancy. Gene therapy (GT) of FA, via the infusion of gene-corrected peripheral blood (PB) autologous hematopoietic stem cells (HSCs), may constitute a cure for BMF. GT bypasses the donor restrictions and adverse events associated with allogenic HSC transplantation. However, adequate harvesting of PB-HSCs is a crucial determinant of successful engraftment in gene therapy. Harvesting the low numbers of HSCs in patients with FA is particularly challenging.

STUDY DESIGN AND METHODS

This open-label phase I/II trial evaluates the feasibility and safety of co-administration of G-CSF and plerixafor in patients with FA for the mobilization and harvesting of peripheral HSCs, intending to use them in a gene therapy trial. Patients with mutations in the FANCA gene received two subcutaneous injections of G-CSF (6 μg/kg × 2/d from D1 to D8. Plerixafor (0.24 mg/kg/d) was administered 2 h before apheresis (from D5 onward).

RESULTS

CD34⁺ cells were mobilized for four patients quickly but transiently after the plerixafor injection. One patient had a CD34⁺ cell count of over 100/μl; the mobilization peaked 2 h after the injection and lasted for more than 9 h. There were no short-term adverse events associated with the mobilization or harvesting procedures.

CONCLUSION

Our data in patients with FA show that the mobilization of HSCs with G-CSF and plerixafor is safe and more efficient in younger individuals without BMF.

A Sorbent with Synthetic Ligand for Removing Pro-atherogenic and Pro-inflammatory Components from Human Blood Plasma

Elevated levels of apoB-100 containing lipoproteins and markers of systemic inflammation are often observed in patients with cardiovascular diseases. The concentrations can be reduced by pharmacotherapy or extracorporeal treatment. The sorbent, which removes CRP and atherogenic lipoproteins, simultaneously reduces the bloodstream concentration of these components. The efficacy and selectivity of the designed sorbent were studied, desorption constants of CRP (Kd = 4.2 × 10-8 M) and LDL (Kd = 7.7 × 10-7 M) were distribution coefficients of CRP (Kc = 101) and Lp(a) (Kc = 38) were calculated, and the ability to bind large amounts of atherogenic lipoproteins (up to 32 mg of TC per mL of the sorbent gel) was demonstrated. Our sorbent can be recommended for performing complex removal of CRP and atherogenic lipoproteins from the blood plasma in patients with refractory hyperlipidemia and CVD that are accompanied by elevated levels of CRP.

Current advances in transfusion medicine 2020: A critical review of selected topics by the AABB Clinical Transfusion Medicine Committee

BACKGROUND

The AABB Clinical Transfusion Medicine Committee (CTMC) compiles an annual synopsis of the published literature covering important developments in the field of transfusion medicine (TM), which has been made available as a manuscript published in Transfusion since 2018.

METHODS

CTMC committee members reviewed original manuscripts including TM-related topics published electronically (ahead) or in print from December 2019 to December 2020. The selection of topics and manuscripts was discussed at committee meetings and chosen based on relevance and originality. Next, committee members worked in pairs to create a synopsis of each topic, which was then reviewed by two additional committee members. The first and senior authors of this manuscript assembled the final manuscript. Although this synopsis is extensive, it is not exhaustive, and some papers may have been excluded or missed.

RESULTS

The following topics are included: COVID-19 effects on the blood supply and regulatory landscape, COVID convalescent plasma, adult transfusion practices, whole blood, molecular immunohematology, pediatric TM, cellular therapy, and apheresis medicine.

CONCLUSIONS

This synopsis provides easy access to relevant topics and may be useful as an educational tool.

Extracorporeal photopheresis chargemasters show haphazard billing practices

BACKGROUND

United States healthcare spending continues to outpace other developed nations although efforts are being made to increase cost-transparency. Recent legislation requires hospitals to publish a chargemaster, a list of all billable procedure codes together with prices. Chargemaster prices have been shown to be highly variable, if available, and are not typically paid, but contribute to negotiated rates. Extracorporeal photopheresis (ECP) is performed for a limited number of indications and could serve as a marker of this variability. We investigated the availability of chargemaster documentation for ECP procedures and the variability of pricing as assessed by institutional characteristics.

STUDY DESIGN AND METHODS

A list of centers with photopheresis systems was obtained from the device manufacturer and the institutional websites were analyzed for chargemaster list prices. Multivariate linear regressions were performed to compare impact of facility variables on chargemaster pricing.

RESULTS

There are 139 locations in the US which are listed as referral centers for ECP; and chargemaster prices were available in 66.2% of these centers. The range was $571.48-183,452.00, maximum price 321 times greater than minimum, and the median price, after outlier exclusion, was $8989.06 (SD = $4361.72). ECP cost did not correlate with hospital size, facility type, ownership, number of hospitals in the referral region, hospital care intensity index, academic status, or region (p ≥ .05).

CONCLUSIONS

Chargemaster costs for ECP procedures are highly variable and nonuniform, and the current data available for patients undergoing these specialized apheresis procedures is insufficient to afford patients the ability to compare prices.

Novel adsorptive type apheresis device Immunopure for ulcerative colitis from clinical perspectives based on clinical trials: Japan and Europe

Several adsorptive type devices for ulcerative colitis are used for the induction of remission in patients with active severe disease worldwide. In 2020, the novel apheresis device Immunopure for ulcerative colitis was launched in Japan. Immunopure, like the polyethylene terephthalate column, uses polyarylate, a type of polyester resin, as the adsorbent. Similar to the cellulose acetate column, Immunopure is filled with adsorbent beads and expected to provide ease of use, with minimal risk of column clogging. Immunopure adsorbs leukocytes and platelets, especially activated platelets and platelet‐leukocyte aggregates. In this article, the capability of Immunopure is evaluated from clinical perspective based on a clinical trial in Japan/Europe. As a result, Immunopure is comparable to other products in clinical effectiveness and indicated for the treatment of patients with refractory moderate ulcerative colitis, making it highly useful in clinical practice.

The first local experiences with rheopheresis treatment

Összefoglaló. Háttér: A rheopheresis egy szelektív, extracorporalis, kettős kaszkádfiltrációs eljárás, mely előzetes plazmaszeparációt követően egy speciális filter segítségével kivonja a vérplazmából a hiperviszkozitásért felelős komponenseket, úgymint alacsony sűrűségű lipoprotein, lipoprotein(a), triglicerid, koleszterin, fibrinogén, α2-makroglobulin, Von Willebrand-faktor, immunglobulin-M. Módszer és Betegek: Klinikánkon az elmúlt 5 évben MONET filter alkalmazásával összesen 80 kezelést végeztünk hiperviszkozitással összefüggő, időskori száraz maculadegeneratióban, diabeteses alsó végtagi fekélyben, illetve neuropathiában. Eredmények: A dolgozatban beszámolunk kedvező klinikai tapasztalatainkról, a viszkozitás, a klinikai tünetek és az elektroneurográfiai paraméterek tükrében. Orv Hetil. 2021; 162(10): 375-382.

SUMMARY

BACKGROUND

Rheopheresis is a selective, extracorporeal, double cascade filtration method. After a previous plasma separation, with the help of a special filter it extracts compounds from blood plasma which are responsible for hyperviscosity such as low-density lipoprotein, lipoprotein(a), triglyceride, cholesterine, fibrinogen, α2-macroglobulin, Von Willebrand factor, immunoglobulin M.

METHOD AND PATIENTS

In the past 5 years, with the application of MONET filter we performed 80 therapies to treat age-related macula degeneration, diabetic foot ulcers and neuropathy which are complicated with hyperviscosity.

RESULTS

The review describes our benefical clinical experiences in consideration of viscosity, clinical symptoms and electroneurography parameters. Orv Hetil. 2021; 162(10): 375-382.

Inflammation-Related Carcinogenesis: Lessons from Animal Models to Clinical Aspects

Simple Summary

In multicellular organisms, inflammation is the body’s most primitive and essential protective response against any external agent. Inflammation, however, not only causes various modern diseases such as cardiovascular disorders, neurological disorders, autoimmune diseases, metabolic syndrome, infectious diseases, and cancer but also shortens the healthy life expectancy. This review focuses on the onset of carcinogenesis due to chronic inflammation caused by pathogen infections and inhalation/ingestion of foreign substances. This study summarizes animal models associated with inflammation-related carcinogenesis by organ. By determining factors common to inflammatory carcinogenesis models, we examined strategies for the prevention and treatment of inflammatory carcinogenesis in humans.

Abstract

Inflammation-related carcinogenesis has long been known as one of the carcinogenesis patterns in humans. Common carcinogenic factors are inflammation caused by infection with pathogens or the uptake of foreign substances from the environment into the body. Inflammation-related carcinogenesis as a cause for cancer-related death worldwide accounts for approximately 20%, and the incidence varies widely by continent, country, and even region of the country and can be affected by economic status or development. Many novel approaches are currently available concerning the development of animal models to elucidate inflammation-related carcinogenesis. By learning from the oldest to the latest animal models for each organ, we sought to uncover the essential common causes of inflammation-related carcinogenesis. This review confirmed that a common etiology of organ-specific animal models that mimic human inflammation-related carcinogenesis is prolonged exudation of inflammatory cells. Genotoxicity or epigenetic modifications by inflammatory cells resulted in gene mutations or altered gene expression, respectively. Inflammatory cytokines/growth factors released from inflammatory cells promote cell proliferation and repair tissue injury, and inflammation serves as a “carcinogenic niche”, because these fundamental biological events are common to all types of carcinogenesis, not just inflammation-related carcinogenesis. Since clinical strategies are needed to prevent carcinogenesis, we propose the therapeutic apheresis of inflammatory cells as a means of eliminating fundamental cause of inflammation-related carcinogenesis.

Role of therapeutic plasma exchanges in refractory severe warm autoimmune hemolytic anemia: Presentation of two case reports

BACKGROUND

Warm autoimmune hemolytic anemia (WAIHA) is a disorder with a usually good response to corticosteroid treatment, whereas in some cases first-line treatment's response is poor and other therapies such as intravenous immunoglobulins (IVIGs), rituximab, or splenectomy must be applied.

STUDY DESIGN AND METHODS

Herein, we describe two patients with severe WAIHA treated at our center, who obtained a response after therapeutic plasma exchanges (TPEs) combined with low doses of IVIG.

RESULTS

The first patient was an 18-year-old man with no relevant past medical history who was diagnosed with WAIHA. The patient presented a progressive clinical worsening despite treatment with prednisone, IVIG, and rituximab. After starting TPEs, signs of hemolysis rapidly improved and hemoglobin started to recover. The second patient was a 38-year-old man with a past history of immune thrombocytopenia and WAIHA. The patient presented a new flare of WAIHA, with no response after 2 weeks of treatment with corticosteroids, IVIG, and rituximab. After initiation of TPEs, the patient had an improvement in hemolysis biomarkers and recovery of hemoglobin concentration.

CONCLUSION

Combination of TPEs with rituximab and IVIG might be considered as a therapeutic option in patients with severe WAIHA without response to corticosteroid and IVIG treatment.

Therapeutic Apheresis, Circulating PLD, and Mucocutaneous Toxicity: Our Clinical Experience through Four Years. Pharmaceutics. 2020;12. [PMID: 33008072 DOI: 10.3390/pharmaceutics12100940]

Cancer treatment has been greatly improved by the combined use of targeted therapies and novel biotechnological methods. Regarding the former, pegylated liposomal doxorubicin (PLD) has a preferential accumulation within cancer tumors, thus having lower toxicity on healthy cells. PLD has been implemented in the targeted treatment of sarcoma, ovarian, breast, and lung cancer. In comparison with conventional doxorubicin, PLD has lower cardiotoxicity and hematotoxicity; however, PLD can induce mucositis and palmo-plantar erythrodysesthesia (PPE, hand-foot syndrome), which limits its use. Therapeutical apheresis is a clinically proven solution against early PLD toxicity without hindering the efficacy of the treatment. The present review summarizes the pharmacokinetics and pharmacodynamics of PLD and the beneficial effects of extracorporeal apheresis on the incidence of PPE during chemoradiotherapy in cancer patients.

Update to the ASFA guidelines on the use of therapeutic apheresis in ANCA-associated vasculitis

Since 1986, the American Society for Apheresis (ASFA) has published practice guidelines on the use of therapeutic apheresis in the Journal of Clinical Apheresis (JCA) Special Issue. Since 2007, updated guidelines have been published every 3 years to reflect current evidence based apheresis practice with the most recent edition (8th) published in 2019. With each edition, the guidelines are reviewed and updated based on any newly published literature since the last review. The PEXIVAS study, an international, randomized controlled trial comparing therapeutic plasma exchange (TPE) vs no TPE and standard vs reduced dose steroid regimen on the primary composite outcome of end stage renal disease or death in patients with ANCA-associated vasculitis (AAV), was published in February 2020. This study represents the largest study on the role of therapeutic apheresis in AAV published to date and prompted the JCA Special Issue Writing Committee to reassess the current AAV fact sheet for updates based on this newly available evidence. This interim fact sheet summarizes current ASFA recommendations for the evidence-based use of therapeutic apheresis in AAV and supersedes the recommendations published in the 2019 guidelines.

Lessons learned from immunoadsorption for hyperviscosity in IgM multiple myeloma-A case report

We report the case of a 63‐year‐old Caucasian woman with multiple relapsed IgM multiple myeloma (MM) and elevated free kappa light chains (fκLC). Due to hyperviscosity syndrome with visual impairment, regular plasma exchanges were performed. As part of her 11th line of therapy, an experimental protocol consisting of pembrolizumab, pomalidomide, and dexamethasone was initiated. To reduce fκLC and immunoglobulin (Ig) M, we performed immunoadsorption (IA) using columns containing recombinant single domain camelid antibody fragments as ligands. We measured pembrolizumab (humanized IgG4 kappa anti‐PD1 antibody) levels before and after each IA session and found a 98.1% reduction from baseline with five sessions of IA. Comparable elimination kinetics were observed for serum IgG, whereas fκLC and IgM were eliminated to a substantially lesser extent. These findings highlight that in hyperviscosity syndrome due to IgM MM, broad spectrum IA columns might be only moderately effective compared to total plasma exchange or double filtration plasmapheresis. Monoclonal antibodies are efficiently reduced by extracorporeal therapies and re‐dosing is necessary to provide sufficient efficacy. In the case of serious adverse events such as immune‐related adverse events, IA might be used to eliminate the monoclonal antibody. Measuring IgG levels might be a reasonable strategy for monitoring drug levels of monoclonal antibodies during IA.

Therapeutic Apheresis in Acute Relapsing Multiple Sclerosis: Current Evidence and Unmet Needs-A Systematic Review

Multiple sclerosis (MS) is the most abundant inflammatory demyelinating disorder of the central nervous system. Despite recent advances in its long-term immunomodulatory treatment, MS patients still suffer from relapses, significantly contributing to disability accrual. In recent years, apheresis procedures such as therapeutic plasma exchange (TPE) and immunoadsorption (IA) have been recognized as two options for treating MS relapses, that do not respond to standard treatment with corticosteroids. TPE is already incorporated in most international guidelines, although evidence for its use resulted mostly from either case series or small unblinded and/or non-randomized trials. Data on IA are still sparse, but several studies indicate comparable efficacy between both apheresis procedures. This article gives an overview of the published evidence on TPE and IA in the treatment of acute relapses in MS. Further, we outline current evidence regarding individual outcome predictors, describe technical details of apheresis procedures, and discuss apheresis treatment in children and during pregnancy.

Successful application of CytoSorb® hemadsorption in an immunocompromised teenager with collapsing glomerulopathy, acute respiratory distress syndrome, and sepsis

OBJECTIVE

CytoSorb^® hemadsorption is an adjunctive therapy in order to reduce elevated cytokine levels of interleukin-6, interleukin-1, and tumor necrosis factor alpha. Here we present a successful administration of CytoSorb^® hemadsorption in an immunocompromised pediatric patient with collapsing glomerulopathy, acute respiratory distress syndrome, and sepsis.

DATA SOURCES

Clinical observations of one patient.

STUDY SELECTION

Case report.

DATA EXTRACTION

Data sources are clinical observation during patient management and patient's medical records if needed. The patient's consent was obtained prior to the study.

DATA SYNTHESIS

A 17-year-old male with diarrhea was admitted to the hospital and was later found to have elevated creatinine levels and proteinuria. The renal biopsy was consistent with collapsing glomerulopathy and treatment with multi immunosuppressive agents including corticosteroids, mycophenolate mofetil, and rituximab coupled with several courses of hemodialysis and plasmapheresis were administered. During the hospital stay, Stenotrophomonas maltophilia bacteremia from the blood and the catheter cultures were identified. No clinical response was achieved, and patient developed severe sepsis despite antibiotics, intravenous immunoglobulin, and supportive management including albumin, platelet and erythrocyte concentrations, and fresh frozen plasma. CytoSorb^® hemadsorption was then added to the ongoing treatment for three consecutive days. Subsequent to CytoSorb^® hemadsorption, immediate laboratory and clinical response were observed.

CONCLUSION

This is the successful clinical report of an immunocompromised teenager with collapsing nephropathy, sepsis, and multi-organ dysfunction syndrome treated with a combination of renal replacement therapy and CytoSorb^® hemadsorption. The usage of CytoSorb^® hemadsorption represents a novel approach to improve survival of the patients with multiple organ dysfunction and sepsis.

[National survey of the therapeutic apheresis in Hungary, 2013-2017]

Therapeutic apheresis is a treatment option for several subspecialities. It is a relatively expensive intervention, which can only be done by dedicated centers based on specific indications. The Therapeutic Apheresis Committee and the National Health Insurance Fund of Hungary jointly control the number of interventions to be made, the introduction of new diagnoses and the application of new apheresis procedures in Hungary. In this work, we review the therapeutic practice of the period between 2013 and 2017 in Hungary, describing also the new modalities under implementation. Orv Hetil. 2019; 160(19): 727-738.

A proposal for sectorial organizing and quality standards in therapeutic apheresis: The therapeutic apheresis unit (TAU) standards

Therapeutic apheresis (TA) includes a wide range of therapeutic procedures based on the separation of blood components and the collection of cells with therapeutic activity or the removal of unwanted plasma or cellular components involved in the etiology of various hematologic, renal, neurological, and medical diseases. The complexity of these interventions requires an organizing model to assure a proper clinical environment, technology, quality requirements, and personnel as well as an active system for outcome monitoring for safety and efficacy. Finally, a structured organizing model may favor the efficiency of the TA unit and economic affordability. Here, we describe the more relevant characteristics of a model of TA standards, named TA unit (TAU) standards, that may help to establish a quality program in units working in the field of TA (shown as supplementary material and available at http://www.ifeit.org/pdf/TAU_Standards_3.0.pdf.

A two-year analysis of therapeutic apheresis practices in a tertiary center: are we chasing the new indications?

BACKGROUND

Therapeutic apheresis (TA) as primary or adjunctive therapy proved itself in a broad spectrum of diseases. This study aims to present TA practices in a tertiary center with an emphasis on the rate of the utility of TA on the new American Society for Apheresis (ASFA) indications.

METHODS

We conducted a retrospective analysis of data regarding TA applications through our electronic medical database from June 2016 to July 2018. The data included demographics, clinical indications, and procedural characteristics. We also searched for the rate of the utility of TA procedures on new ASFA indications by entering both the diagnostic and TA modality codes for these indications on the electronic database during the study interval.

RESULTS

A total of 720 TA procedures were performed on 96 patients (54 males, 42 females, with a mean age of 48.15 ± 26.71 years). The procedures were 68.8 % therapeutic plasma exchange (TPE), 16.4 % leukocytapheresis, 11.5 % immunoadsorption (IA), 3.1 % double filtration plasmapheresis (DFPP), and 0.13 % erythrocyte exchange. The categorical indications included 60.41 % category I and category II, 28.12 % category III, and 1.04 % category IV. The most common indication was thrombotic thrombocytopenic purpura (TTP) (26.04 %). The procedure failure rate was 2.08 %. Patient-related adverse events were reported in 7.5 % of procedures. The case mortality rate was 16.66 %. TA utility rate was 0.98 % for the new indications in the ASFA 2016 guideline.

CONCLUSION

Therapeutic apheresis is a progressively developing, safe, and effective treatment modality with add-on indications.  Physicians should keep track of new developments on this modality to implement the appropriate indications into clinical practice. HIPPOKRATIA 2018, 22(4): 167-172.

Apheresis data registration in WWA registry-10-year experience of our center

INTRODUCTION

The WAA Registry allows detailed registration of hemapheresis data. Our center registers results there as well. We summarize our results as compared to those of the WAA Registry.

MATERIALS AND METHODS

Hemapheresis results are registered in the WAA Registry in Umea, Sweden. The patients' identity is protected by coding. General data (age, gender, weight, procedure, technique used etc.) or special data (occurrence and type of adverse reactions, health condition, quality of life etc.) are completed in a pre-defined form.

RESULTS

In 2006-2016, we registered 7,927 hemaphereses in 956 patients in the WAA Registry; 40.4% in men and 59.6% in women aged 53±15years. There were mostly no significant differences in the individual interventions between our center and the WAA Registry; only the share of cascade filtrations/rheophereses is quite different (9 times higher in our center - 18.2% of interventions as compared to 2.1% in the WAA Registry). The share of photophereses (32.1%) is relatively high - due to cooperation with the bone marrow transplantations department.

DISCUSSION AND CONCLUSION

In regular quality assessment, one center usually does not have enough data and experience with some diseases or interventions; therefore, comparison with the WAA Registry results is valuable not only for the quality of interventions but also for side effect prevention. On the other hand, the advantage is that every center has its unique code and may work quite independently (quick and independent non-competitive assessments). Five-minute duration of registration is advantageous in a time-demanding work; moreover, the registration is free.

From vulnerable plaque to blood healthy therapy

Cardiovascular atherosclerotic disease is the leading cause of death in China and in Western nations. People with plaque or stenosis in the coronary artery or the carotid artery are the most susceptible population to suffer from acute events. Current investigations showed that plaque with the characteristics of intra-plaque hemorrhage or a thin cap with a large lipid core was causally associated with vulnerable plaque and plaque rupture. Of the many plaque ruptures occurring in patients with atherosclerotic disease, very few will trigger symptomatic events, rendering it exceedingly difficult to predict adverse outcomes. The assumption that identifying lesions prone to rupture will prevent acute coronary events was unrealistic. Factors in blood, especially those risk factors associated with thrombosis, play an important role as a bridge between plaque rupture and subsequent clinical events. Since there is little management to efficiently decrease the frequency of plaque rupture or erosion, blood healthy therapy, as a therapeutic apheresis to decrease the blood hypercoagulability to modulate the blood to be thrombosis resisting, should be considered as a potential therapeutic approach to reducing the incidence of acute coronary syndrome and stroke.

Perfect storm: Therapeutic plasma exchange for a patient with thyroid storm

Thyroid storm is a potentially lethal complication of hyperthyroidism with increased thyroid hormones and exaggerated symptoms of thyrotoxicosis. First-line therapy includes methimazole (MMI) or propylthiouracil (PTU) to block production of thyroid hormones as a bridge toward definitive surgical treatment. Untreated thyroid storm has a mortality rate of up to 30%; this is particularly alarming when patients cannot tolerate or fail pharmacotherapy, especially if they cannot undergo thyroidectomy. Therapeutic plasma exchange (TPE) is an ASFA category III indication for thyroid storm, meaning the optimum role of this therapy is not established, and there are a limited number of cases in the literature. Yet TPE can remove T3 and T4 bound to albumin, autoantibodies, catecholamines and cytokines and is likely beneficial for these patients. We report a patient with thyroid storm who could not tolerate PTU, subsequently failed therapy with MMI, and was not appropriate for thyroidectomy. TPE was therefore performed daily for 4 days (1.0 plasma volume with 5% albumin replacement and 2 U of plasma). Over the treatment course, the patient's thyroid hormones normalized and symptoms of thyroid storm largely resolved; his T3 decreased from 2.27 to 0.81 ng/mL (normal 0.8-2.0), T4 decreased from 4.8 to 1.7 ng/mL (0.8-1.8), heart rate normalized, altered mental status improved, and he converted to normal sinus rhythm. He was ultimately discharged in euthyroid state. He experienced no side effects from his TPE procedures. TPE is a safe and effective treatment for thyroid storm when conventional treatments are not successful or appropriate.

The tipping point: The critical role of therapeutic apheresis in a case of refractory acquired hemophilia

Acquired hemophilia A (AHA) is a rare autoimmune disorder that leads to factor VIII (FVIII) deficiency via autoantibody formation. Standard treatment options include FVIII bypassing factors and immunosuppression. However, the role of therapeutic plasma exchange (TPE) is not clear in the treatment of AHA. We present a case of idiopathic AHA in a 66 year old female with severe bleeding and a FVIII inhibitor of 17.6 Bethesda units (BU). She failed to respond to standard treatment including maximum dose of recombinant FVIIa (rFVIIa), rituximab, and other immunosuppressive agents. Her FVIII inhibitor rapidly increased to 140 BU and FVIII was below 5%. TPE was initiated 3 weeks after admission and her bleeding stabilized after the first treatment and completely stopped after three treatments. Repeat testing revealed increased FVIII to 15% and FVIII inhibitor decreased to 2.0 BU. After an additional TPE treatment, her FVIII increased to 27% and FVIII inhibitor decreased to 0.6 BU and she was discharged without bleeding 40 days after admission. In this case, TPE played a critical role in reducing FVIII inhibitor, which resulted in a recovery of FVIII activity and hemostasis. Therefore, TPE should be initiated early in AHA patients with bleeding and high titer of FVIII inhibitor.

How we treat thrombotic thrombocytopenic purpura: Results of a Canadian TTP practice survey

BACKGROUND

Thrombotic thrombocytopenic purpura (TTP) is a rare disease with 90% mortality if untreated. Since the Canadian Apheresis Group (CAG) trial showed greater survival with therapeutic plasma exchange (TPE) versus plasma infusion, there has been widespread adoption of TPE. Beyond TPE, there is significant practice variation. To characterize this, we developed a survey sent to physicians who might be directly involved in TTP management.

METHODS

The survey was sent to CAG members as well as hematologists and nephrologists nationwide and addressed areas of controversy or recognized practice heterogeneity. Descriptive statistics were used to summarize responses, and the χ² test was used to compare respondents who were and were not CAG physicians. We also compared responses by estimated frequency of TTP cases per year.

RESULTS

The CAG response rate was 31% (13 of 42). The survey was sent to 665 non-CAG physicians, of whom 41 responded (6.1%). Though not statistically different, CAG and non-CAG respondents varied regarding use of corticosteroids, aspirin, and venous thromboembolism (VTE) prophylaxis. Significant differences were found between CAG and non-CAG groups regarding cryosupernatant as fluid choice (69.2% vs. 22.5%, P = .004) and the use of TPE tapering (84.6% vs. 51.3%, P = .034), respectively.

CONCLUSION

TTP treatment is variable across centres in Canada. Areas of significant variation include the choice of replacement fluid for TPE and whether or not and how to taper TPE. Our survey highlights the practice heterogeneity that exists and identifies areas where more evidence is needed and perhaps where trials should be performed.

Removal of Soluble Fms-Like Tyrosine Kinase-1 by Dextran Sulfate Apheresis in Preeclampsia

Preeclampsia is a devastating complication of pregnancy. Soluble Fms-like tyrosine kinase-1 (sFlt-1) is an antiangiogenic protein believed to mediate the signs and symptoms of preeclampsia. We conducted an open pilot study to evaluate the safety and potential efficacy of therapeutic apheresis with a plasma-specific dextran sulfate column to remove circulating sFlt-1 in 11 pregnant women (20-38 years of age) with very preterm preeclampsia (23-32 weeks of gestation, systolic BP ≥140 mmHg or diastolic BP ≥90 mmHg, new onset protein/creatinine ratio >0.30 g/g, and sFlt-1/placental growth factor ratio >85). We evaluated the extent of sFlt-1 removal, proteinuria reduction, pregnancy continuation, and neonatal and fetal safety of apheresis after one (n=6), two (n=4), or three (n=1) apheresis treatments. Mean sFlt-1 levels were reduced by 18% (range 7%-28%) with concomitant reductions of 44% in protein/creatinine ratios. Pregnancy continued for 8 days (range 2-11) and 15 days (range 11-21) in women treated once and multiple times, respectively, compared with 3 days (range 0-14) in untreated contemporaneous preeclampsia controls (n=22). Transient maternal BP reduction during apheresis was managed by withholding pre-apheresis antihypertensive therapy, saline prehydration, and reducing blood flow through the apheresis column. Compared with infants born prematurely to untreated women with and without preeclampsia (n=22 per group), no adverse effects of apheresis were observed. In conclusion, therapeutic apheresis reduced circulating sFlt-1 and proteinuria in women with very preterm preeclampsia and appeared to prolong pregnancy without major adverse maternal or fetal consequences. A controlled trial is warranted to confirm these findings.

Apheresis in developing countries around the World

At the combined American Society for Apheresis (ASFA) Annual Meeting/World Apheresis Association (WAA) Congress in San Francisco, California, in April of 2014, the opening session highlighted the status of apheresis outside of the United States. The organizers invited physicians active in apheresis in countries not usually represented at such international gatherings to give them a forum to share their experiences, challenges, and expectations in their respective countries with regard to both donor and therapeutic apheresis. Apheresis technology is expensive as well as technically and medically demanding, and low and median income countries have different experiences to share with the rest of the world. Apheresis procedures also require resources taken for granted in the developed world, such as reliable electrical power, that can be unpredictable in parts of the developing world. On the other hand, it was obvious that there are significant disparities in access to apheresis within the same country (such as in Brazil), as well as between neighboring nations in Africa and South America. A common trend in the presentations from Brazil, Indonesia, Malaysia, Nigeria, and South Africa, was the need for more and better physicians and practitioners' training in the indications of the various apheresis modalities and patient oversight during the procedures. As ASFA and WAA continue to work together, and globalization allows for increased knowledge-sharing, improved access to apheresis procedures performed by qualified personnel with safety and high-quality standards will be increasingly available.

Therapeutic apheresis in Asia: An Indonesia single center experience

In developing countries, like Indonesia, apheresis is still a relative new procedure. Nowadays, therapeutic apheresis procedures are performed in the field of hematology and neurology, especially in the teaching hospitals in Indonesia. Therapeutic apheresis procedure, that is, leukocytapheresis, therapeutic plasma exchange (TPE), and thrombocytapheresis are already performed. In the period 2009-2013, 204 apheresis procedures in 137 patients to reduce the leukocytes, 72 TPE procedures in 17 patients, and 14 thrombocyte reductions were performed in the Sardjito hospital, Yogyakarta, Indonesia. In the future, to improve the therapeutic apheresis implementation, it is important to increase the insurance coverage and also should be considered to introduce the apheresis medicine into the curriculum of appropriate physician programs in Indonesia. Especially in Indonesia, a lot of efforts are still being needed to improve implementation of therapeutic apheresis.

Therapeutic apheresis in autoimmune diseases

Systemic autoimmune diseases based on an immune pathogenesis produce autoantibodies and circulating immune complexes, which cause inflammation in the tissues of various organs. In most cases, these diseases have a bad prognosis without treatment. Therapeutic apheresis in combination with immunosuppressive therapies has led to a steady increase in survival rates over the last 35 years. Here we provide an overview of the most important pathogenic aspects indicating that therapeutic apheresis can be a supportive therapy in some systemic autoimmune diseases, such as systemic lupus erythematosus, antiphospholipid syndrome, rheumatoid arthritis, and inflammatory eye disease. With the introduction of novel and effective biologic agents, therapeutic apheresis is indicated only in severe cases, such as in rapid progression despite immunosuppressive therapy and/or biologic agents, and in patients with renal involvement, acute generalized vasculitis, thrombocytopenia, leucopenia, pulmonary, cardiac, or cerebral involvement. In mild forms of autoimmune disease, treatment with immunosuppressive therapies and/or biologic agents seems to be sufficient. The prognosis of autoimmune diseases with varying organ manifestations has improved considerably in recent years, due in part to very aggressive therapy schemes.