Therapeutic apheresis in hematological and oncological diseases

Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating and categorizing indications for the evidence-based use of therapeutic apheresis (TA) in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Eighth Edition of the JCA Special Issue continues to maintain this methodology and rigor in order to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Eighth Edition, like its predecessor, continues to apply the category and grading system definitions in fact sheets. The general layout and concept of a fact sheet that was introduced in the Fourth Edition, has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of TA in a specific disease entity or medical condition. The Eighth Edition comprises 84 fact sheets for relevant diseases and medical conditions, with 157 graded and categorized indications and/or TA modalities. The Eighth Edition of the JCA Special Issue seeks to continue to serve as a key resource that guides the utilization of TA in the treatment of human disease.

Effects of extracts prepared from modified porous poly(ether imide) microparticulate absorbers on cytotoxicity, macrophage differentiation and proinflammatory behavior of human monocytic (THP-1) cells

Remaining uremic toxins in the blood of chronic renal failure patients represent one central challenge in hemodialysis therapies. Highly porous poly(ether imide) (PEI) microparticles have been recently introduced as candidate absorber materials, which show a high absorption capacity for uremic toxins and allow hydrophilic surface modification suitable for minimization of serum protein absorption. In this work, the effects of extracts prepared from PEI microparticles modified by nucleophilic reaction with low molecular weight polyethylene imine (Pei) or potassium hydroxide (KOH), on human monocytic (THP-1) cells are studied. The obtained results suggested that the extracts of Pei and KOH modified PEI absorbers have no negative effect on THP-1 cell viability and do not initiate the critical differentiation towards macrophages. The extracts did not enhance transcript or protein levels of investigated proinflammatory markers in THP-1 cells, namely, TNFμ, MCP1, IL6 and IL8. Based on these findings such modified PEI microparticles should be qualified for further pre-clinical evaluation i.e. in an in vivo animal experiment.

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

The American Society for Apheresis (ASFA) Journal of Clinical Apheresis (JCA) Special Issue Writing Committee is charged with reviewing, updating, and categorizing indications for the evidence-based use of therapeutic apheresis in human disease. Since the 2007 JCA Special Issue (Fourth Edition), the Committee has incorporated systematic review and evidence-based approaches in the grading and categorization of apheresis indications. This Seventh Edition of the JCA Special Issue continues to maintain this methodology and rigor to make recommendations on the use of apheresis in a wide variety of diseases/conditions. The JCA Seventh Edition, like its predecessor, has consistently applied the category and grading system definitions in the fact sheets. The general layout and concept of a fact sheet that was used since the fourth edition has largely been maintained in this edition. Each fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis in a specific disease entity. The Seventh Edition discusses 87 fact sheets (14 new fact sheets since the Sixth Edition) for therapeutic apheresis diseases and medical conditions, with 179 indications, which are separately graded and categorized within the listed fact sheets. Several diseases that are Category IV which have been described in detail in previous editions and do not have significant new evidence since the last publication are summarized in a separate table. The Seventh Edition of the JCA Special Issue serves as a key resource that guides the utilization of therapeutic apheresis in the treatment of human disease. J. Clin. Apheresis 31:149-162, 2016. © 2016 Wiley Periodicals, Inc.

Use of Cellular and Plasma Apheresis in the Critically Ill Patient: Part II: Clinical Indications and Applications

Apheresis is the process of separating the blood and removing or manipulating a cellular or plasma component for therapeutic benefit. Such procedures may be indicated in the critical care setting as primary or adjunctive therapy for certain hematologic, neurologic, renal, and autoimmune/rheumatologic disorders. In part I of this series, the technical aspects of apheresis were described and the physiologic rationale and clinical considerations were discussed. This review highlights the pathophysiologic basis, specific clinical indications, and treatment parameters for disorders that more commonly require management in the intensive care unit. The choice of plasma or cellular apheresis in these cases is guided by wellaccepted, evidence-based clinical treatment guidelines. For some disorders, such as liver failure, severe sepsis, and multiple-organ dysfunction syndrome, apheresis treatment approaches remain experimental. Ongoing studies are investigating the potential utility of conventional plasma exchange, ex vivo plasma manipulation, and newer technologies for these and other disorders in severely ill patients.

American Society for Apheresis guidelines on the use of apheresis in clinical practice: practical, concise, evidence-based recommendations for the apheresis practitioner

The 6th Guidelines on the use of therapeutic apheresis in clinical practice published by the American Society of Apheresis provide practical, concise, and evidence based guidance for the apheresis medicine practitioner. The overall format of the Guidelines has remained unchanged with the 6th edition, compared to the 5th edition, with enhancements in the committee process of creating the guidelines. Because of changes in the writing committee structure, a number of changes have occurred in the ASFA category and recommendation grade for the use of apheresis in the treatment for a number of previously categorized clinical indications. In addition, eight new indications for apheresis, twenty three new clinical situations for previously categorized diseases, and ten new apheresis treatments for previously categorized disorders have been added. The 6th Guidelines continue to be an invaluable resource for those involved in apheresis medicine.

Spinal surgery in a patient with essential thrombocythemia resulting in leg paraplegia: a case report

BACKGROUND CONTEXT

Essential thrombocythemia (ET) is a chronic myeloproliferative disorder characterized by a relatively benign clinical course that may be complicated by conflicting thrombosis and bleeding. Postoperative spinal epidural hematoma is an uncommon, but well-known, complication after spinal surgery.

PURPOSE

To describe a patient with ET who underwent surgery for lumbar spinal canal stenosis resulting in leg paraplegia and discuss the perioperative management for ET.

STUDY DESIGN

Case report.

RESULTS

The patient with ET underwent laminoplasty and posterolateral fusion for degenerative spondylolisthesis and spinal stenosis at L4-L5. A hematoma was observed in the epidural cavity after surgery, and emergency surgical evacuation was performed. After revision surgery, bleeding from the wound continued for 2 months, despite transfusions of platelets and coagulation factors, and right unilateral leg paralysis developed.

CONCLUSIONS

This case presentation increases the awareness of this disorder to the spinal community and the need to establish guidelines for the perioperative management of patients who require surgery in similar settings.

Infections in patients with hematologic neoplasms and hematopoietic stem cell transplantation: neutropenia, humoral, and splenic defects

Infections are common in patients with hematologic neoplasms and following allogeneic hematopoietic transplantation. Neutropenia and defects in adaptive B-cell-mediated immunity and/or lack of splenic function predispose patients to a host of diverse and often serious infections. It is important to recognize that patients who undergo treatment for hematologic neoplasms may have mixed immune defects, and their vulnerability to infection may continue to change, in part as a reflection of the dynamic developments in the practice of oncology. The main obstacle in providing targeted, evidence-based antimicrobial treatment is the unpredictable results of even the new generation of diagnostic assays. A definite diagnosis for most end-organ opportunistic diseases requires tissue samples that are seldom available. Because immune defects may coexist, empirical therapy is directed toward a wide spectrum of pathogens. Real-time information about innate and adaptive immune functions and the role of acute and chronic phase molecules may improve target-specific therapy.

Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. Beginning with the 2007 ASFA Special Issue (fourth edition), the subcommittee has incorporated systematic review and evidence-based approach in the grading and categorization of indications. This Fifth ASFA Special Issue has further improved the process of using evidence-based medicine in the recommendations by refining the category definitions and by adding a grade of recommendation based on widely accepted GRADE system. The concept of a fact sheet was introduced in the Fourth edition and is only slightly modified in this current edition. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. The article consists of 59 fact sheets devoted to each disease entity currently categorized by the ASFA as category I through III. Category IV indications are also listed.

Diagnosis and treatment of tick infestation and tick-borne diseases with cutaneous manifestations

Hard and soft ticks may be associated directly or indirectly with a number of dermatoses, both infectious and inflammatory in origin. Morbidity may occur as a result of tick bites, tick toxicosis, and even infestation. These arthropod vectors may transmit life-threatening protozoan, bacterial, rickettsial, and viral diseases with systemic and cutaneous findings. Additionally, ticks may transmit more than one pathogen with subsequent human coinfection. This article reviews the presentation of tick-borne illnesses and the medical management of these diseases. Among others, diseases such as ehrlichiosis, anaplasmosis, babesiosis, tularemia, borrelioses, tick-borne encephalitides, rickettsial spotted fevers, and tick typhus are discussed in this article. The recognition of skin manifestations associated with these diseases is paramount to early diagnosis and treatment initiation.

Therapeutic apheresis: Results from a single center in Turkey

BACKGROUND

Therapeutic apheresis (TA) is carried out for a broad spectrum of diseases and syndromes.

AIM

We retrospectively evaluated the results of therapeutic apheresis (TA) including plasma exchange, therapeutic plateletpheresis, and leukapheresis during 2000-2006.

METHODS

A total of 195 procedures were performed in 44 patients (25 male and 19 female, with a mean age of 52+/-15 years). These procedures consist of 165 plasma exchanges, 20 therapeutic plateletpheresis, and 10 leukapheresis. The most common indications were hematological, neurological, and metabolic diseases. Eighty-three percent of plasma exchange, 100% of plateletpheresis and leukapheresis belonged to indication Category I or II, according to the guidelines of the American Society for Apheresis.

RESULTS

While hemoglobin levels significantly increased (p<0.05), platelet counts decreased (p<0.005) after plasma exchange. Hematological parameters did not statistically change significantly with leukapheresis (p>0.05). Platelet counts significantly decreased with plateletpheresis (p<0.001). Total complications were detected in 21% of the procedures. Adverse events (AE) were seen in 17% of the procedures. None of the patients died (Grade-IV) from any complication. AEs occurred in 14% (Grade-I), 1% (Grade-II), and 2% (Grade-III) of the procedures. The most common AEs were nausea/vomiting, hypotension, and abdominal pain.

CONCLUSION

TA, an important procedure in Transfusion Medicine, is safely carried out in our center in several hematological, neurological, and metabolic diseases which are similar to previous reports.

Therapeutic erythrocytapheresis versus phlebotomy in the initial treatment of hereditary hemochromatosis – A pilot study

Hereditary Hemochromatosis (HH) is a genetic disorder of iron metabolism, resulting in excessive iron overload. Currently, phlebotomy is the standard effective treatment that prevents progression of tissue damage. Aim of the therapy is to reach ferritin levels between 20 and 50mugl(-1). In patients with total iron stores of more than 30g, intensive treatment by means of weekly phlebotomies during 2-3 years is required to reach this aim. More recently mechanical removal of erythrocytes through therapeutic erythrocytapheresis (TE) has become a new therapeutic modality. By means of TE, up to 1000ml erythrocytes per session can be removed, depending on patient characteristics, compared to 250ml erythrocytes per phlebotomy. Thus, TE potentially offers a more efficient method of removing iron overload with less procedures in a shorter treatment period. In a pilot study between 2002 and 2005, results from a group of HH patients treated with TE (N=6) were compared to the results of a historical control group of HH patients (N=6) treated with phlebotomy. The results showed a reduction of almost 70% in both the total number and the duration of treatments in the TE group. Although, the procedure costs compared on the basis of a single TE session were higher, the total costs for the whole treatment were comparable or cheaper with the use of TE. Future prospective studies are needed to compare both therapies in a randomized setting.

Guidelines on the use of therapeutic apheresis in clinical practice—Evidence-based approach from the apheresis applications committee of the American society for apheresis

The American Society for Apheresis (ASFA) Apheresis Applications Committee is charged with a review and categorization of indications for therapeutic apheresis. This elaborate process had been undertaken every 7 years resulting in three prior publications in 1986, 1993, and 2000 of "The ASFA Special Issues." This article is the integral part of the Fourth ASFA Special Issue. The Fourth ASFA Special Issue is significantly modified in comparison to the previous editions. A new concept of a fact sheet has been introduced. The fact sheet succinctly summarizes the evidence for the use of therapeutic apheresis. A detailed description of the fact sheet is provided. The article consists of 53 fact sheets devoted to each disease entity currently categorized by the ASFA. Categories I, II, and III are defined as previously in the Third Special Issue. However, a few new therapeutic apheresis modalities, not yet approved in the United States or are currently in clinical trials, have been assigned category P (pending) by the ASFA Clinical Categories Subcommittee. The diseases assigned to category IV are discussed in a separate article in this issue.

Patterns of platelet response in idiopathic TTP/HUS: frequency of declining platelet counts with plasma exchange and the recognition and significance of a pseudo refractory state

For thrombotic thrombocytopenic purpura (TTP), daily plasma exchange (TPE) is typically discontinued when the platelet count normalizes (>150 x 10(9)/L). We observed a decline in platelet count during TPE and in patients who appeared pseudo-refractory because of a platelet count plateau (100-150 10(9)/L range). In the present study, we evaluated platelet count trends in TTP patients. Retrospective review of TTP patients from 01/1999 to 12/2004 was completed. Patients were categorized based on platelet count trends: Group I, counts rose then decreased to levels <100 x 10(9)/L; Group II, counts declined following TPE initiation; Group III, counts rose continuously; Group IV, counts decreased after the count was >100 x 10(9)/L. Additionally, we identified pseudo-refractory patients caused by a platelet count plateau (>100 x 10(9)/L but <150 x 10(9)/L). We identified 60 TTP patients. Within Group I (17 patients/17 series/19.1% of total), the mean decrease in platelet count was 67.3% +/- 22.1% following initial rise. Within Group II (24 patients/25 series/28.1% of total), the mean decrease was 28% +/- 5.3% following presentation. Group III included 31 patients/39 series (43.8% of the total). Within Group IV (seven patients/eight series/9.0% of total), the mean decrease was 17.4% +/- 12.6% following a sustained rise >100 x 10(9)/L. With a declining platelet count and daily TPE, it is generally sufficient to stay the course and the decline will reverse. Our limited experience with pseudo-refractory patients supports discontinuing TPE when counts plateau between 100 and 150 x 10(9)/L when a therapy goal is a platelet count of 150 x 10(9)/L. Recognition of this pseudo-refractory state can minimize the risks of prolonged TPE and the risks of adjunct interventions.

Recovery of splenic infarction with anti-platelet treatments and platelet-apheresis in polycythemia vera

Thrombo-embolic events in coronary and peripheral arteries, and cerebral, pulmonary, portal, hepatic, and deep veins are seen in 27-45% of patients with polycythemia vera (PV). A 79-year-old man was admitted with complaints of pruritus increasing after bath and left upper abdominal pain radiating to left shoulder for two months. On physical examination, ruddy and hyperemic appearances of his face and conjunctiva, tenderness on the left upper quadrant, and splenomegaly were noted. Hemoglobin level was 16.6g/dl, hematocrit 53.8%, white blood cell count 26x10(9)/l, and platelet count 1.032x10(9)/l. Bone marrow aspiration and biopsy revealed hypercellularity, megakaryocytic hyperplasia and dysplasia. The leukocyte alkaline phosphatase score was 190. The levels of serum vitamin B12 and D-dimer were 316 pg/ml and 744 ng/ml, respectively. Arterial O2 saturation was 96%. Red cell mass was measured as 43 ml/kg using radionuclide 51Cr labelled erythrocyte scintigraphy. On cytogenetic analysis, deletion of 20q was found. Computed tomography of whole abdomen showed diffuse splenomegaly and two hypodense areas indicating splenic infarction in 2.5x2 and 3.5x3 cm diameters in subcapsular localization of the spleen. The patient was treated with therapeutic platelet-apheresis, 40 mg/day aspirin, analgesic drugs, and 3g/day hydroxyurea. After 1.5 months, platelet counts dropped to less than 500x10(9)/l and splenic infarcts were not detected on computed tomography. Splenic infarction may be the first evidence of thrombosis in PV. The reduction of platelet counts with platelet-apheresis, anti-platelet drugs, and careful clinical observation may be satisfactory in the treatment of splenic infarction.

Iron overload is a major risk factor for severe infection after autologous stem cell transplantation: a study of 367 myeloma patients

We evaluated the risk factors for infection of 367 consecutive myeloma patients who underwent high-dose melphalan and autologous stem cell transplantation (ASCT). Examination of bone marrow iron stores (BMIS) prior to ASCT was used to evaluate body iron stores. Other variables included age, sex, active smoking, myeloma remission status, severity of mucositis and duration of severe neutropenia post-ASCT (<100 absolute neutrophils counts (ANC)/microl). Median age was 56 years; 61% of patients were males. 140 episodes of severe infections occurred in 116 patients, including bacteremia (73), pneumonia (40), severe colitis (25) and bacteremia with septic shock (two). The infection incidence per 1,000 days at risk was 45.2. Pre-ASCT risk factors for severe infection by univariate analysis were increased BMIS (OR=2.686; 95% CI 1.707-4.226; P<0.0001), smoking (OR=1.565; 95% CI 1.005-2.437; P=0.0474) and male gender (OR=1.624; 95% CI 1.019-2.589; P=0.0414). Increased BMIS (OR=2.716; 95% CI 1.720-4.287; P<0.0001) and smoking (OR=1.714; 95% CI 1.081-2.718; P=0.022) remained significant by multivariate analysis. Duration of ANC <100 micro/l (OR=1.129; 95% CI 1.039-1.226; P=0.0069 and OR=1.127; 95% CI 1.038-1.224; P=0.0045 by both univariate and multivariate analysis, respectively) was the only post-ASCT risk factor for infection. Increased pre-transplant BMIS and smoking are significant predictors of severe infection after myeloablative chemotherapy followed by ASCT in myeloma patients.

Quo vadis haemapheresis. Current developments in haemapheresis

The techniques of haemapheresis originated in the development of centrifugal devices separating cells from plasma and later on plasma from cells. Subsequently membrane filtration was developed allowing for plasma-cell separation. The unspecificity of therapeutic plasma exchange led to the development of secondary plasma separation technologies being specific, semi-selective or selective such as adsorption, filtration or precipitation. In contrast on-line differential separation of cells is still under development. Whereas erythrocytapheresis, granulocytapheresis, lymphocytapheresis and stem cell apheresis are technically advanced, monocytapheresis may need further improvement. Also, indications such as erythrocytapheresis for the treatment of polycythaemia vera or photopheresis though being clinically effective and of considerable importance for an appropriate disease control are to some extent under debate as being either too costly or without sufficient understanding of the mechanism. Other forms of cell therapy are under development. Rheohaemapheresis as the most advanced technology of extracorporeal haemorheotherapy is a rapidly developing approach contributing to the treatment of microcirculatory diseases and tissue repair. Whereas the control of a considerable number of (auto-) antibody mediated diseases is beyond discussion, the indication of apheresis therapy for immune complex mediated diseases is quite often still under debate. Detoxification for artificial liver support advanced considerably during the last years, whereas conclusions on the efficacy of septicaemia treatment are debatable indeed. LDL-apheresis initiated in 1981 as immune apheresis is well established since 24 years, other semi-selective or unspecific procedures, allowing for the elimination of LDL-cholesterol among other plasma components are also being used. Correspondingly Lp(a) apheresis is available as a specific, highly efficient elimination procedure superior to techniques which also eliminate Lp(a). Quality control systems, more economical technologies as for instance by increasing automation, influencing the over-interpretation of evidence based medicine especially in patients with rare diseases without treatment alternative, more insight into the need of controlled clinical trials or alternatively improved diagnostic procedures are among others tools ways to expand the application of haemapheresis so far applied in cardiology, dermatology, haematology, immunology, nephrology, neurology, ophthalmology, otology, paediatrics, rheumatology, surgery and transfusion medicine.

Photopheresis in solid organ transplant rejection

Photopheresis has become a key component in the therapeutic armamentarium of cutaneous T-cell lymphoma, graft-versus-host disease following stem cell transplant, and allograft rejection of solid organs such as heart. Although it is considered a new treatment modality in its present form, the field of phototherapy dates back thousands of years. In this review, the reader will learn more about the history of photopheresis and how it became a therapeutic alternative for patients with solid organ transplants. An extensive literature search will highlight the evidence-based benefits of photopheresis (or lack thereof). A discussion of the mechanism of action of photopheresis and the technical aspects of the procedure will also be covered. Since photopheresis may be the best tolerated form of immunomodulation, current promising, albeit preliminary data on its efficacy warrant further investigation and understanding.

Thrombosis and haemorrhage in polycythaemia vera and essential thrombocythaemia

Despite decades of clinical and laboratory research, relatively little has been accomplished concerning the pathogenesis as well as the identification of risk factors for thrombosis and bleeding in myeloproliferative disorders. In polycythaemia vera, the pro-thrombotic effect of an elevated haematocrit is well established. In contrast, thrombocytosis per se has not been similarly incriminated in essential thrombocythaemia. In both conditions, advanced age and the presence of a prior event identify thrombosis-prone patients. There is increasing evidence to suggest an additional role by leucocytes that might partly explain the antithrombotic effects of myelosuppressive therapy. A substantial minority of affected patients display reduced levels of high molecular weight von Willebrand protein in the plasma during extreme thrombocytosis and it is believed that this might explain the bleeding diathesis of such patients. Recent controlled studies support the therapeutic value of hydroxyurea and aspirin in essential thrombocythaemia and polycythaemia vera, respectively. The current communication will address the incidence, phenotype, pathogenesis, risk factors, prevention, and treatment of both thrombosis and haemorrhage in these disorders.

Efficacy of HPA-1a (PlA1)-negative platelets in a patient with post-transfusion purpura

Post-transfusion purpura (PTP) is a rare form of alloimmune thrombocytopenia that is self-limited but which carries a 10-15% mortality related to fatal hemorrhage. Immunomodulatory therapies such as plasmapheresis and intravenous immunoglobulin G (IVIg) can shorten the duration of thrombocytopenia. However, in a bleeding patient with PTP, more urgent therapy may be required. Textbooks of hematology [1-3] as well as reports in the literature [4,5] suggest that patients do not respond to platelet transfusions. We report a case of PTP in a patient homozygous for HPA-1b who suffered an intracranial hemorrhage. The patient was treated with IVIg and plasmapheresis. Because of her life-threatening bleeding, we also transfused the patient with HPA-1a-negative platelets. These transfusions consistently resulted in transient improvements in her platelet counts and may have limited the degree of intracranial bleeding. Our experience suggests that transfusion of platelets that lack the offending epitope in patients with PTP may be efficacious.

New directions in plasma exchange

PURPOSE OF REVIEW

This review examines the literature published on therapeutic plasma exchange during 2002. The review was performed by searching Medline for pertinent articles.

RECENT FINDINGS

One hundred thirty articles were identified, of which 11 are reviewed. During the period, reviews of the use of therapeutic plasma exchange for managing Guillain-Barré syndrome and myasthenia gravis were published. A large randomized trial of the use of plasma exchange to treat sepsis also appeared. Finally, a large case series of the use of plasma exchange in Wegener granulomatosis was published.

SUMMARY

The literature confirms the use of plasma exchange for Guillain-Barré syndrome but suggests that inadequate evidence exists to support its use for long-term improvement in myasthenia gravis. The study of patients with severe sepsis suggests that plasma exchange may benefit a subset of patients, those with abdominal infections. Finally, plasma exchange for Wegener granulomatosis with severe renal dysfunction appears not to offer any benefit over immunosuppressive therapy.

A survey of therapeutic hemapheresis in Norway year 2000

In a survey of therapeutic hemapheresis in Norway, we sent a questionnaire to all regional and central hospitals, asking about hemapheresis activities, patients, indications, and adverse events. All units responded to the questionnaire: 17 dialysis units, 7 blood units, and 2 specialized units for stem cell apheresis. In total, they performed 2141 procedures that is 5.0 stem cell collections and 42.5 therapeutic apheresis procedures per 100,000 inhabitants. The most frequent indications were Guillain-Barré syndrome, hypercholesterolemia, and myasthenia gravis. Adverse effects were frequent, but mild. Dialysis units performed a majority of the procedures, leading to an extensive use of filtration techniques.

An approach to evidence-based therapeutic apheresis

This review is derived from a memorial lecture honoring Dr. Francis Morrison, a former President of the American Society For Apheresis (ASFA). The author had numerous professional contacts with Dr. Morrison through ASFA in the early 1990s, having served with him on the Board of Directors and followed him as President, and also came to know him well on a personal level. Professionally, Dr. Morrison stood out as a courtly gentleman with a marvelous baritone voice whose ability to facilitate organization contributed to a growing sense of dignity and purpose in the affairs of the society. On the personal side, however, there wasn't an ounce of pretension in him. He was accessible and down-to-earth; a genuine character with an active and appealing sense of humor. Not surprisingly, he seemed to have a wealth of insight and "common sense," and since the topic of this study is a kind of common sense approach to assessing the effectiveness of therapeutic apheresis, it seems a fitting way to honor his memory.

Serum hyperviscosity syndrome responding to therapeutic plasmapheresis in a patient with primary Sjögren's syndrome

Hyperviscosity syndrome is a disorder first described in patients with Waldenström's macroglobulinemia and is not commonly seen in rheumatic diseases. Its association with Sjögren's syndrome is very rare and it has been reported in very few patients. We report the case of a patient with primary Sjögren's syndrome presenting as hyperviscosity syndrome who was successfully treated with therapeutic plasma exchange.

The role of blood component removal in essential and reactive thrombocytosis

An elevated platelet count is now a common finding in both hospitalized and ambulatory patients with the advent of automated complete blood cell counters. Clinicians may be called upon to make a distinction between a reactive process and a primary hematologic disorder as the cause of a thrombocytosis and to determine whether treatment is indicated. Essential thrombocythemia and other myeloproliferative disorders may present with marked increases in the platelet counts and may be associated with thrombohemorrhagic complications. Reactive thrombocytosis can be caused by iron deficiency and a variety of inflammatory conditions, infections, malignancy, bleeding or hemolysis, splenectomy, and drugs. Acute therapy for all of these disorders has included blood component removal, specifically plateletpheresis. The role of plateletpheresis in current management of thrombocytosis is considered, based on current knowledge of pathophysiology and a review of the literature.

Immunosuppressive treatment of acquired aplastic anemia and immune-mediated bone marrow failure syndromes

Modern therapeutic strategies for the treatment of acquired aplastic anemia are based on the current understanding of its pathophysiology as well as empiric observations. Most cases of aplastic anemia appear to be the result of immune-mediated destruction of hematopoietic cells, which can be approached by stem cell transplantation in younger patients with appropriate histocompatible donors or by immunosuppression to reduce T-cell activity. Popular treatment regimens combine antithymocyte globulin with cyclosporine. Although a majority of patients respond with improved blood counts and achieve transfusion-independence, late clonal complications of myelodysplasia and cytogenetic abnormalities occur in a substantial minority of cases. Additionally, there is no clear algorithm for the treatment of refractory disease. Newer methods of treatment, including high-dose cyclophosphamide and the development of potentially tolerizing combinations of drugs. are under study. Effective therapies for aplastic anemia might also be applied to other T-cell mediated, organ-specific human diseases.

The role of red blood cell exchange transfusion in the treatment and prevention of complications of sickle cell disease

Patients with sickle cell disease have abnormal red blood cells (RBCs). This can cause chronic hemolytic anemia and vaso-occlusion leading to tissue hypoxemia and organ dysfunction. RBC exchange transfusion can, without increasing the whole-blood viscosity, quickly replace abnormal erythrocytes with normal and raise the hematocrit resulting in improved delivery of oxygen to hypoxic tissues. Unfortunately, transfusion can also be associated with complications. This paper reviews the role of transfusion, both simple and exchange, in the treatment and prevention of sickle-related complications. The benefits of exchange versus simple transfusion and transfusion versus alternative therapies are discussed.

Treatment of autoimmune hemolytic anemias

Treatment of autoimmune hemolytic anemias varies depending on whether the patient has autoimmune hemolytic anemia of warm antibody type, cold agglutinin syndrome, paroxysmal cold hemoglobinuria, or autoimmune hemolytic anemia secondary to an underlying disorder. Initial therapy for warm antibody autoimmune hemolytic anemia should be corticosteroids, such as prednisone at conventional doses of 1 to 1.5 mg/kg/d orally. Criteria must be established to determine whether the therapeutic response is adequate, because long-term therapy may lead to significant detrimental side effects. Splenectomy has the advantage over therapeutic options in that it has the potential for complete and long-term remission. The major adverse effect is the syndrome of overwhelming postsplenectomy infection. Other therapeutic options, which are less likely to have long-term benefit, are immunosuppressive drugs, danazol, intravenous immunoglobulin, and plasma exchange. Therapy of cold agglutinin syndrome often is unsatisfactory. All patients should avoid exposure to cold, and if additional therapy is necessary, the therapies used for warm antibody autoimmune hemolytic anemia may be tried with less likelihood of response. Paroxysmal cold hemoglobinuria requires aggressive supportive therapy, generally supplemented by corticosteroids. Hemolysis usually terminates spontaneously. Patients with secondary autoimmune hemolytic anemia may be treated similarly to those with idiopathic autoimmune hemolytic anemia, and additional therapy for the underlying disorder also may result in remission of the hemolysis.

Adverse events and problems in therapeutic hemapheresis. A report from the Swedish registry

BACKGROUND

Since 1996 adverse events (AE) in therapeutic apheresis (TA) have been more extensively registered in Sweden. This report analyzes the extent and relation of AEs to procedures and diagnoses.

MATERIALS AND METHODS

Reporting of TA performed in Sweden was centralized. A separate system for the registration of AE in TA was established and the data received were entered into a central database for registration and analyses. Fifteen of all 35 apheresis units reported both TA and AE during 1996-1999. These centers performed 75% of all TA procedures. Adverse events included medical symptoms, vascular access problems, technical and other problems.

RESULTS

More than 14,000 procedures were registered during the observation period. No fatalities occurred. AEs occurred in 3.7% (1996), 4.6% (1997), 4.2% (1998) and 4.4% (1999) of procedures. Interventions during the adverse event were performed in about 65% of the events. Apheresis procedures were interrupted due to an adverse event in about 1%. Adverse events occurred in 5.6% of plasma exchanges, 1.9% of plasma modulations and 6.8% of cytapheresis procedures. Paresthesia was registered in 22% and hypotensive events in 20.5%. Other more frequent symptoms were urticaria (14.4%), shivering (7.4%) and nausea (7.4%). AEs were most frequent in patients with Goodpasture's syndrome (12.5%), TTP/HUS (10.5%) and GuillainBarré syndrome (11.0%).

CONCLUSION

AEs are few, often mild and less common in plasma modulation than plasma exchange. AEs are more frequent during TA of patients with certain diagnoses such as TTP/HUS.