Clinical Use of Apheresis (BSH 2025)
Plasma Exchange
Indications
Disease caused by pathogenic antibodies or other macromolecules found in the plasma
The 10 most frequent indications in UK in 2019 included:
TTP / aHUS
Cryoglobulinaemia
Waldenstroms with symptomatic hyperviscosity
Non-haem - Autoimmune encephalitis, Neuromyelitis optical, CIDP, Anti-GBM disease, FSGS, ANCA-vasculitis
Rarer indications: Myasthenia Gravis, Guillain-Barre, ABO-incompatible living donor renal transplant, HLA donor specific antibody rejection in renal transplant
Technical Aspects
Aim 100-150% of patient’s plasma volume exchanged per session
TTP regimen – daily 1.5 plasma vol exchange until platelet count normal for 3 days, then wean down.
Typically centrifugation or filtration system (addenbrookes use centrifugation)
Newer column-based extracorporeal immunoadsorption techniques more rapid effect
SE: Hypofibrinogenaemia, Removal of albumin-bound drugs
Replacement Fluid
SD-FFP for TMA’s
SD-FFP due to anticipated large total volumes of FFP so want to reduce TTI risk.
SD-FFP also contains some fibrinogen, making hypofibrinogenaemia less likely.
4.5% HAS is widely used for all other indications
Pts at risk of haemorrhage: Consider FFP as partial replacement fluid, or post-exchange cryoprecipitate transfusions.
Red Cell Apheresis / Automated red cell exchange
Indications
Primarily sickle cell disease – ACS, Stroke (acute, 1o or 2o prevention), Pre-op
Also considered for severe malaria/babesiosis, polycythaemia, genetic haemochromatosis
Advantages over top-up transfusion
Faster reduction in HbS in acute setting
Reduced frequency of treatments for patient on chronic programs
Reduced iron loading
Top up should not be used where patients Hb is within the normal range
Technical Aspects
Red cell units should be ABO compatible, Rh and Kell compatible, HbS-
Typically 8-10 RBC units required to maintain HbS <30% in chronic Ex program
Vascular access can be challenging
Depletion erythrocytapheresis = initial phase is with saline replacement, similar to manual exchange, and may reduce blood use and iron loading.
Extracorporeal Photopheresis (ECP)
Principle
Collect 5% of patient’s mononuclear cells, expose them to UVA and psoralen and then re-infuse into patient.
Indications
Cutaneous T-cell Lymphoma, Mycosis fungoides / Sezary Syn
Chronic GVHD – 2nd line treatment for skin, mucosal and liver chronic GVHD
Acute GVHD – 2nd line
Technical Aspects
Can use an open or closed system – open gives higher cell dose but risk of infection
Typically administered fortnightly for at least 3 months
Cytoreductive Apheresis (Leukopheresis / Thrombocytapheresis)
Leukopheresis
Lack of evidence showing benefit + resource-intensive procedure
Might consider for specific cases of leukaemia / MPN with WBC >100 and clinical hyperviscosity
E.g. when chemotherapy is problematic, such as in pregnancy
NOT to be used in APML as worsen coagulopathy
Adsorptive leukopheresis
Current area of research for IBD, RA, Alcohol hepatitis etc
Not currently sufficient evidence to recommend at present (as of 2025)
Thrombocytapheresis
Achieves partial and temporary reductions in plt count (around 30-60%)
Has been very occasionally used in MPN.
Cellular Therapy Product Collection by Apheresis
Indications
Stem cell collection in Auto and Allograft
T-cell collection for CAR-T and Donor Lymphocyte Infusions (DLI)
Technical Aspects
Cell mobilisation
Donors for allograft should be mobilized by GCSF alone
Autograft patients may use GCSF +/- Chemotherapy. Plerixafor is a 2nd line option
Plerixafor (chemokine receptor antagonist) is a 2nd line option for mobilisation
Autografts
CD34+ count should be assessed by flow cytometry prior to starting apheresis to ensure adequate mobilization. Most centres use cut-off of CD34+ cells >10 per ul.
2-3 blood volumes are processed for stem cell collection
Preferred collection dose is 3-5 x10e6 CD34+ cells/kg. (Bare minimum is 2 x10e6)
CAR-T & Other Advance Therapy Medicinal Products (ATMPs)
Perform in accordance with manufacturer recommendations (BSH does not specify further)
lipoprotein apheresis (LA)
This procedure is possible for hereditary hypercholesterolaemias. See guideline for details.
Patient Management
Pre-Apheresis Care
Written informed consent
Rationale, alternatives, explanation of procedure, serious + frequent complications, use of blood products.
Requirements for consent are set out in Human Tissue Authority (HTA) Codes of Practice.
Clinical assessment of patient
Psychological issues, General health, Haemodynamic stability, Adequate vascular access, Lifestyle of stem cell donors (for TTI risks)
Pre-Procedure Laboratory investigation
FBC, biochemistry, fibrinogen, microbiology screening if stem cell donor
Treatment Plan
Prepare an apheresis treatment plan specific for patient covering all of the above along with technical details of the procedure and the therapy end point.
During the procedure
Omit 1 prior dose of ACEI to avoid vasovagal
With exception of IV calcium to correct hypocalcaemia, no meds should be administered during procedure
Continuous monitoring by trained healthcare professional throughout procedure
Post-treatment care
Contact card for patient
Written information about any blood products they received
Complications
More Common
Citrate-related hypocalcaemia
Vasovagal syncope / pre-syncope
Allergic reactions
Albumin-bound drugs are removed by plasma exchange
Less Common
Dilutional coagulopathy
Type II HIT
Line-related thrombosis
Apheresis Service Management
Apheresis service requires
An apheresis lead
Trained staff with regular competency assessment
Adequate, designated space for apheresis procedures
Adherence to JACIE standards if transplant centre
(Joint Accreditation Committee – ISCT & EMBT)
Quality Management - Standard Operating Procedures, audit, AE reporting
Local Guideline
Good transfusion laboratory support