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