HISTORY AND DEVELOPMENT

 Early developments in apheresis

began when Dr. Edwin J. Cohn
devised a method, based on a
dairy centrifuge (Cohn
centrifuge)
 Cohn centrifuge: Purification
of albumin from pooled
human plasma
 Apheresis consists of
withdrawing a small volume of
whole blood from a donor or
patient and separating into its
component for therapeutic
components
purposes (therapeutic apheresis)
 Apheresis: 1 or more
components are collected and
retained; remaining
components are recombined
and returned; you will only get
what is needed

 Platelets, RBCs, or WBCs can be

removed (or collected) using
apheresis technology

METHODOLOGY
 Modern apheresis instruments
utilize a computerized control
panel, allowing the operator to
select the desired component to
 Can be performed on the donor be collected or removed
to collect specific blood  By manipulating the variables on
component (donor apheresis) an apheresis instrument, the
 Can be performed on the patient operator can harvest plasma,
to remove particular blood platelets, WBCs, or RBCs
TWO COMMON METHODS OF  Collection of each apheresis
CENTRIFUGATION blood carries with it different
 Intermittent Flow Centrifugation deferral period
(IFC)  Written informed consent must be
 Blood component is obtained from the donor
processed in batches or  Must include the statements
cycles of risk
 Continuous Flow Centrifugation
(CFC) RED BLOOD CELLS (RBCS;
 Blood withdrawal, processing, ERYTHROCYTES)
and reinfusion are performed  Typically collected as a double
simultaneously in an unit
“ongoing manner”  Designation: 2BC or double
RBC procedure
MEMBRANE FILTRATION  Clinical advantage
 Membrane separators are  Reduced donor exposure
typically composed of bundles of for the recipient (the
hollow fibers or that plate patient can receive two
membranes with specific pore units from the same
sizes individual)
 Pores can be sized (whether
small or large) to prevent the PLASMA
passage of even small cellular  Plasmapheresis: collection of
elements during plasma plasma by apheresis
collection  Each apheresis unit (“jumbo
plasma”) is the volume
COMPONENT COLLECTION equivalent of at least 2 whole
 A qualified, licensed physician blood-derived plasma units
must be responsible for all  Varied purposes
aspects of the apheresis program  Augment the inventory of
fresh frozen plasma (FFP) of
a particular ABO group
 Prepare immune globulin
 Further manufacturing into
products, such as intravenous
immune globulin (IVIG),
hepatitis immune globulin,
and RhIg
 For donor purposes, collection
divided into frequent and
infrequent plasmapheresis

PLATELETS (plateletpheresis)
 Platelet count must be at least
150,000/uL to provide adequate
 platelet collection and for donor  Can be irradiated to prevent
to safely undergo collection transfusion-associated graft vs
procedure host disease
 Apheresis platelets provide the  Use of oral corticosteroids to
equivalent of 6 to 8 units of mobilized marginal pool
random-donor platelets granulocytes and increase
 Routine plateletpheresis circulating cells
procedure typically takes 45-90  Granulocytes follow the same
minutes compatibility rules as red blood
 Plateletpheresis collections cells
should not be performed on  Donor must be ABO and Rh
potential donors taking compatible with the recipient
antiplatelet medications like (patient)
aspirin (2 days before donating  Unit must be crossmatch
blood; it is a type of anti-platelet compatible with the recipient
medication)
 Platelet count will decrease by THERAPEUTIC APHERESIS (TA)
30% to 60%  The rationale is based on:
 May donate every 7 days up to  A pathogenic substance exist
24 times a year in the blood contributes to a
disease process or its
GRANULOCYTES symptoms
 Patients who are most likely to  Substance can be more
benefit from granulocyte effectively removed by
transfusions apheresis rather than the
 Patients with fever body’s own mechanism
 Neutrophil counts <500/uL  The TA procedure is classified
 Septicemia according to the blood
 Bacterial infection component removed
unresponsive to antibiotics  Cytapheresis procedures
 Reversible bone marrow  Selectively removed
hypoplasia RBCs, WBCs, or platelets
 Reasonable chance of  Plasmapheresis procedures
survival  Used to remove plasma
 Neonatal neutrophils who when the pathological
have impaired function substance is found in the
 Newborn infants may develop circulation
overwhelming infection with
neutropenia because of their THERAPEUTIC PLASMA EXCHANGE
limited bone marrow reserve for (TPE) / PLASMAPHERESIS
neutrophil production  The removal and retention of all
 Granulocyte components should the plasma, with return of all
be administered as soon as cellular components
possible, and within 24 hours of  To remove an offending agent in
collection the plasma
  To replace a normal factor or ERYHTROCYTAPHERESIS (RED
substance that may be missing or CELL EXCHANGE)
deficient in the patient’s plasma  Most commonly performed to
 Factors removed by therapeutic reduced the complication of
plasmapheresis sickle cell disease in order to
 Immune complexes (e.g. reduce hemoglobin S-containing
systemic lupus RBCs
erythematosus)  Donor RBCs selected for
 Alloantibodies: Ab that targets transfusion should be ABO and
Ag not present on the patient Rh compatible
RC (e.g. Ab-mediated  Removes a large number of
transplant rejection) RBCs from the patient and
 Autoantibodies: Ab that returns the patient’s plasma and
targets Ag present on the platelets with compatible
patient RC (e.g. Goodpasture allogeneic donor RBCs
syndrome and Guillain-Barre  Therapeutic goal: decrease the
syndrome) level of hemoglobin S to less than
 Immunoglobulins causing 30%
hyperviscosity (e.g.
Waldenstrom FLUID REPLACEMENT
macroglobulinemia  Most common replacement fluid
 Protein-bound toxins or drugs for TPE: human serum albumin
(e.g. barbiturate poisoning) (HSA) as a 5% solution
 Lipoproteins  In therapeutic plasmapheresis,
 Phytanic acid large volumes of the patient’s
plasma are retained
LEUKAPHERESIS  Reserved for treatment of TTP
 Used to treat patients with  Replacement is necessary to
hyperleukocytosis/leukostasis maintain appropriate
 WBC or circulating blasts intravascular volume and oncotic
count greater than 100,000/uL pressure
 Complications associated with  Fresh frozen plasma (FFP)
leukostasis contains all the constituents of
 Risk for organ dysfunction the removed plasma and thus,
from microthrombi in the would appear to be the optimal
pulmonary and cerebral replacement fluid for TPE
microvasculature procedures
 The prediction of required  However, the use of FFP is
blood volume is difficult not without risk and additive
 More common in patients with effects that might contribute to
acute myeloid leukemia (AML) citrate toxicity and
 Use of a red cell sedimenting sensitization to plasma
agent, such as HES, may be of proteins
benefit during the procedure  For patients with TTP who do not
respond in a timely manner to
replacement with FFP
  Alternative: Cryoprecipitate-
reduced plasma (can also be
used by patients with liver
disease)
SPECIAL PROCEDURES
 New technology has allowed the
collection of very specialized
components, as well as the
removal of specific plasma
constituents
[1] Hematopoietic progenitor cells
(peripheral blood stem cells)
 Can be collected by apheresis
from autologous or allogenic
donor
 Found in the upper portion of
buffy coat during
centrifugation
[2] Immunoadsorption or selective
absorption
 Method in which a specific
ligand is bound to an insoluble
matrix in a column or filter
[3] Photopheresis
 Utilizes leukapheresis to
collect buffy coat layer from
whole blood
 Has subsequently been used
to treat acute and chronic graft
vs host disease, solid organ
transplant rejection, and
selected immunologically
mediated disease
ADVERSE EFFECTS OF APHERESIS
 Citrate toxicity
 Vascular access difficulties
 Vasovagal reactions
 Hypovolemia
 Allergic reactions
 Hemolysis
 FATALITIES
 Rare fatalities during therapeutic
apheresis procedures have been
reported
 Most cause by: circulatory (e.g.
cardiac arrest and arrhythmia) or
respiratory complications (e.g.
acute pulmonary edema or
respiratory distress syndrome)
 FFP is recommended only in
cases of TTP or hemolytic uremic
syndrome
 NOTE: There is a possibility
of disease transmission
TRANSFUSION THERAPY
 Used to primarily to treat two
conditions
 Inadequate oxygen-carrying
capacity (due to anemia or
blood loss)
 Insufficient coagulation
proteins or platelets to provide
adequate hemostasis
Table 15-1
Blood components and plasma
derivatives
WHOLE BLOOD
 Used to replace the loss of both
RBC mass and plasma volume
 Contains RBC and plasma
 Rapidly bleeding patients can
receive whole blood, although
most commonly RBCs and
plasma are used and are equally
effective clinically
 For a 70-kg (155-lb) adult, each
unit of whole blood should
increase the hematocrit level
3% or hemoglobin 1 g/dL
 After transfusion, the increase
may not be apparent until 48-
72 hours when the patient’s
blood volume adjust to normal
  Severe chronic anemia: a  Leukocyte content must be
definite contraindication reduced to less than 5 x 106 by
 Reduced amount of RBCs but use of leukocyte reduction filters
compensated by increasing  Used to reduce HLA
plasma volume to restore total alloimmunization, CMV
blood volume transmission, febrile
nonhemolytic transfusion reaction
RED BLOOD CELLS (RBCs;
ERYHTROCYTES)
 Indicated for increasing the RBC
mass in patients who require
increased oxygen-carrying
capacity
 Considerations
 Pulse rate: >100 beats/min
 Respiration rate: >30
breaths/min
 May experience dizziness
during RBC transfusion (FNHTR), TA-GVHD, and
therapy transfusion-related immune
 Weakness suppression
 Angina (chest pain)
 Difficulty in thinking
 RBCs should not be used to WASHED AND FROZEN /
treat nutritional anemia, such as DEGLYCEROLIZED RBCs
iron deficiency or pernicious  Washed RBCs: used for rare
anemia, unless the patients patients who has moderate to
shows signs of decompensation severe allergic transfusion
 RBC transfusion is not to be reactions, and those who has
used: anti-IgA Ab (due to IgA
 to enhance general well-being deficiencies)
 promote wound healing  May be used with patients who
 prevent infection have anaphylactic transfusion
 expand the blood volume reactions to ordinary units of
when oxygen-carrying RBCs
capacity is adequate  The washing process removes
 to prevent future anemia plasma proteins, the cause of
 no set hemoglobin levels most allergic reactions
indicate a need for  Freezing RBCs allows the long-
transfusion term storage of rare blood donor
 Critical level: 6 g/dL or less units, autologous units, and units
for special purposes (e.g.
LEUKOCYTE-REDUCED RBCs intrauterine transfusion)

PLATELETS AND
PLATELETPHERESIS
  Plateletpheresis components are
prepared from one donor and
must contain a minimum of 3 x
1011 platelets
 Bacterial testing is required in
each platelet product
 Indicate for patients with
thrombocytopenia or abnormally
functioning platelets
 Includes fresh frozen plasma,
plasma 24 (frozen within 24
hours) and thawed plasma
 Plasma and plasma 24 contain all
coagulation factors
 Thawed plasma after 5-day
storage has less factor V and
VIII (labile factors) but is still
therapeutic
 Given if the patient is actively
bleeding or if time is not available
for warfarin reversal before
surgery
 Product of choice for patients
with multiple factor deficiency,
hemorrhage, or impeding
surgery: plasma (not a
concentrate; volume overload
may be a serious complication of
transfusion; should be ABO
compatible with recipient’s RBC)
 Rh type can be disregarded

GRANULOCYTE PHERESIS CRYOPRECIPITATE

 Criteria have been developed to  Used primarily for fibrinogen
identify patients who are most replacement
likely to benefit from granulocyte  Was used as a source for fibrin
transfusion sealant, which uses
 Fever cryoprecipitate as the source of
 Neutrophil count: <500/uL fibrinogen
 Septicemia or bacterial  AABB requirements for fibrinogen
infection unresponsive to content: 150 mg of fibrinogen and
antibiotics 80 units of Factor VIII/unit
 Reversible bone marrow  Cryoprecipitate was originally
hypoplasia prepared as a source of factor
 Reasonable chance of VIII
survival  No longer considered as the
product of choice for factor VIII
PLASMA deficiency or von Willebrand’s
 Used in treatment of single and disease
multiple coagulation deficiencies,  Mild or moderate factor VIII
vitamin K deficiency or warfarin deficiency now treated with
overdose, liver disease or failure, desmopressin acetate
and treatment of DIC  Cryoprecipitate was used to treat
patients with von Willebrand’s
disease, a deficiency of vWF

FACTOR VIII
 Treated by different methods to
ensure sterility for
 HIV
 Hepatitis B virus
 Hepatitis C virus
 Patients with hemophilia A or
factor VIII deficiency are treated
with factor VIII
 Only factor VIII products labeled
as containing vWF should be
used for patients with von
Willebrand’s disorder
FACTOR IX
 It is recommend for factor IX-
deficient patients (hemophilia B),
patients with factor VII or X
deficiency (rare), and selected
patients with factor VIII inhibitors
 FIX complex (prothrombin
complex) is prepared from
pooled plasma
ANTITHROMBIN AND OTHER
CONCENTRATES
 Antithrombin
 Type of protease inhibitor with
activity towards thrombin
 Heparin
 Accelerates the binding and
inactivation of thrombin by
anti-thrombin
 Protein C and protein S are
vitamin K-dependent proteins
synthesized in the liver
 Protein C: cofactor for
activated protein C (which in
turn inactivates factors V and
VIII, preventing thrombus
formation)
ALBUMIN
 Used in patients requiring volume
replacement
 Used as a replacement fluid in
plasmapheresis
 Used as treatment of burn
patients
 Prepared by chemical and
physical fractionation of pooled
plasma
 Available as a 5% or a 25%
solution, of which 96% of the
protein content is albumin
IMMUNE GLOBULIN
 Used for patients with congenital
hypogammaglobulinemia and
those who are exposed to
hepatitis A or measles
 Immune globulin prepared from
pooled plasma is primarily IgG
 Rh immune globulin (RhIG) was
developed to protect the Rh-
negative female who is pregnant
or who delivers an Rh-positive
infant
LEUKOCYTE-REDUCED CELLULAR
BLOOD COMPONENTS (RBCs or
platelets)
 Goal: fewer than 5 x 10 6
leukocyte remaining in the RBC
unit
  Used to prevent FNHTR, prevent  Common after allogenic bone
or delay the development of HLA marrow or hematopoietic
Ab, and reduce the risk of CMV progenitor cell transplantation,
transmission GVHD is a syndrome affecting
 Leukocyte-reduction filters are mainly skin, liver, and gut
designed to remove more than  Irradiation doses range from
99.9% of leukocytes from RBCs 2,500 to 5,000 cGy, with the
and platelet products higher doses being
 Leukocyte-reduced RBCs and  Irradiation: more effective but
platelets can be used to more damaging to RBCs
 Immunocompetent patients have
CMV-NEGATIVE CELLULAR BLOOD experience TAGVHD after
COMPONENTS receiving non-irradiated blood
 Risk is greatest for components from a directed
 CMV negative pregnant donation (first-degree relatives)
women
 Allogenic CMV SURGICAL BLOOD ORDER
 Negative bone marrow SCHEDULE, TYPE AND SCREEN
 HPC transplant recipients  Disadvantages of crossmatching
 Premature infants weighing for procedures with a low
<1200g likelihood of requiring transfusion
 CMV-negative or leukocyte-  Increases the number of
reduced components are crossmatches performed
indicated for recipients who are  Increases the amount of blood
CMV-negative and at risk for inventory in reserve and
severe sequelae of CMV unavailable for transfusion
infections  Contributes to aging and
 Risk is greatest for possible outdating of
components
IRRADIATED CELLULAR BLOOD
COMPONENTS ADVANTAGES OF TYPE AND
 Blood components are irradiated SCREEN
with gamma radiation to  Potential for more economic
prevent graft versus host transfusion service (due to
disease (GVHD), as in these decreased blood inventory
conditions requirements)
 Transfusion or transplantation  Decreased reagents needed
of immunocompetent T  More efficient use of technologist
lymphocytes time
 Histocompatibility differences
between the graft and
recipient
 Immunocompromised
recipients

AUTOLOGOUS TRANSFUSION
 Homologous transfusion:
Infusion of blood from another
donor
 1 type of autologous transfusion
 Pre-deposit of blood by the
patient: collected by a regular
donation procedure; blood
can be stored as liquid (for
longer storage; frozen)
 Donation of blood by the intended
recipient
 Reduces the possibility of
transfusion reaction or
transmission of infectious disease
 Another type of autologous
transfusion, intraoperative
hemodilution, is the collection of
1 or 2 units of blood from the
patients just before a surgical
procedure, replacing the removed
blood volume with crystalloid or
colloid solution
EMERGENCY TRANSFUSION
 Group O RBCs (universal donor
for red cell) are selected for
patients for whom transfusion
cannot wait until their ABO and
Rh type can be determined
 Used in patients who are rapidly
or uncontrollably bleeding, losing
more than 20% of their blood
volume
 Female of childbearing potential
 Group O-negative RBC
MASSIVE TRANSFUSION
 Replacement of 1 or more blood
volume, or about 10 units within
24 hours (applicable for adults)
NEONATAL TRANSFUSION
 The aliquot must be labeled
clearly with the name and
identifying numbers of the
patient and donor
 Premature infants frequently
require transfusion of small
amounts of RBCs to replace the
blood drawn for laboratory tests
and to treat anemia of
prematurity
 Blood must be fully tested as
done for adults
 Preferred: <7 days old blood
units
 to reduce the risk of
hyperkalemia
 to maximize the 2,3-
diphosphoglycerate levels
 CMV-seronegative or leukocyte
reduced is used to prevent CMV
infection
 Irradiation of the blood is
recommended to prevent
possible TA-GVHD when blood is
used for intrauterine transfusion,
for an exchange transfusion, or
for transfusion of a premature
(less than 1,200 g) neonate