Therapeutic Apheresis

Therapeutic apheresis is the removal of blood or one of its components from the body, usually by automated blood cell separators. Cytapheresis removes cellular constitutents, whereas plasmapheresis removes plasma. When large volumes of material are removed some form of replacement is required. Common applications are summarized below:

Therapeutic Cytapheresis - the removal of white cells or platelets from patients with extremely elevated counts to reduce associated clinical symptoms. This is a temporary measure used in conjunction with chemotherapy and/or radiation therapy.

Therapeutic Plasmapheresis - The removal of plasma, usually 1500-2000 mL, from patients with hyperglobulinemia such as Waldenstrom's macroglobulinemia to reduce paraproteins and viscosity. Crystalloid solutions and occasionally albumin are used for volume replacement. This protocol is used for managing both acute symptoms and chronic disease.

Plasma Exchange - The removal of larger volumes of plasma (up to 3L in adults) and its replacement using a combination of FFP and crystalloid solutions. This procedure is used for a variety of diseases including myasthenia gravis, Goodpasture's disease, and thrombotic thrombocytopenic purpura (TTP). The purpose is to remove circulating antibody or immune complexes.

Red Cell Exchange - The removal of 6-12 units of red cells and their replacement with an equivalent volume of allogeneic RBC. This procedure is usually used for sickle cell crisis.

Photopheresis - The removal and reinfusion of autologous blood that is exposed to UV light during extra corporeal circulation. This procedure is used for cutaneous T Cell Lymphoma and chronic graft-versus-host disease.

The American Society of Apheresis and the American Association of Blood Banks has reviewed therapeutic apheresis outcomes and published the following practice guidelines. Disorders have been placed into four categories.

Category I: Therapeutic apheresis is standard and acceptable either as primary therapy or as a first line adjunct to other therapy.
Category II: Therapeutic apheresis is generally accepted in a supportive role.
Category III: Therapeutic apheresis is not clearly indicated.
Category IV: Therapeutic apheresis has been demonstrated to lack therapeutic efficacy.

Category I diseases include:

Disease	Procedure
Antiglomerular basement membrane antibody disease	Plasma exchange
Familial hypercholesterolemia	Selective adsorption
Harvested marrow for ABO mismatched transplant	RBC removal
Polycythemia vera or erythrocytosis	Phlebotomy
Leukocytosis & thrombocytosis	Cytapheresis
Thrombotic thrombocytopenic purpura	Plasma exchange
Posttransfusion purpura	Plasma exchange
Sickle Cell disease	RBC exchange
Cutaneous T cell lymphoma	Photopheresis
Chronic inflammatory demyelinating polyradiculoneuropathy	Plasma exchange
Acute inflammatory demyelinating polyradiculoneuropathy	Plasma exchange
Demyelinating polyneuropathy with IgG & IgA	Plasma exchange
Myasthenia Gravis	Plasma exchange
Phytanic acid storage disease	Plasma exchange

Category II diseases include:

Rapidly progressive glomerulonephritis	Plasma exchange
Cryoglobulinemia	Plasma exchange
Rheumatoid arthritis	Lymphoplasmapheresis
ABO mismatched BMT recipient	Plasma exchange
Polycythemia vera	Erythrocytapheresis
Myeloma, hyperviscosity	Plasma exchange
Coagulation factor inhibitors	Plasma exchange
Lambert Eaton myasthenia syndrome	Plasma exchange
Sydenham's chorea	Plasma exchange
Polyneurophathy with IgM	Plasma exchange
Cryoglobulinemia with polyneuropathy
Pediatric autoimmune neuropsychiatric disorder

Category III diseases include:

Hemolytic uremic syndrome	Plasma exchange
Renal transplant sensitization	Plasma exchange
Heart transplant rejection	Plasma exchange
Acute hepatic failure	Plasma exchange
Overdose or poisoning	Plasma exchange
Raynaud's phenomenon	Plasma exchange
Scleroderma	Plasma exchange
Systemic lupus erythematosis	Plasma exchange
Polymyositis	Plasma exchange
Aplastic anemia or pure red cell aplasia	Plasma exchange
Hemolytic disease of the newborn	Plasma exchange
Platelet alloimmunization	Plasma exchange
Malaria or babesiosis	Red cell exchange
Multiple sclerosis	Plasma exchange
Multiple myeloma with polyneuropathy	Plasma exchange
POEMS syndrome	Plasma exchange
Paraneoplastic syndromes	Plasma exchange

Category IV diseases include:

Renal transplant rejection	Plasma exchange
Rheumatoid arthritis	Plasma exchange
Amyloidosis	Plasma exchange

Smith JW, Weinstein R, Hillyer KL for the AABB Hemapheresis Committee, Transfusion 2003;43:820-822.




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