Escolar Documentos
Profissional Documentos
Cultura Documentos
April 9, 2013
Tuesday, 9 April, 13
Disclosures
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Objectives
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Case
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History of Apheresis
Apheresis = separation
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The History of Apheresis
1971
1950 MD Andersen
Glass bottles performs first
replaced with peripheral blood
1960 1980s
plastic bags. stem cell collection.
1914 Schwab and Fahey
Refinements to IBM
John Abel describes machine lead to
perform plasmapheresis on
manual plasmapheresis introduction of COBE
patient with Waldenstroms
procedure in dogs. Spectra in 1987.
macroglobulinemia.
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Methods of Separation
Centrifugation
VS
Membrane
Separation
Tuesday, 9 April, 13
Methods of Separation:
Centrifugation
HEMATOCRIT
0%
2%
3%
100%
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Methods of Separation:
Centrifugation
Calcium
(other fluids) Anticoagulant Waste
2
5 1 3
Centrifuge
Replacement
Fluid
Blood ECV
Warmer ~180mL
4 3
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Methods of Separation:
Membrane Filtration
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Methods of Separation:
Membrane Filtration
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Therapeutic Apheresis:
Physiologic Considerations and Effects
Tuesday, 9 April, 13
The Importance of Factor IV
Heparin use limited by the degree of
systemic anticoagulation and
concerns regarding HIT.
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Anticoagulation
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Fluid Balance and Shifts
{
+250
}
Balance 0
(mL) Initial n
io
Diversion
~ECV
infus
CD
/A
-193 l cium
Ca
Start Finish
Procedure Time
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Fluid Balance and Shifts
Procedural variability:
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Dilutional Effects on Plasma
Immunoglobulins
Electrolytes
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Dilutional Coagulopathy
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Cellular Loss
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Adverse Effects
Vasovagal reactions
Citrate toxicity
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Adverse Effects
1995 survey of 18 apheresis centres; 3429 procedures.
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Methods of Separation
Centrifugation
VS
Membrane
Separation
Tuesday, 9 April, 13
Methods of Separation
Low blood flow rate (50-100mL/min) High blood flow rate (400-600mL/min)
Tuesday, 9 April, 13
Therapeutic Apheresis: Why, When and How?
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Apheresis Applications
1. Plasmapheresis
2. Cytapheresis Plateletpheresis Therapeutic plateletpheresis
Single donor platelet collection
Leukapheresis Leukoreduction
PBSC collection
Donor lymphocyte collection
(Granulocyte collection)
Erythrocytapheresis RBC exchange
RBC depletion
3. Photopheresis
4. Selective plasma LDL-pheresis
adsorption Staphylococcal protein A columns
Tuesday, 9 April, 13
Plasma Exchange:
Therapeutic Considerations
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Case
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Therapeutic Plasma Exchange (TPE)
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Therapeutic Plasma Exchange:
Indications
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Plasma Exchange:
Therapeutic Considerations
McLeods Criteria
Plausible The current understanding of the disease
Pathogenesis process supports a clear rationale for the
use of therapeutic apheresis (TA).
Better Blood The abnormality, which makes TA plausible,
can be meaningfully corrected by its use.
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ASFA Guidelines (J Clin Apher 2010)
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Category I Indications for Therapeutic Apheresis
Plasmapheresis Cytapheresis
Demyelinating polyneuropathy with IgG and IgA Cutaneous T-cell lymphoma, erythrodermic (ECP)
Anti-GBM disease
Cryoglobulinemia
PANDAS
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Category II Indications for Therapeutic Apheresis
Plasmapheresis Cytapheresis
Eaton-Lambert Syndrome
Rasmussens encephalitis
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Therapeutic Plasma Exchange:
Most Common Indications
(CAG 2010)
Diagnosis n
TTP-HUS 211
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Plasma Exchange:
Therapeutic Considerations
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Plasma Exchange:
Therapeutic Considerations
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Vascular Access
Peripheral Central
Short (3 inches) 1. Dialysis catheter (large diameter)
4. PICC
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Plasma Exchange:
Therapeutic Considerations
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Therapeutic Plasma Exchange (TPE)
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Plasma Volume
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Protein Kinetics
IgM is removed more efficiently than IgG; both re-equilibrate within 24-48 hrs
To effectively deplete total body IgG by ~85% requires 5 exchanges q2 days; only
2-3 exchanges for IgM.
Effect of plasma exchange is temporary (T of normal IgG ~21 days, IgM 7-10
days)
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Therapeutic Plasma Exchange:
Replacement Fluid
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512 512
PE 1.0 plasma volume
AB plasma 5% albumin
ATG ATG ATG ATG ATG
Intraprocedural Ca2+ levels
PE PE PE PE PE PE PE IVIG IVIG
256
Anti-B IgM
Anti-B IgG
192
128
64
0
20 21 22 23 24 25 26 27 28 29 30 1 2 3 4 5 6 7 8 9 10
September October
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Summary
The most common side effects include vasovagal reaction, citrate toxicity
(hypocalcemia) and tranfusion reactions.
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An Approach to the Therapeutic Apheresis Patient
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Thank you! Questions?
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