Apheresis

Question 1

Erythrocytapheresis:

Answer 1

Erythrocytapheresis: Red Blood Cell Exchange. Replacement fluid of choice: RBC or RBC LR; if for polycythemia vera: colloid solution.

Question 2

Leukocytapheresis:

Answer 2

Leukocytapheresis: Selective removal of white blood cells in disease states or for transfusion [stem cells, donor lymphocyte infusion (DLI), or granulocytes.] Replacement fluid: none or colloid/crystalloid. May need a sedimenting agent such as hydroxyethyl starch.

Question 3

Thrombocytapheresis:

Answer 3

Thrombocytapheresis: Removal of platelets for Thrombocytosis. Replacement fluid: none or colloid/crystalloid.

Question 4

Plasma Exchange (TPE):

Answer 4

Plasma Exchange (TPE): Removal of plasma. Replacement fluid: plasma, colloid or colloid/crystalloid; depends on the disease state.

Question 5

Filtration Selective Removal:

Answer 5

Filtration Selective Removal: Plasma is separated from whole blood using a filter with a selective pore size. Used for plasma exchange, collection, or as a preliminary step to further process plasma on an immunoadsorption column. Replacement fluid: plasma, colloid or patient’s treated plasma

Question 6

Immunoadsorption:

Answer 6

Immunoadsorption: passing the separated plasma over a column with an active component such as Staph Protein A to remove immunoglobulins. Replacement fluid: patient’s treated plasma

Question 7

Extracorporeal photopheresis:

Answer 7

Extracorporeal photopheresis: removal of WBCs after patient treatment with photoactive psoralen, followed by treatment of WBCs with Ultraviolet A light, and reinifusion of the treated WBCs to produce an immunomodulative effect.

Question 8

LDL Apheresis:

Answer 8

LDL Apheresis: removal of low-density lipoproteins using, various filtration or adsorption techniques.

Question 9

TA Indication Catagories I-IV

Answer 9

1. Therapeutic apheresis (TA) is standard and acceptable.
2. TA is generally acceptable but not usually the primary treatment
3. Possible benefit but insufficient evidence or supporting clinical trial.
4. Controlled clinical trials have shown no benefit.

Question 10

Frequent Plasma Donor:

Answer 10

A person donating more than every 4 weeks.
Must be at least two days between procedures.
No more than two procedures in 7 days.
Annual physical, total protein, protein electrophoresis and Ig levels are required.

Question 11

Infrequent Plasma Donor:

Answer 11

Person who donates no more than one plasma donation in 4 weeks.

Question 12

Donation Frequency for platelets (and granulocyte) donors

Answer 12

At least 48 hours between two procedures
No more than 2 procedures in 7 days
No more than 24 procedures per year

Question 13

Platelet Count for donors

Answer 13

Platelet count
No count needed for first time donors or if interval is 8 weeks or more
Needed if more frequent than every 8 weeks
Post count from previous donation can be used
Pre-procedure >150,000
Previous donation in 4 weeks but post donation count less than 150,000

Question 14

Leukocyte Reduction for blood components must reduce WBCs to:

Answer 14

< 5 x 10^6

Question 15

Leukocyte Reduction for platelets must reduce WBCs to:

Answer 15

<8.3 x 10^6

Question 16

Platelet by Apheresis QC requirements

Answer 16

3.10^11 platelets in 90%
pH >6.2 in 90%
If leukoreduced <5 x 10^6 in 95%

Question 17

Which of the following statements regarding plateletpheresis donation is true?

a. Donors cannot donate more than 24 times per year
b. Donors cannot donate more frequently than every 56 days unless approval of the medical director is obtained
c. Donors must have a minimum platelet count of 150,000/ul to be eligible to donate without approval of the medical director
d. Donors must have abstained from ingested aspirin-containing products for at least 24 hours prior to donation in order to be eligible.

Answer 17

Correct: Donors cannot donate more than 24 times per year

Plateletspheresis donors cannot donate more than 24 times in a year.

Plateletspheresis donors do not have to wait 56 days in between donations.

The choice regarding the platelet count is not a true statement ALL of the time. The AABB standards does mandate that a sample is collected BEFORE the donation to determine the platelet count, but the platelet count is not required to qualify a first time donor. The testing for platelet count may occur at any time before, during or after the donation.

The choice that states that donors who ingest aspirin containing compounds must wait 24 hours is not true. They must wait a minimum of 48 hours before donating. In addition, donors who ingest clopidogrel and piroxicam must wait a minimum of 14 days before donating plateletspheresis.

Question 18

The shelf life of a granulocyte component collected via apheresis is:

a. 24 hours
b. 48 hours
c. 3 days
d. 5 days

Answer 18

Correct: 24 hours

Granulocytes have a 24 hour outdate because of the fragility of the component. In addition, granulocyte transfusion is often a last-ditch kind of treatment when conventional antibiotic therapy is not successful.

The short outdate means that components are emergency released without the viral marker testing being complete. Typically the ABO, Rh and Antibody screen are done prior to release.

Question 19

What is the purpose of performing Therapuetic Plasma Exchange (TPE) procedures?

a. removal of the plasma containing the pathologic substance, and infusion of replacement fluid.
b. collection of a 1 liter plasma component for transfusion.
c. Reducing the patient’s total blood volume
d. Replacement of vital plasma proteins in an immunocompromised patient.

Answer 19

Correct: removal of the plasma containing the pathologic substance, and infusion of replacement fluid.

Note:
Plasmapheresis refers to a procedure in which the plasma is separated from the blood either by centrifugation or membrane filtration. Once separated the plasma can be manipulated in a variety of ways. Plasma exchange refers to discarding the plasma totally and substituting a replacement fluid.

TPE is used in the treatment of various autoimmune diseases, conditions that cause the body to recognize a part of itself as foreign and generate proteins (called autoantibodies) that attack part of the body. These proteins are found in the plasma component of blood.

The question is asking about therapeutic plasma exchange. The word “exchange” should tell you that we need to remove something harmful and replace it, or exchange it, with a neutral fluid.

If we needed to reduce the patient’s blood volume, we might do therapeutic phlebotomy but we would NOT do an exchange.

Question 20

Which granulocyte component below reflects the minimum standard for acceptability? (/uL)

a. 3.0 X 10^11
b. 5.5 X. 10^10
c. 1.0 X 10^10
d. 5.0 X 10^6

Answer 20

Correct: 1.0 X 1010

The question is asking which unit reflects the minimum standard, so you should select the component that has a count at the minimum requirement of 1.0 X 1010.

This may seem picky, but these QC numbers are critical for you to know for the SBB exam as well as for your career as an SBB. There may be times when a number is given to you and you will be the person who has to make the determination of whether or not the component is acceptable.

Question 21

What is the purpose of administering Hydroxyethyl Starch (HES) prior to a granulocyte donation?

a. To protect the donor’s RBCs from hemolyzing
b. To hemolyze the RBCs in order to separate and collect the granulocytes
c. To improve the yield of granulocytes by enhancing RBC aggregation and sedimentation
d. To increase the amount of circulating granulocytes by mobilizing them from the marginal pool

Answer 21

Correct: to improve the yield of granulocytes by enhancing RBC aggregation and sedimentation

Hydroxyethyl starch is sometimes given to WBC pheresis donors to promote the harvest of WBCs with minimal RBC contamination.

HES is used as a physical means to promote cell separation and is NOT stimulating more granulocytes to be produced by the donor.

Granulocyte Stimulating Colony Factor (GSCF) can also be administered to donors prior to donation and THAT solution will increase the release of granulocytes so that the total number of circulating granulocytes is increased, and in turn, may enhance the collection during donation.

Corticosteroids are also agents that cause more granulocytes to be released from the periphery.

Question 22

Plasma removed from patients undergoing therapeutic plasma exchange may be ______?

a. Used for transfusion as FFP if the donor qualifications and component preparation standards are met.
b. Sold for further manufacturing
c. Reinfused to the patient
d. Discarded

Answer 22

Correct: discarded

TPE and plasmapheresis are not the same but similar. See below for differences. The key word is therapeutic plasma exchange. The plasma is beging removed following plasmapheresis.

The plasma removed as part of TPE is considered part of the treatment process, and as such may not be transfused or sold. Remember that the patient undergoing TPE is receiving a treatment and as such is not being assessed in any way for donor suitability.

Note:
Plasmapheresis refers to a procedure in which the plasma is separated from the blood either by centrifugation or membrane filtration. Once separated the plasma can be manipulated in a variety of ways. Plasma exchange refers to discarding the plasma totally and substituting a replacement fluid.

Question 23

During the process of apheresis, using centrifugation to separate blood components, which component is locate the farthest from the axis of rotation?

a. Plasma
b. Platelets
c. Lymphocytes
d. Red Cells
e. Granulocytes

Answer 23

Centrifugall force separates the various components of blood according to their specific gravity (density). The densest components collected the farthest from the axis of rotation, while the least dense layer collects the closest. The order of the layers of separation from the axis of rotation outward is plasma, platelets,lymphocytes, granulocytes and red cells. Red cells and granulocytes have an overlap in densities resulting in poor separation. This is why granulocyte products contain large numbers of red cells. Greater separation can be achieved by the addition of hydroxyethl starch. This aggregates the red cells, resulting in their having a greater density than the granulocytes.

Question 24

Which blood component is removed during a leukapheresis procedure?

a. Red Cells.
b. Buffy coat.
c. Platelet rich plasma.
d. Plasma.
Specific plasma protein.

Answer 24

During a leukapheresis procedure, the buff coat is removed from the patient’s blood. The buffy coat is also removed during an extracorporeal photopheresis procedure; however, this buffy coat is reinfused to the patient after treatment with a psoralen compound and UVA light.

Question 25

Case Study Apheresis Platelet Donation

A 40-year-old female arrives for her first-time apheresis platelet donation. Her past medical history was remarkable for hypertension, hyperlipidemia, and depression. Reported medications included bumetanide, pravastatin, and paroxetine. Thirty minutes from the start of the procedure, the donor notes tingling around the mouth, hands, and feet. She then very rapidly develops acute onset of severe facial and extremity tetany.

Question 1:

What is a possible source of the patient’s adverse reactions?

a. Allergic Reaction
b. Hepatitis
c. Hemolysis
d. Citrate Effect

Answer 25

answer: Citrate Effect

Citrate is the standard anticoagulant (AC) used during apheresis donation procedures. The two most common citrate anticoagulant solutions used in platelet apheresis are acid citrate dextrose (ACD)-A which is 3% citrate and ACD-B which is 2% citrate. Trisodium citrate (4%) is predominantly used in plasmapheresis and citrate phosphate dextrose (CPD) is commonly used in red-cell only apheresis.

The amount of citrate returned to an apheresis blood donor depends on a number of factors. Because citrate anticoagulation in the extracorporeal circuit is based on concentration, the volume of the blood component(s) returned, the concentration of citrate within the blood component(s), and the return speed determine citrate exposure to the donor. Therefore, total citrate exposure to a donor is highly varied but generally correlated with the volume of plasma returned and the concentration of citrate in the component(s) that is returned.

Citrate’s role as a metal chelating agent that binds divalent cations, such as calcium, has been thoroughly characterized. Like endogenous citrate, citrate AC solutions chelate calcium ions in the blood by forming calcium-citrate complexes that disrupt coagulation. Studies show reductions in circulating calcium concentrations in apheresis blood donors of 22–35% when comparing pre- and post-apheresis concentrations.

A study presented at the annual meeting of the American Association of Blood Banks demonstrated a rate of citrate reactions nearing 7% in over 80,000 apheresis procedures involving nearly 15,000 donors.
Symptoms of hypocalcemia include:

    Twitching in your hands, face, and feet.
    Numbness.
    Tingling.
    Depression.
    Memory loss.

Question 26

Case Study Apheresis Platelet Donation

A 40-year-old female arrives for her first-time apheresis platelet donation. Her past medical history was remarkable for hypertension, hyperlipidemia, and depression. Reported medications included bumetanide, pravastatin, and paroxetine. Thirty minutes from the start of the procedure, the donor notes tingling around the mouth, hands, and feet. She then very rapidly develops acute onset of severe facial and extremity tetany.

Question 2:

Select the side effect below most consistent with tetany.

a. Sweating
b. Coughing
c. Muscle Spasms
d. Paranoia

Answer 26

Answer; Muscle Spasms

Tetany is a condition that causes involuntary muscle contractions and changes in your brain cells. Some people don’t have any symptoms, but it can be life-threatening for others.

Symptoms of tetany include:

Muscle spasmsLinks to an external site.
Laryngospasm — which causes muscle spasms in your vocal cords, making speaking and breathing difficult
Numbness in your hands and feet
SeizuresLinks to an external site.
Heart problems
Carpopedal spasm, a hand spasm when your blood pressure is taken

Tetany usually is caused by low calcium levels

Question 27

Case Study Apheresis Platelet Donation

A 40-year-old female arrives for her first-time apheresis platelet donation. Her past medical history was remarkable for hypertension, hyperlipidemia, and depression. Reported medications included bumetanide, pravastatin, and paroxetine. Thirty minutes from the start of the procedure, the donor notes tingling around the mouth, hands, and feet. She then very rapidly develops acute onset of severe facial and extremity tetany.

Question 3:

What medication could be provided to the donor to help alleviate the symptoms described in this case?

a. Aspirin
b. Calcium Carbonate (ie TUMS)
c. Additional rounds of her pre-perscribed medications (bumetanide, pravastatin, and paroxetine)
d. Anti- seziure medications

Answer 27

Answer: Calcium Carbonate (ie TUMS)

Oral calcium supplements have been shown to be effective for management of mild symptomatic hypocalcemia. Oral calcium carbonate (2 grams in the form of an antacid, such as TUMS) can be given prophylactically 30 minutes before the initiation of apheresis or used to alleviate side effects during/after donation.

Aspirin should not be ingested for >48 hours before a plateletpheresis donation

This case study is an actual patient reported to have experienced citrate toxicity. Upon additional retrospective analysis, it was noted that the patient’s pre-perscribed bumetanide medication was a loop diuretic that had the potential to cause significant hypocalcemia. Thus, additional rounds of this medication could potentially increase citrate effect.

Anti-seziure medications would not be the best immediate course of action in this case.

Question 28

What is the maximum volume of blood that can be drawn in a 450 mL bag?

Answer 28

495 mL

Question 29

For plateletpheresis if the return of the donor’s red cells becomes impossible how long should the donor be deferred?

Answer 29

8 weeks

Question 30

Apheresis platelets must contain at least:

Answer 30

90%, 3 x 10^11 platelets and have a pH of >6.2

Question 31

Leukoreduced platelets must contain:

Answer 31

95%, <5 x 10^6

Question 32

Therapeutic plasma exchange is most useful in treating patients with:

a. Circulating immune complexes
b. Autoimmune diseases
c. Hyperimmune syndromes
d. Red Cell Aplasia

Answer 32

Correct = Circulating immune complexes

For therapeutic plasma pheresis, the goal is to remove a harmful substance from the patient’s circulation such that it does not return.

Hyperimmune syndromes and Autoimmune diseases are caused by the patient making an immune response to his own cells. So removing the circulating antibodies is not effective because the patient will just make more.

Red cell aplasia is a condition in which the bone marrow will not produce RBCs, so there is nothing in the peripheral circulation that is “hurting” the patient.

Circulating immune complexes are antigen-antibody bound together that are large harmful substances to the patient. They typically represent a transient problem and so removing them via plasmapheresis is effective.

Question 33

A patient undergoing a total hip replacement had his own blood salvaged intraoperatively. The unit was labeled with the patient’s name, medical record number, collection information and the time of collection which was 1:00pm. At 6:00pm the doctor wanted to reinfuse the unit to the patient. The unit had not been washed and had remained at room temperature.

Select the best answer; What should be done with this unit of autologous blood?

a. The unit has exceeded the 4 hour expiration time and should be discarded.

b.The unit may be used ONLY if it is washed prior to infusion.

c. The unit was not stored at 1-6C and must be discarded

d. The unit is acceptable for transfusion.

Answer 33

Correct: The unit is acceptable for transfusion.

Autologous blood collected as intraoperative blood salvage may be used washed or unwashed, and is stored up to 6 hours at room temperature. Therefore this unit was stored properly and has not yet expired as it is 5 hours old.

It is critically important to understand that washing does not remove infections agents, rather reduces risk of contamination. AABB reccomends washing but does currrently not require washing.