Therapeutic apheresis

Question 1

Categories of therapeutic apheresis

Answer 1

1. Category I
   
   • marked leukocytosis with leukostasis (cytapheresis)
   • SCD, acute stroke
   • apheresis is standard and acceptable as a primary therapy or firstline adjunct therapy
   • is not mandatory in all cases
2. Category II
   
   • SCD, acute chest, stroke prophylaxis or prevention of iron overload
   • thrombocytosis, symptomatic
   • apheresis is generally accepted but considered tobe supportive or adjunctive to other treatments rather than a first line treatment
3. Category III
   
   • Heart transplantation antibody mediated rejection, acute hepatic failure, posttransfusion purpura, chronic progressive MS
   • apheresis may be beneficial, however there is insufficient evidence to establish the efficacy or to clarify the risk or benefit
4. Category IV
   
   • ITP, HUS, SLE nephritis
   • Controlled trials have not shown benefit, or anecdotal reports have been discouraging
   • apheresis for these disorders should be carried out only in the context of an IRB approved research protocol

Question 2

Category I apheresis indications

Answer 2

1. marked leukocytosis
2. SCD, acute stroke
3. Acute inflammatory demyelinating polyneuropathy (Guillain-Barre)
4. ANCA associated rapidly progressive GN
5. Antiglomular basement membrane disease (Goodpasture)
6. CIDP
7. Cryoglobulinemia: severe or symptomatic
8. FSGS, recurrent
9. Hyperviscosity 2/2 monoclonal gammopathy (especially IgM)
10. MG
11. Paraproteinemic polyneuropathies
12. Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS) and Sydenham chorea
13. Renal transplantation, antibody mediated rejection
14. TTP

Question 3

Category II apheresis indications

Answer 3

1. SCD, acute chest, stroke prophylaxis or prevention of iron overload
2. symptomatic thrombocytosis
3. SLE: cerebritis, diffuse alveolar hemorrhage
4. Renal transplantation: HLA desensitization or ABO incompatible transplant
5. Catastrophic antiphospholipid syndrome
6. chronic focal encephalitis (Rasmussen encephalitis)
7. MS: acute CNS inflammatory demyelinating disease refractory to steroids
8. Mushroom poisoning
9. Phytanic acid storage disease (Refsum disease)
10. Neuromyelitis optica (Devic syndrome)

Question 4

apheresis replacement fluids

Answer 4

• normal saline
• 5% albumin
• allogeneic plasma (FFP or cryo poor FFP) in TTP

Question 5

Medication interactions with apheresis

Answer 5

• highly protein bound meds or meds with low volume of distribution (vd<0.2 L/kg) may be removed
• dosing immediately after apheresis should be considered
• ACE inhibitors should be d/c’d 24 hours prior to apheresis since they can cause hypotension