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Apheresis Principles (April 9, 2013 ) 0
Concepts In Biochemistry And Microbiology (SHGB6115 )
Universiti Malaya
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Principles of Therapeutic Apheresis: A Method to the Madness Paul Yenson, MD FRCPC Clinical Hematology, Vancouver General Hospital April 9, 2013 Tuesday, 9 April, 13 Disclosures • Unrestricted educational grant from Octapharma Canada. Tuesday, 9 April, 13 Case • 66yo F, end-stage liver disease secondary to primary biliary cirrhosis. • Past Hx: hypertrophic cardiomyopathy. • Patient blood group A POS. • Undergoes cadaveric liver transplant. • Apheresis Physician contacted 1 hour post-op when surgeon realizes that liver is group AB. • Plasma exchange requested to prevent hyperacute graft rejection due to major ABO incompatibility. Tuesday, 9 April, 13 History of Apheresis • Apheresis = separation • Greek apairesos / Roman aphairesis: “to take away” • Process in which blood is removed from a patient and continuously separated into component parts; allowing a component to be retained while the remainder is returned to the patient. Tuesday, 9 April, 13 Methods of Separation Centrifugation VS Membrane Separation Tuesday, 9 April, 13 Methods of Separation: Centrifugation • Separation of blood components according to density. HEMATOCRIT 0% 2% 3% 100% Tuesday, 9 April, 13 Methods of Separation: Membrane Filtration • Separation of blood components according to molecular size. • Extracorporeal blood pumped across a hollow-fibre, capillary plasma filter with varying pore sizes. Tuesday, 9 April, 13 Methods of Separation: Membrane Filtration Hur M et al. ABO-incompatible kidney transplantation. 2011. Tuesday, 9 April, 13 Tuesday, 9 April, 13 Tuesday, 9 April, 13 The Importance of Factor IV • Heparin use limited by the degree of systemic anticoagulation and concerns regarding HIT. • With centrifuge devices, citrate is the anticoagulant of choice. • Chelates ionized calcium thereby blocking all calcium-dependent steps in coagulation cascade. • Mild, transient hypocalcemia can occur; usually well-tolerated and responds to oral or intravenous calcium supplementation. Tuesday, 9 April, 13 Anticoagulation • Citrate is rapidly metabolized by the liver (normal levels within 4 hours). Hepatic dysfunction severe hypocalcemia • Citrate metabolism consumes hydrogen ions ⇒ bicarbonate production Renal failure metabolic alkalosis • Factors affecting citrate “dose”/risk of toxicity: - Duration of procedure - Type of procedure - ?Patient weight Tuesday, 9 April, 13 - Rate blood is drawn from pt - “AC ratio” Fluid Balance and Shifts • Procedural variability: • Cytoreduction procedures have net fluid removal (e. stem cell collection bag ≈ 300-400 mL) • Plasma exchange usually results in net fluid gain (Fluid balance can be modified to a modest degree, generally 90-110%) • Granulocyte collections require use of starch (volume expander). Tuesday, 9 April, 13
Apheresis Principles (April 9, 2013 ) 0
Course: Concepts In Biochemistry And Microbiology (SHGB6115 )
University: Universiti Malaya
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