Apheresis Services Research Articles

Starting a new therapeutic apheresis service: Medical directorship and other matters

Starting a new therapeutic apheresis service: Medical directorship and other matters

Comparison of Erythrocytapheresis and Simple Transfusion for the Treatment of Children with Sickle Cell Disease Acute Chest Syndrome

AbstractAbstract 4765 Introduction:Therapy for acute chest syndrome (ACS) in our hospital includes IV hydration, pain control, antibiotic therapy, incentive spirometry, and an inhaled bronchodilator in patients who are wheezing or who have a history of asthma. Patients also receive red blood cells as either a simple transfusion (ST) or an exchange transfusion using automated erythrocytapheresis (RCE). Here we present clinical and laboratory data from patients with ACS who were treated with RCE and compare these results to a contemporaneous control group of patients with ACS who were treated with ST. Methods:This was a retrospective study of all patients who presented to Arkansas Children’s Hospital from 1996 through 2010 for the treatment of newly diagnosed ACS. Episodes of ACS were separated into a control group who were treated with ST and a RCE group. Patients were referred to the apheresis service by the treating hematologist for RCE when they presented with severe ACS and impending respiratory failure (n=20) or when they failed to improve, or deteriorated, following ST (n=29). Summary statistics were described as mean ± standard deviation for continuous data and frequency and percentage for categorical data. Because there were patients with multiple episodes, repeated measures analyses were performed to evaluate the clinical differences between the RCE and ST episodes. Results:We identified a total of 81 patients who were diagnosed with a total of 119 episodes of ACS. The average age at presentation was 8.5 years (range 5 months to 20 years), 64% were male, and 78% had SS disease. Twelve patients (accounting for 11 episodes each in the RCE and ST groups) had a previous history of asthma and 23 patients had multiple episodes of ACS (median 2, range 2–6). Episodes treated with RCE were significantly more likely to present with tachypnea, retractions, nasal flaring, and decreased air movement but episodes treated with ST were significantly more likely to present with cough and wheezing, even though a previous history of asthma was not more common in the ST group than in the RCE group. The RCE group spent significantly more time on oxygen, eight episodes required BiPAP, and 3 episodes required mechanical ventilation but no ST episodes required either BiPAP or mechanical ventilation. The median WBC at diagnosis was significantly higher in the RCE group but there were no significant differences in hemoglobin level or platelet count between the groups. As expected, blood product utilization was significantly higher in the RCE group. There were no procedural or catheter-related complications in the RCE group. Mean length of stay was not significantly longer in the RCE group but total hospital costs were significantly higher as expected in the RCE group due to the expense of RCE and the need for ICU care, BiPAP, and mechanical ventilation. There were no deaths from ACS during the study period.TableClinical variables in children with ACS treated with RCE or standard transfusion therapyVariableRCE Group (n=49)ST Group (n=70)p-valueRetractions22%9%0.03Nasal flaring14%3%0.049Tachypnea71%46%0.003Decreased air movement20%3%0.005Cough33%53%0.046History of asthma22%16%0.74Wheezing8%21%0.04Initial WBC (K/ml)21.519.90.04Total RBC transfusion volume (ml/kg)53.914.8<0.001Days on oxygen (mean)52.80.001Mean length of stay (days)6.85.40.06Total hospital costs$24,502$14,3090.003Additional variables that were studied but did not differ significantly between the groups included fever, sites of pain, vomiting, grunting, accessory muscle use, crackles, decreased breath sounds, color, oxygen saturation, chest radiograph findings, initial hemoglobin and platelet count, and post-treatment blood counts. Discussion:We found that children treated with RCE were sicker than those treated with ST, as determined by tachypnea, retractions, nasal flaring, decreased air movement, duration of oxygen therapy, need for BiPAP, and need for mechanical ventilation. We also found that children with ACS who present with cough and wheezing are significantly less likely to require RCE. We conclude that RCE is an effective therapy for sicker patients with ACS but that further work is required to develop a predictive scoring system to discriminate prospectively between children with ACS who will benefit from RCE and those who can be treated successfully with ST. Disclosures:No relevant conflicts of interest to declare.

American society for apheresis white paper: Considerations for medical staff apheresis medicine physician credentialing and privileging

Physician supervision of apheresis contributes to safe and high-quality patient care. Literature is limited regarding the requirements for hospital privileges of physicians providing apheresis services. This report provides recommendations from the American Society for Apheresis (ASFA) regarding this topic. The ASFA Public Affairs Committee was charged by the society's Board of Directors (BOD) to work collaboratively with other ASFA committees to develop guidance pertaining to requirements for hospital privileges of physicians in apheresis medicine. After review of the literature and discussions with members from diverse practice environments, draft guidance was created and circulated among pertinent parties for comment and revision. The final document, approved by the BOD in 2011, is presented herein. Assurance of patient safety was the paramount focus in the deliberations. Establishment and maintenance of physician competency in the discipline of apheresis medicine, and the documentation thereof, were consensus priorities. The importance of care teams involving non-physicians and the support structures within hospitals were also identified as other important contributors to patient safety. Patient safety during therapeutic apheresis involves both practitioners' and institutional provision of care aspects. Physician training experiences, medical licensing, and board certification status, along with continuing medical education and participation in risk management/patient safety projects are characteristic facets of physician competency in the provision of quality apheresis medicine interventions. Documentation of such indicators may help in medical staff deliberations regarding physician privileging in the oversight and management of apheresis medicine activities in hospitals.

Building a new therapeutic apheresis service

Building a new therapeutic apheresis service

Why nephrologists should perform therapeutic plasma exchange

Why nephrologists should perform therapeutic plasma exchange

The 2007 Heart-UK Survey of Lipid Clinics and Clinical Practice in the UK

An electronic survey of lipid clinics and clinical practice was sent to 120 UK clinics and 67 replied. Clinics were provided by chemical pathology in 31%, general medicine in 21% and diabetes services in 17%. The average clinic size was 638 patients and saw 168 new patients/year. 70% of referrals originated from primary care, 8% from cardiology and 7% from diabetes. 90% of patients had previously tried statins and 40% ezetimibe. 22% of patients had familial hypercholesterolaemia (FH) but only 9% of clinics had access to genetic nurse services. The Joint British Societies-2 Guideline was used in 50% and the National Service Framework in 25%. Targets used were total cholesterol (TC) <5 or 4 mmol/L; LDL-C <3 or 2 mmol/L; HDL-C >1 mmol/L in men, >1 or 1.2 mmol/L in women; triglycerides <1.7 or <2 mmol/L in primary prevention. In secondary prevention TC <4 and LDL-C <2 was preferred. 56% preferred to use the JBS-2 secondary prevention targets for FH. Patients were managed with statins alone in 45%, statin-ezetimibe 20% and statin-fibrate in 15%. 14% were considered statin intolerant and 10% unresponsive. There was wide variation in target attainment with statins. Compliance was considered a major issue by 80% and affected the use of bile acid sequestrants, niacin and statins. Children with FH were seen with parents in 73% of services with about 20 children/clinic. 32 patients were receiving apheresis. 84% of clinics did not use apheresis services. 34% of clinics audited target attainment using a mixture of notes and databases. Only 27% of clinics discharged FH patients to primary care.

An analysis of the optimal timing of peripheral blood stem cell harvesting following priming with cyclophosphamide and G-CSF

Increasing demand on the apheresis service makes efficient harvesting of peripheral blood stem cells (PBSCs) essential. A total of 168 adult patients with haematological malignancy were primed using low-moderate dose cyclophosphamide (1.5-3 g/m(2)) with G-CSF 5-10 microg/kg per day. Harvesting was booked and peripheral blood (PB) counts first checked between 6 and 10 days post-priming. One hundred and thirty (77%) patients harvested successfully (total harvest yield > or =2 x 10(6) CD34(+)/kg) and the median PBSC collection per procedure was 2.18 x 10(6)/kg (range 0.1-14.5). Only more lines of prior chemotherapy predicted failure to harvest in multivariate analysis (P=0.003). The PB CD34(+) cell count correlated significantly with harvest yield (r=0.8448, P<0.0001). A PB CD34(+) count > or =10/microl predicted a collection of > or =2 x 10(6)/kg (positive-predictive value of 61%, negative-predictive-value 100%). Patients first attending day 9 required significantly fewer visits to achieve a successful harvest than those first attending days 6-8 without increasing the risk of failure. No significant difference in failure rates, number of days attending and total harvest yield was found between days 9 and 10 attendees. Collection from day 9 may however enable higher target yields to be achieved. PB CD34(+) count monitoring should commence and harvesting booked from day 9 to optimize both the harvest and the efficiency of the PBSC harvesting service.

National Survey of Hemapheresis Practice in Hungary 2001–2004

In the current study, the authors evaluated data provided by Hungarian hemapheresis centers to the National Health Insurance (NHI) organization between 2001 and 2004 with the intention of having costs reimbursed. The primary objective of the present study was to rank data by frequency of indications of therapeutic plasma exchange (TPE). Furthermore, we compared frequency data with the Canadian TPE Registry and reviewed medical evidence regarding the adequacy of applying TPE at chosen indications based on data in literature. It was concluded that the number of TPEs (and thus the reimbursed costs) increased steadily year by year. It is worth considering the difference between the five most frequent indications of TPE in Hungary or in Canada. Clinicians tend to apply TPE in many cases as a last resort treatment of many diseases unresponsive to conventional therapy. Consequently, there are many illnesses for which the value of TPE is still questionable (or unproven) and its use is considered investigational or experimental. Nevertheless, cumulative medical experience does not always confirm the adequacy of TPE in all treatments, retrospectively. Thus, limited financial resources oblige clinicians to be judicious in providing apheresis services.

Delivery of therapeutic apheresis services in the United States

Delivery of therapeutic apheresis services in the United States

A large university medical center delivery system for therapeutic apheresis services

The clinical applications of therapeutic apheresis (TA) encompass a broad spectrum. Diversity exists not only in the age and acuity of patients treated, but also in the range of therapeutic approaches and technology. Particularly over the past decade, there has been rapid expansion of TA for primary, adjuvant, and empiric therapies for myriad clinical settings. Recognizing this context, it is not surprising that a variety of delivery models for providing TA services have emerged. In this paper, the structure of an apheresis service at a large academic university hospital will be described to illustrate one example of an effective apheresis delivery model. Alternatives to this delivery model are certainly possible. The discussion will also indicate where some organizational variations may occur within this category of facility.

Therapeutic apheresis services provided by a community blood bank

Therapeutic apheresis services can be provided from a community-based blood center. The Oklahoma Blood Institute uses a mobile approach, primarily servicing 10 major hospitals in the Oklahoma City metropolitan area within a 15 to 20 mile radius. Apheresis staff and equipment are available 24 hours per day, 7 days per week in the event of patient referral requiring an emergency therapeutic apheresis procedure. This model requires close communication between the therapeutic apheresis medical director and the referring clinician. Telephone and facsimile transmissions of information are used to facilitate the transfer of information to all persons/facilities involved in providing treatment. This approach has proven effective in providing the required procedures for a referral population base of several million people spread over a fairly large geographic area.

Adverse reactions associated with mobile therapeutic apheresis: analysis of 17,940 procedures.

In order to evaluate the nature and frequency of adverse reactions associated with Therapeutic Apheresis (TA), database information from two large mobile apheresis services was analyzed. A total of 17,940 procedures performed on 3,583 patients were studied using an Access Database. Seventy percent (12,558) of the procedures were performed on a Fresenius AS104 blood cell separator and 30% (5,382) were performed on a COBE Spectra. The five most commonly treated diseases were Guillain-Barre Syndrome (25%), thrombotic thrombocytopenic purpura (20%), myasthenia gravis (18%), the hyperviscosity syndrome (12%), and chronic inflammatory demyelinating polyneuropathy (9%). All patients received calcium gluconate supplement during the procedures. Cardiac monitoring was used during 80% of the procedures and blood pressure monitoring was used during all procedures. All procedures were supervised by a physician. Both apheresis services fully comply with the ASFA Guidelines for Therapeutic Apheresis Providers. Adverse reactions occurred in 3.9% of all procedures. The following adverse reactions were documented: reactions related to ACD toxicity (3%), vasovagal reactions (0.5%), vascular access related complications (0.15%), reactions related to FFP (0.12%), hepatitis B from FFP (0.06%), arrhythmias (0.01%), hemolysis due to inappropriate dilution of 25% albumin (0.01%), and one death (from underlying disease) during a TA procedure (0.006%). These data demonstrate that therapeutic apheresis is associated with a low rate of side effects when performed by well-trained and certified nurses under the direction of experienced physicians, even in the diverse setting of large mobile therapeutic apheresis programs.

Circulating CD34+ counts and apheresis planning.

The success of peripheral blood progenitor cell (PBPC) transplantation depends upon harvesting adequate numbers of cells and accurate prediction of when to commence apheresis. Although peripheral white cell count (WBC) is commonly used to identify when to initiate apheresis it does not uniformly predict the CD34+ content of the apheresis product nor the number of exchange procedures required. We investigated whether the peripheral blood CD34+ count would not only predict harvest yield but whether it would also predict the number of apheresis procedures needed to generate at least 2 x 10(6)/kg CD34+ cells. CD34+ counts were performed over an 8-month period on the peripheral blood and PBPC harvests of all patients undergoing leucopheresis. Regression analysis showed a highly significant correlation between peripheral blood CD34+ count and yield of CD34+ cells in the apheresis product. The regression plot with WBC was weaker. We have shown that a peripheral CD34+ count > or = 62 x 10(6)/l is required to confidently achieve an adequate harvest in one apheresis, two aphereses are needed if the initial count is > or = 40 x 10(6)/l. Therefore peripheral blood CD34+ counts not only are able to determine the threshold at which to commence apheresis but are useful in predicting apheresis requirements and planning demands on the apheresis service.

Prospective Comparison of Plateletpheresis With Three Cell Separators Using Identical Donors

Each of 41 donors underwent plateletpheresis on the CS–3000 (Fenwal), 2997 (IBM/Cobe), and V50 (Haemonetics) blood cell separators. Platelet collection efficiency was highest with the 2997. The fewest number of lymphocytes were present in products collected with the 2997. Procedures with the CS#x2013;3000 resulted in the least amount of change in donor ionized calcium levels and in the fewest number of donor reactions. Products collected with the 2997 had the largest volume and had the longest set-up time but shortest processing time to obtain the highest yields. These data may help apheresis services select equipment best suited to the particular needs of their staff, donors, and patients.