Therapeutic Apheresis Services Research Articles

Identification of HLA alleles involved in immune thrombotic thrombocytopenic purpura patients from Turkey.

Thrombotic thrombocytopenic purpura (TTP) is one of the rare group disorders classified as thrombotic microangiopathies (TMAs). Approximately 90% of TTP developed immune-mediation by the formation of antibodies against the enzyme ADAMTS-13. The exact cause is unknown. To establish an association between human leukocyte antigen (HLA) and autoimmune basis, as susceptibility or protection against the disease, we contributed a study aiming to evaluate the role of HLA in immune-mediated TTP (iTTP). Considering epidemiological factors such as age, sex, ethnicity, and geographical origins, we contributed the study in our country, Turkey, which consist of a very heterogeneous population. Patients' data collection was retrospectively from electronic database on two University hospitals having big therapeutic apheresis service. Control arm was healthy people registered as stem cell donors matched in terms of age and sex. The frequency of HLA-DRB1 and HLA-DQB1 alleles between acquired TTP and the control group was compared using the chi-square method. Yates correction and logistic regression were performed on these results. A total of 75 iTTP patients and 150 healthy individuals enrolled to the study. HLA-DRB1∗11, HLA-DQB1∗03, HLA-DRB1∗11:01, HLA-DRB1∗14:01, HLA-DRB1∗13:05, HLA-DRB1∗11 + HLA-DQB1∗03 allele pair and HLA-DRB1∗15 + HLA- DQB1∗06 were proved to be susceptibility allele pairs for iTTP. HLA-DRB1∗15, HLA-DRB1∗01:01, HLA-DRB1∗07:01, HLA-DRB1∗13:01, HLA-DRB1∗14:54, HLA-DQB1∗05:01, HLA-DQB1∗02:02 and HLA-DRB1∗07 + HLA-DQB1∗02 allele pair were found to be protective against iTTP. Our findings support an association with iTTP across very heterogenous populations in Turkey.

Therapy plans for therapeutic apheresis in Epic HealthLink.

A common required duty of pathology resident physicians while rotating on transfusion medicine is the medical oversight of the therapeutic apheresis service. A task often performed on this clinical medicine service is formulating and writing orders for therapeutic apheresis procedures. The EpicCare tool called the therapy plan provides unique advantages over a standard electronic order set for therapeutic apheresis. Transfusion medicine physicians, apheresis nurses, pharmacists, and information technology professionals collaborated to create therapy plans for three therapeutic apheresis procedures: plasmapheresis, red cell exchange, and photopheresis. Therapy plans were implemented and have been well-received for several years. Over a six-year time period, a total of 613 therapy plans were created and signed. We speculate that this implementation may have increased both physician efficiency and patient safety. This article reports our experience using therapy plans in EpicCare in order to raise awareness of this tool and to serve as an encouragement for wider adoption.

Bortezomib As Frontline Therapy in the Management of TTP

IntroductionThe current International Society on Thrombosis and Hemostasis (ISTH) guideline of Thrombotic Thrombocytopenic Purpura (TTP) recommends Therapeutic Plasma exchange (TPE) and corticosteroid in the management of TTP, with Rituximab and Caplasizumab as additional potential therapies [X Long Zheng et al, J Thromb Haemost. 2020;18:2496-2502]. This potentially fatal condition requires prompt diagnosis and treatment but large volume plasma treatment is not without risk and in settings with limited access with sufficient compatible plasma for apheretic exchange, this can delay this emergency therapy. We have been running the first therapeutic apheresis services with an Optia instrument in Uganda at the Joint Clinical Research Centre in Kampala city and TTP is the main indication for TPE. We present 2 recent sequential cases of TTP that were successfully managed when Bortezomib was combined with plasma therapy.Case1.A 25yr woman referred to our service on 29/09/2020, with recent onset of bruising, icterus, severe anemia Hgb5.7g/dL, Severe thrombocytopenia 8 x 10 3/uL, a high LDH 3909U with schistocytes on the peripheral blood film severe thrombocytopenia and a negative Direct Antiglobulin test. She was Blood Group B+. She was managed with 3 sessions of TPE of 2.1, 1.1 and 2.0 plasma volume exchanges with 6727mL, 3026mL and 5459mL of replacement plasma respectively and oral prednisone 60mg daily without remission. Subsequent quantities of plasma were insufficient for apheresis and were instead transfused. She also received weekly Rituximab 500mg (IV) but without significant recovery in the platelet count until she received Bortezomib 2mg (SC) when there was corresponding recovery of the platelet count and with each dose to a total of 4 doses (Figure 1).Case2.A 55yr man was previously well and shopping in a mall when he had an index episode of seizures on 19.Jun.2021 and was hospitalized that day with altered consciousness and focal motor signs. He required intubation for 3 days and at the time of hospitalization, he had Hgb 9gm/dL, PLT 17 x 10 3/uL, LDH2177U, with numerous schistocytes on the peripheral blood film and a negative Direct Antiglobulin Test. The baseline blood sample functional ADAMTS13 was 3% and had Blood Group AB+. He had received the 1 st dose of the Astra-Zeneca Covid19 vaccine on 06.May.2021. It was not possible to get any AB plasma and we considered it risky to perform large volume TPE with non-AB plasma and he was instead treated with daily transfusion with Group A+ Plasma concurrent with daily Prednisone 60mg. Because of our previous experience of poor response to Rituximab, we opted to treat him upfront with 4 doses of 2mg bortezomib (SC) given 3 days apart. He made brisk recovery to complete remission and was discharged for weekly outpatient CBC and LDH monitoring. His platelet count subsequently dropped without a corresponding drop in the Hgb and no rise in the Hgb. We initially re-hospitalized him for 4 more days of plasma transfusion but without a brisk response and since the LDH was not increasing, the isolated Thrombocytopenia was considered a side effect of Bortezomib that was expected to resolve and he receive no further treatment but continued to recover to complete remission as an out-patient (figure 2).Discussion:Our findings suggest a possible role for Bortezomib in frontline therapy for TTP with potential to reduce the plasma requirement in TPE and this approach warrants a randomized clinical trial. [Display omitted] DisclosuresNo relevant conflicts of interest to declare. OffLabel Disclosure:Bortezomib Indicated in the management of Multiple Myeloma and Plasma Cell Dyscrasia

Apheresis medicine in the era of advanced telehealth technologies: An American Society for Apheresis position paper Part I: Understanding the basic technologies and apheresis medicine practice models.

The wide spread availability and use of sophisticated high-speed telecommunication networks coupled with inexpensive and easily accessible computing capacity have catalyzed the creation of new tools and strategies for healthcare delivery. Such tools and strategies are of value to apheresis medicine (AM) practitioners if they improve delivery of patient care, enhance safety during a therapeutic apheresis (TA) intervention, facilitate care access, advance technical capabilities of apheresis devices, and/or elevate quality performance within TA programs. In the past several years, healthcare delivery systems' adoption of telecommunication technologies has been fostered by organizational financial and quality improvement objectives. More recently, adoption of telehealth technologies has been catalyzed by the COVID-19 pandemic as these technologies enhance both patient and provider safety in an era of social distancing. These changes will also influence the delivery of TA services which now can be generally viewed in a tripartite model format comprised of traditional hospital-based fixed site locales, mobile TA operations and lately an evolving telemedicine remote management model now reffered to as telapheresis (TLA). This communication developed by the Public Affairs and Advocacy Committee of the American Society for Apheresis (ASFA) and endorsed by its Board of Directors, reviews and describes various aspects of established and evolving electronic technologies related to TLA and the practice of AM. In subsequent companion publications, additional aspects to TLA will be explored and ASFA's vision of reasonable, regulatory compliant and high-quality TLA practices will be expounded.

Therapeutic apheresis services: a unique field of nursing within NHSBT.

Therapeutic apheresis services: a unique field of nursing within NHSBT.

Vascular access practices for therapeutic apheresis: Results of a survey.

Obtaining vascular access (VA) is a critical part of the therapeutic apheresis (TA) treatment plan. Currently, there are no guidelines for VA decision-making and maintenance related to TA procedures. A 28-question survey to gather qualitative information regarding VA practices was distributed to the American Society for Apheresis (ASFA) 2018 Annual Meeting attendees and all ASFA members for voluntary participation. The descriptive analyses were reported as the number and frequency of responses for each question. Total participation was 206 with 147 (71.4%) answering some or all 16 VA focused questions. The majority of respondents were nurses or physicians (89.0%) at sites providing ≥100 procedures. The most common TA procedures were plasma exchange, red cell exchange, and leukocytapheresis. The VA evaluation was predominantly performed by the TA service (80.3%, 118/147). The majority of TA physicians and/or providers do not insert (91.7%, 132/144) or remove (81.2%, 117/143) VA catheters. When an emergent TA procedure is needed, the majority of respondents felt <2 hours was an acceptable turnaround time for VA placement (64.3%, 92/143). The most common anticoagulant for locking catheters and/or ports was heparin. The majority of TA services (54.3%, 76/140) collect data on aborted procedures due to catheter/line/port problems unrelated to infection, but only 41.4% (58/140) collect data on infections. VA contributes significantly to the overall risks associated with and the safety of TA. Our survey shows that there is substantial variation but common themes in TA VA practices. Several areas for future research may be identified.

Establishing an institutional therapeutic apheresis registry.

Apheresis was first performed as a therapeutic procedure in the 1950s. The first national therapeutic apheresis (TA) registry was established in Canada in 1981 and other national registries followed, including two attempts at establishing an international TA registry. There is no national registry in the United States. Our large, academic, tertiary hospital has a very active TA service. We created a TA database to track all procedures performed by the apheresis service by transferring data from paper appointment logs and the electronic medical records into a Microsoft Access database. Retrospective data from each TA procedure performed at UAB from January 1, 2003 through December 31, 2012 were entered, including the type of procedure, indication, date, and patient demographics. Microsoft Excel was used for data analysis. During the 10-year period, our TA service treated 1,060 patients and performed 11,718 procedures. Of these patients, 70% received therapeutic plasma exchange (TPE), 21% received extracorporeal photopheresis (ECP), 4.5% received red cell exchange (RCE), 4.2% received leukocytapheresis, and 0.6% underwent platelet depletion. Among the procedures, 54% were TPEs, 44% were ECPs, 1.3% were RCEs, 0.5% were leukocytaphereses, and 0.1% were platelet depletions. According to the current literature, national and international TA use is underreported. We believe that the UAB TA registry provides useful information about TA practices in our region and can serve as a model for other institutions. Furthermore, data from multiple institutional registries can be used for clinical research to increase the available evidence for the role of TA in various conditions. J. Clin. Apheresis 31:516-522, 2016. © 2015 Wiley Periodicals, Inc.

Benefits and challenges of starting a new therapeutic apheresis service in a resource-constrained setting.

Therapeutic apheresis (TA) refers to a group of extracorporeal blood treatment modalities with clinical indications for which the clinicians' knowledge, availability and applicability vary widely worldwide. Therapeutic plasma exchange (TPE), the most common TA technique, is neither readily available nor affordable in many parts of Africa. This article focuses on the challenges of starting a TPE program in a resource-constrained economy and the result of a survey of Nigerian nephrology professionals on TPE. A critical appraisal of published manuscripts from Nigeria on TA was undertaken to assess uses, methods, and challenges encountered followed by a survey of the perceptions of Nigerian nephrology professionals on TPE. Survey results: 56.7% of respondents had very little or no knowledge of TPE; 40.5% moderate and only 2.7% admitting to having a good knowledge. Only 18.9% of respondents have ever participated or observed a TPE procedure with the remaining 81.1% not having any exposure to the procedure. A vast majority of the respondents 97.3% felt they needed better exposure and training in TPE and its applications. Among consultants, 56% had little knowledge, 88% had never participated or observed the TPE procedure, and 94% felt they needed better exposure and training. There is significant limitation in accessibility, availability, and use of TPE in Nigeria; knowledge of TPE and its applications is minimal among nephrology professionals. Efforts should be concentrated on improving the knowledge and availability of TPE in resource-constrained economy like Nigeria. Centers that would be able to manage cases requiring TA should be developed.

One week education in apheresis at Dharmais National Cancer Hospital

In Indonesia, an increasing number of apheresis procedures are performed. Single donor platelets are collected at six Blood Transfusion Services and five hospitals. Also therapeutic apheresis procedures are performed in all of these hospitals. In the last 3 years, in Indonesia in total 448 therapeutic apheresis procedures (TPE, leukoand platelet reduction, and PBSC collection) were performed of which 146 (32.5%) in the Dharmais Cancer Hospital. More hospitals in East Java planned to start a therapeutic apheresis service and asked for education of physicians and nurses. Therefore, a 1 week educational program to increase the knowledge, skills and capability of apheresis nurses to perform therapeutic apheresis procedures was developed and organised (August 2010) at the Dharmais Hospital in Jakarta.

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

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

Building a new therapeutic apheresis service

Building a new therapeutic apheresis service

Delivery of therapeutic apheresis services in the United States

Delivery of therapeutic apheresis services in the United States

Exclusive therapeutic apheresis delivery system

The demand for plasma exchange has grown significantly since the early 1980s after the publication of articles describing the benefits of this treatment modality in a number of serious medical conditions [1–4]. New indications for cytapheresis procedures have expanded the demand for therapeutic apheresis (TA) even further. [5,6] Most TA procedures before the 1980s were usually performed in a research setting [1–4]. With the development of clear clinical indications for TA [7,8], the need for medically and technically competent TA providers became obvious. The Bay Area Mobile Apheresis Program (BAMAP) was conceived as an entity that would: one, provide exclusively TA services to patients who needed them, two, provide a setting for training of physicians and nurses in this new field, and three, be in the forefront of research through participation in clinical trials. Twenty years later, BAMAP continues to be an exclusive TA provider serving patients throughout the state of California. This paper discusses the development, organization and function of this stand-alone TA delivery system.

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.