Therapeutic Apheresis Services

Therapeutic Plasma Exchange (TPE) is a medical procedure that involves the use of a device to withdraw a patient's blood, separate the plasma (the liquid portion) from the blood cells, and then return the blood cells to the patient's body after mixing them with a liquid such as a 5% albumin solution or healthy plasma obtained from a blood donor. The purpose of this procedure is to remove specific abnormal components circulating in the patient's plasma, such as antibodies, abnormal proteins, and other harmful substances.

In cases where the patient's diagnosis is unclear or certain blood test results are pending, we will collaborate with the ordering physician to discuss the rationale behind requesting apheresis and explore the availability of alternative treatment options.

We determine the appropriate plasma volume to be replaced, extracorporeal red cell volume and the need to prime the circuit with either albumin or red blood cells as necessary, especially in pediatric patients.

Conditions We Treat with Therapeutic Plasma Exchange

The American Society of Apheresis (ASFA) provides a comprehensive list of indications for the use of therapeutic plasma exchange in various disorders, including autoimmune, hematologic, and neurological disorders. These indications are based on the latest guidelines and clinical trials. You can find more information about these indications by clicking [here].

The decision whether a patient qualify for a trial of TPE depends on the specific disease or condition and indication as highlighted by the ASFA guidelines. Briefly, each patient’s disease refers to a specific disease (i.e., myasthenia gravis), or condition such as liver transplantation. Indication refers to the use of TPE in specific situations encountered in the patient disease/condition (for example, myasthenia gravis [disease], acute respiratory failure [indication] for the use of TPE. Based on this information, each disease/condition is assigned a category and grade recommendation. The timing of TPE (i.e., routine procedure vs a medical emergency) and frequency of TPE (i.e., three vs five treatments) will vary depending on the disease ASFA category and indication. There are a total of 84 diseases and 157 indications addressed in the eighth edition of ASFA publication.

The American Society of Apharesis (ASFA) publishes a list of indications for the use of therapeutic plasma exchange (TPE) based on the most current guidelines and clinical trials.

If the patient’s diagnosis is unclear or awaiting certain blood test results, we will discuss this with the ordering physician to determine the rationale behind requesting apheresis and availability of alternative treatment options.

We determine the appropriate plasma volume to be replaced, extracorporeal red cell volume and the need to prime the circuit with either albumin or red blood cells as necessary, especially in pediatric patients.

Therapeutic Plasma Exchange: What to Expect

During this therapy, small amounts of blood are gradually lost during vascular access and circulating through the apheresis machine that separates blood into red cells, white cells, platelets, and plasma.

The plasma portion of the blood is removed and replaced by a plasma substitute and then added back to the cells (red cells, white cells, and platelets) and finally returned by intravenous or central venous catheter access. The removed plasma is discarded.

One procedure typically removes 65% to 70% of the disease-causing proteins (antibodies) in the plasma. As the patient continues making offending protein, patients typically require several procedures. Most diseases are successfully treated in five treatments that can be delivered every day or every other day, alternating with therapeutic medications.

Affiliated Hospitals:

Our TPE service is considered a mobile apheresis service as highlighted by ASFA. The service is exclusively offered to neighboring hospitals. We start by obtaining an agreement with the hospital, provide hospitals our SOPs, consent forms, pre- and post-treatment lab order sets, medication order set and replacement fluid order set.

Before TPE:

Prior TPE, we start our procedure by patient or family interview (in case if patient on life support or unable to give consent), explaining the reason of plasmapheresis and obtaining patient consent. The consent will function for all procedures done under that patient admission. All patient medications and replacement fluid will be requested from hospital pharmacy and blood bank.

During TPE:
The procedure begins by obtaining vascular. A large catheter or port is used for this purpose that provides flow and return ports. If vascular access is difficult to obtain such as in patients on high-dose anticoagulants, peripheral IV access is used.

During the procedure, patients may experience some mild numbness, tingling, light-headedness, or nausea. Our nurses are well trained to deal with most common side effects such as mild allergies, manifestation of hypocalcemia and citrate effect. Patients should tell their nurse of any side effects or symptoms they feel.

After TPE:

After the procedure is completed, we will complete a consultation and nurse worksheet documentation of all information pertaining to the procedure. We record every detail and how well patient tolerated the procedure and discussion with treating team on the number of treatments and patient progress till discharge. Our notes can be downloaded in a PDF format on NanoLink to be incorporated into hospital medical records.

We aim to provide a safe successful procedure for our patients. We value every feedback and take any criticism as an opportunity to improve. Therefore, we encourage our patients and referring doctors to fill in our survey and let us know how we did.

Red Cell Exchange (RCE) is a therapeutic procedure replacing patients’ own red blood with healthy donor red cells. The procedure is done to prevent serve complications or to decrease vascular occlusive risk in patients with sickle cell disease and decease parasite-infected red cells in patients with severe malaria or babesiosis infection while on antiparasitic therapy.

Procedure taken into consideration the desired end procedure of fractioned autologous red cell remaining (FCR) and hematocrit. The hematocrit and FCR are individualized to patients based on diagnosis, but typically we prefer HCT around 27 in sickle cell patients and hemoglobin S concentration below 30. This ratio is considered adequate in reversing major complications caused by the disease.

We perform two types of procedures:

• Red cell exchange – Same volume of diseased red cells are replaced by healthy cells.
• Red cell depletion / exchange – replace unequal volume of red cells with healthy cells, indicated during blood shortage, and to lower the risk of iron overload (high success rate in sickle cell anemia patients).

Cellular apheresis or depletion is replacing a specific cell type (platelet, white blood cells or red cells) with crystalloid such as saline or albumin. It is most indicated in hyperproliferative malignancies (myeloproliferative syndrome) to prevent the excess of abnormal cells in the blood that may cause increased viscosity, vascular stasis, thrombosis or hemorrhage.

White cell depletion is also indicated in acute leukemia and symptomatic leukocytosis or as a prophylactic from tumor lysis syndrome. White cells/blast greater than 100,000 per cubic mL in acute myelogenous leukemia or 400,000 in acute lymphoblastic leukemia.

Red cell apheresis/depletion in hereditary hemochromatosis, a common condition in middle-aged men in the Middle East is an ASFA category I due to the high success rate of removing excess iron compared to simple therapeutic phlebotomy.

For platelet and white cell depletion, the procedure typically reduce the absolute count by 30-50% per treatment.

Extracorporeal photopheresis (ECP) is an apheresis technique in which whole blood is centrifuged and separated extracorporeally into different components. All components return back to the patient, except for the buffy coat which contains white blood cells (lymphocytes, monocytes and granulocytes), which is mixed with a photosensitized drug (methoxslaen) and then activated through ultraviolent-A (UA-A). A light radiation results in enhancing apoptosis (programed cells death) of these cells. The sensitized cells then returned back to the patient.

This technique is used primarily in treating circulating cutaneous T-cell lymphoma (Sezary) cells, but has been used in treatment of refractory Hodgkin lymphoma, chronic lung and heart allograft rejection. Recent publications have shown benefits of ECP in preventing rejection.

Two treatments are usually given on two consecutive days and repeated weekly or monthly depending on the indication.

We adhere to the established protocol outlined in the TPE (Therapeutic Plasma Exchange) sections. Each treatment typically lasts a few hours, and patient can be discharged same day.

[For patients, it can be challenging to grasp the mechanism of ECP (Extracorporeal Photopheresis) on the body. However, to simplify, you can think of it as giving your immune cells a "suntan". This rejuvenates the cells and encourages them to regulate their behavior, ultimately helping to restore their normal function and reduce any erratic activity].