APHERESIS.

Apheresis is special type of donation in which a specific component, viz. platelets, gametocytes (white cells) plasma or stem cells are withdrawn from a donor using a special equipment called Cell Separator. The process of apheresis involves removal of whole blood from a patient or donor. Within an instrument that is essentially designed as a centrifuge, the components of whole blood are separated. One of the separated portions is then withdrawn and the remaining components are retransfused into the patient or donor. This procedure takes about 90 minutes during which time the donor is constantly monitored by trained medical personnel. It is thus an extracorporeal therapy. The components which are separated and withdrawn include:
y y y y y

Plasma (plasmapheresis) Platelets (plateletpheresis) Leukocytes (leukapheresis) Lymphocytes (lymphopheresis or lymphapheresis) Red blood cells (erythropheresis)

Advantage of Apheresis: y Platelet concentrate prepared from one unit of whole blood contains very few platelets. Six to ten such whole-blood derived platelets would be required to supply enough platelets for one patient. However, platelets donated during one apheresis session by one donor are sufficient for one transfusion, thus reducing the chance of transfusion transmitted infections. Patients with cancer or leukemia or patients with blood disorders benefit immensely from such plateletapheresis. The donor benefits too since there is no loss of red cells. One can donate apheresis components more frequently than whole blood donation. One major benefit of apheresis donation is that one apheresis donation is equivalent to six to eight whole blood donations. To explain, if apheresis donation is not used, the same effect can be achieved using whole blood but the platelets must be centrifuged from whole blood units and pooled together to get the same amount of platelets as one apheresis donation. The remaining components of blood from the whole blood units are wasted. Another advantage is that use of apheresis products gives a lower incidence of sensitization for the patient. By using a tissue typing system known as Human Leukocyte Antigen (HLA) matching, Wadley can achieve as nearly a perfect match as possible donor-to-patient match. The result is that patients have fewer incidences of immunologic response (rejection of platelet transfusion.) Also by providing a large number of platelets from a single donor as opposed to a pooled donation from many different donors, the immunologic response is somewhat diminished. The greatest advantage of apheresis donation is that its use increases long term survival of the patient. Apheresis products can be used as a therapeutic modality. Transfusion of donated platelets into diseased patients can help alleviate symptoms of their diseases and improve the recovery process. Similarly cancer patients who have undergone chemotherapy have a markedly reduced capability to produce their own blood cells so apheresis provides the cells they need. Only the blood components needed are collected for our patients; the other components are returned to the donor.

y y

Disadvantage of apheresis: 1. Citrate toxicity  Cause: Citrate is the anticoagulant used in blood products. It is usually rapidly metabolised by the liver. Rapid administration of large quantities of stored blood may cause hypocalcaemia and hypomagnesaemia when citrate binds calcium and magnesium. This can result in myocardial depression or coagulopathy. Patients most at risk are those with liver dysfunction or neonates with immature liver function having rapid large volume transfusion.  Management: Slowing or temporarily stopping the transfusion allows citrate to be metabolised. Replacement therapy may be required for symptomatic hypocalcaemia or hypomagnesaemia.

2. Hematoma  Hematomas can occur within a muscle. Some hematomas form into hard masses under the surface of the skin. This is caused by the limitation of the blood to a subcutaneous or intramuscular tissue space isolated by fascial planes. This is a key anatomical feature that prevents such injuries from causing massive blood loss. In most cases the sac of blood or hematoma eventually dissolves; however, in some cases they may continue to grow or show no change. If the sac of blood does not disappear, then it may need to be surgically removed. Hematomas can occur when heparin is given via an intramuscular route; to avoid this, heparin must be given intravenously or subcutaneously.  The slow process of reabsorption of hematomas can allow the broken down blood cells and hemoglobin pigment to move in the connective tissue. For example, a patient who injures the base of his thumb might cause a hematoma, which will slowly move all through the finger within a week. Gravity is the main determinant of this process.  Hematomas on articulations can reduce mobility of a member and present roughly the same symptoms as a fracture.  Blood vessels that are fragile may contribute to hematoma formation. For example, an aneurysm or weakening in a blood vessel wall may spontaneously leak.  There are many people who take blood thinners (anti-coagulation) medications. Examples include warfarin (Coumadin), aspirin, clopidogrel (Plavix) and prasugrel (Effient). These medications increase the potential for spontaneous bleeding and for hematomas to expand because the body cannot efficiently repair blood vessels and blood continues to leak through the damaged areas.

3. Vasovagal reaction (neurocardiogenic reaction)  The donors who developed pallor were divided into two groups: those in whom the venipuncture had been traumatic and those in whom the venipuncture had been efficient. The logistic regression analysis showed that the group of donors, in whom the venipuncture was difficult, had a statistically higher probability of developing pallor (95% CI and p < 0.001). From these data, it can be concluded that a traumatic venipuncture, compared to an easy one, is a strong determinant of a vasovagal reaction. It can, therefore, be stated that a painful stimulus caused by venipuncture can lead to a vasovagal reaction.  Some people pain or emotional stress cause vigorous left vigorous left ventricular contractions that activate cardiac mechanoreceptors & the vagus nerve > block to the sympathetic response.  A type of malfunction in the ANS.  Normally a decrease in venous return to the right heart triggers a sympathetic response.  Baroreceptors in carotid arteries, aortic arch & c fiber of heart signal the brain to make adrenaline which raise heart rate & cause vasoconstriction (increase BP & cardiac output).  Prolonged standing, rapidly standing up.  Smoking, hunger, lack of sleep, N&V.  Stress or onset of extreme emotional reaction.  Painful, venepuncture, med procedure with local anes, needle injection, watching someone donate blood, sight of blood, watching a med procedure.  Related to donor anxiety, fear and pain.

4. Hypovolaemia  Alcohol use after donating vasodilatation in response to alcohol with mild hypovolemia.  Smoking nicotine that acts as a vasodilator.  Increase ambient temperature blood donor walk from 70 degree donor room to 90 degree outside temp and suddenly vasodilates in response to the heat and passes out.  Anti-hypertensive drugs y Reduce peripheral vascular resistance (ACE inhibitors). y Reduce HR & CO (beta blockers). y Reduce intravascular volume (diuetics)

5. Allergic Reactions  Allergic reactions to plasma proteins can range from complaints of hives and itching to anaphylaxis. Such reactions may occur in up to 1 in 200 transfusions of RBCs and 1 in 30 transfusions of platelets.

6. Circulatory Overload  Circulatory overload can occur with administration of blood or any intravenous fluid, particularly in patients with diminished cardiac function.

7. Air embolus air embolism can happen if a diver runs out of air and holds their breath while coming up to the surface. This can cause damage to the lungs, called pulmonary barotrauma, which allows air bubbles to enter the blood. Air embolism can also happen when a diver surface too quickly. This is commonly known as the bend or decompression sickness. surgery to the blood vessels or large blood transfusions, if a large quantity of air is mistakenly injected into the vessels (although doctors are trained to remove excess air from a syringe before giving injections), operations including caesarean sections or open-heart surgery, if air becomes trapped inside the body, an injury in which the chest is crushed, such as in a car crash removal of a catheter (a thin, flexible tube that is inserted into the body) oral sex during pregnancy (there have been a few reported cases of an air embolism occurring when air blown into the vagina has got into the enlarged blood vessels surrounding the pregnant woman's vagina) It result when more than 3 to 8 ml/kg of air enters the venous system through either a leak in the hemapheresis instrument or the venous access. These result from air entering the right ventricle and pulmonary artery with obstruction of the right ventricular output as well as pulmonary artery vasoconstriction.. This traps the air in the apex of the right ventricle, away from the pulmonary outflow tract, improving right ventricular function. with time, the air will dissolve.Entrance of a large volume of air or donor hemodynamic instability may require surginal intervention with the placement of a pulmonary artery catheter to aspirate the air.

8. Transfusion Transmitted Diseases I. Hepatitis B

Hepatitis B virus (HBV) is transmitted through parenteral and sexual exposure. The incubation time is a mean of 90 days with a range of 30 to 180 days. Donor blood is routinely tested for HBsAg and HBcAb. There is no routine testing for hepatitis A, because it is rarely transmitted by blood products. Recipients of blood products can also be infected with hepatitis delta, which is a defective RNA virus that needs a HBV superinfection to replicate. Persons who have received a hepatitis B vaccination (recommended for all health care workers with patient contact) will have hepatitis B surface antibody present, but not HBsAg or HBcAb Risk of transmission (RT) = 1 in 200,000 to 500,000

II.

Hepatitis C

The route of transmission is parenteral, with sexual transmission lower than previously throught. The mean incubation time is 6 to 8 weeks. Blood Bank testing for HCV started in 1990. At present, only testing for hepatitis C antibody is available. Risk of transmission (RT) = 1 in 2,000,00

III.

Human Immunodeficiency Virus (HIV)

In 1982 the first cases of AIDS obtained from blood or blood components were reported, but the etiology of the infections was not known at that time. By 1983 changes occurred in the donor cirteria to exclude those at high risk for transmission of HIV. The first testing of blood products for HIV started in 1985 and is a test to detect the presence of antibody directed against HIV. Testing for HIV p24 antigen was mandated in 1996. Risk of transmission = 1 in 1,000,000 to to 2,000,000

IV.

Human T-lymphocytotrophic Virus (HTLV-I/II).

HTLV-1 is a retrovirus that is endemic in Japan and the Caribbean. Implicated as causing adult T-cell leukemia/lymphoma and a neurological disorder similar to multiple sclerosis. Blood is routinely screened for antibodies to HTLV-I. Risk of transmission = 1 in 250,000 to 2,000,000 (but only 1-3% of seropositive individuals will develop disease).

V.

Cytomegalovirus (CMV)

The prevalence of CMV antibody ranges from 50 to 80% of the population. Blood contaminated with CMV can cause problems in neonates or immunocompromised patients. Potential problems in selected patient populations can be prevented by transfusing CMV negative blood or frozen, deglycerolized RBC's.Donor blood is not routinely tested for CMV. VI. Malaria

Malaria is rarely transmitted by RBC products, although the number of transfusion associated cases of malaria is at an all-time high. There are no practical laboratory tests available to test donor blood, so donors travelling to high risk malaria areas are excluded from donating blood for six months. Potential donors may be screened by questionnaire regarding travel to endemic areas or contact with persons at risk. Antibody tests available for all but babesiosis and CJD are available, preferentially applied in regions of high prevalence. VII. Transfusion related acute lung injury (TRALI)

TRALI is caused when donor plasma contains HLA or granulocyte specific antibodies. Recipient leukocytes are 'primed' by underlying illness to become more adherent to pulmonary alveolar epithelium. Introduction of the donor antibodies into the recipient causes granulocyte enzymes to be released, increasing capillary permeability and resulting in sudden pulmonary edema, typically within 6 hours of tranfusion. TRALI most often occurs with administration of blood products with plasma, such as FFP. Use of plasma from men reduces the incidence of TRALI, since women who have been pregnant are more likely to have higher titer HLA antibodies.

VIII.

Transfution-transmitted disease:

Transfusion associated Graft Versus-Host Disease (Ta-GVHD) Cause: Ta-GVHD occurs when donor lymphocytes in cellular blood products engraft in a susceptible transfusion recipient. These donor lymphocytes proliferate and damage target organs especially bone marrow, skin, liver and gastrointestinal tract. The clinical syndrome comprises fever, skin rash, pancytopenia, abnormal liver function and diarrhoea and is fatal in over 80% of cases. The usual onset is 8-10 days post transfusion, with a longer interval between transfusion and onset of symptoms in infants. The most commonly reported setting for Ta-GVHD is immunocompetent recipients of blood from biologically related (directed) or HLA identical donors. The disease is also reported in immunologically compromised patients.

IX. Infectious Disease transmission A variety of infectious agents may be transmitted by transfusion. Definitive evidence of transmission by transfusion requires demonstration of seroconversion or new infection in the recipient and isolation of an agent with genomic identity from both the recipient and the implicated donor. Strong presumptive evidence of transfusion transmission includes recipient seroconversion within an appropriate interval after transfusion, the recognition of appropriate infectious markers in an implicated donor on follow-up investigation, or both. Transfusion transmitted disease should be reported to the Australian Red Cross Blood Service. Suspected transfusion-transmitted bacterial or parasitic infection (malaria) should be reported urgently in order to recall other potentially infectious blood products from the same donation.

X.

Others

Additional diseases which are rarely transmitted by blood products include:

Lyme disease Chagas disease Dengue fever West Nile virus Babesiosis Creutzfeldt-Jakob disease

Reference: y y y y y y y y y y http://library.med.utah.edu/WebPath/webpath.html#MENU http://en.wikipedia.org/wiki/Apheresis http://www.sgpgi.ac.in/tm/tm_donation.html#Apheresis http://lyle.smu.edu/~barr/4395/sdabs/node32.html http://www.sgrh.com/supercat.aspx?id=51 http://www.rch.org.au/bloodtrans/adverse.cfm?doc_id=5323 http://www.medicinenet.com/hematoma/page2.htm#causes http://www.anzsbt.org.au/publications/documents/Therapeutic_Apheresis_Operator_ Competency_Aug06.pdf http://www.apheresis.org/~ASSETS/DOCUMENT/ASFA%202011%20Presentations/ Thursday%2013h15%20Gilcher_.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2535889/