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Immunoadsorption

Immunoadsorption (IA) selectively removes certain plasma proteins. IA can be specific (only removing antibody specific for single antigen) or nonspecific (removing all antibodies). Although several IA systems are available worldwide, none are currently used in the United States. This chapter discusses only IA using staphylococcal protein A (SPA) columns, which remove immunoglobulin, as an example of a selective system. SPA is a cell wall component of…

LDL Apheresis

Low-density lipoprotein (LDL) apheresis (LA) removes apo-B containing lipoprotein (LDL and lipoprotein(a) [Lp(a)]). The primary indication for LA is familial hypercholesterolemia (FH), an autosomal dominant disorder of cholesterol metabolism, resulting in elevated plasma LDL-C levels. Numerous LDL-C removal methodologies are used by various systems available worldwide. Available technologies include heparin-induced extracorporeal LDL-C precipitation, dextran sulfate cellulose adsorption, double filtration plasmapheresis, polyacrylate full blood adsorption, and immunoadsorption—all…

Extracorporeal Photopheresis

Extracorporeal photopheresis (ECP) involves the ex vivo exposure of peripheral blood mononuclear cells (MNCs), including pathogenic or autoreactive T-lymphocytes, to photoreactive 8-methoxypsoralen (8-MOP) and ultraviolet A (UVA) light, followed by reinfusion of these MNCs. ECP was first successfully used for the treatment of cutaneous T-cell lymphoma (CTCL), its only FDA-approved indication. It is also used in the treatment of cell-mediated immunity disorders and autoimmune diseases, such as…

Therapeutic Leukocytapheresis and Adsorptive Cytapheresis

Therapeutic leukocytapheresis (or leukapheresis) is a procedure in which white blood cells (WBCs) are selectively removed from patient’s circulation, generally with the aim of treating hyperleukocytosis and/or hyperviscosity. Additionally, leukocytapheresis has been performed prophylactically, such as to prevent tumor lysis syndrome before initiation of chemotherapy. Unfortunately, neither therapeutic nor prophylactic leukocytapheresis appear to effect long-term survival in leukemic patients. Selective leukocyte apheresis incorporates adsorptive columns into…

Therapeutic Thrombocytapheresis

Therapeutic thrombocytapheresis (or commonly referred to as plateletpheresis or platelet depletion) is used in primary and sometimes secondary thrombocytosis to rapidly remove platelets for prevention or treatment of hemorrhage and/or thrombosis. Reduction of platelet count achieved by this procedure is short-lived; thus, other definitive and longer-term therapies are also needed. Volume Exchanged 1.5–2 total blood volumes (TBVs) are typically processed, resulting in approximately 30%–60% reductions in…

Therapeutic Erythrocytapheresis and Red Cell Exchange

Therapeutic erythrocytapheresis (ET) is a procedure in which patients’ RBCs are selectively removed to reduce excessive RBC mass. It has been used for treatment of polycythemia vera, reactive erythrocytosis, and hereditary hemochromocytosis. RBC exchange (RBCx) is a procedure in which the patient’s RBCs are replaced with allogeneic RBCs. RBCx is mostly used to treat patients with sickle cell disease (SCD). RBCx is safe; however, use of…

Therapeutic Plasma Exchange

Therapeutic plasma exchange (TPE) is a procedure in which whole blood of the patient is passed through an apheresis device, which separates and removes plasma. Other components are returned to the patient together with replacement fluid. Pathophysiology TPE is used to treat diseases that are thought to be caused by a substance in plasma whose removal can help with disease resolution. TPE is mostly used for…

Overview of Therapeutic Apheresis

Apheresis is derived from a Greek word “aphairesis,” which means “to remove forcibly.” Whole blood is removed from a subject, separated into components extracorporeally (RBCs, white blood cells, platelets, and plasma), desired blood component is removed, and remaining components are returned with or without replacement fluid(s). Therapeutic apheresis (TA) is used to remove pathogenic substances in the plasma (termed therapeutic plasma exchange [TPE]) or pathogenic cells…

Transfusion-Transmitted Diseases

Introduction Transfusion-transmitted diseases (TTDs) are caused by viruses, bacteria, protozoa, and prions. Examples of broad spectrum of infections of contemporary interest to transfusion medicine community include Babesia , Plasmodia , dengue, and Zika viruses in addition to historically important transfusion-transmitted agents—human immunodeficiency virus (HIV), hepatitis C virus (HCV), and hepatitis B virus (HBV). Bacterial sepsis from contaminated platelets is considered elsewhere. The minimal prerequisites for a…

Iron Overload

Iron overload is an excess of systemic iron, leading to its progressive accumulation in vital organs (e.g., liver, heart, pancreas, and endocrine organs). When untreated, iron overload increases the risk of liver cirrhosis, heart failure, diabetes mellitus, osteoporosis, hypogonadism, and neurodegenerative symptoms. These potentially fatal complications are preventable by iron depletion therapies. Iron overload results from pathologically increased intestinal iron absorption or as a side effect…

Transfusion-Related Immunomodulation

Transfused blood products may have effects on recipient immunity. Broadly, these effects have been called transfusion-related immunomodulation (TRIM). Some TRIM effects are generally accepted, while others are a matter of debate. The TRIM effects can be categorized as beneficial or deleterious ( Table 71.1 ). The following effects are more evident with blood that has not been leukoreduced. Table 71.1 Established and Proposed Transfusion-Related Immunomodulation Effects…

Transfusion-Associated Graft-Versus-Host Disease

Transfusion-associated graft-versus-host disease (TA-GVHD), a rare (1 fatality reported to FDA 2011–15) and almost universally fatal complication of blood product transfusion, is due to the cotransfusion of viable lymphocytes in cellular blood products, such as whole blood, red blood cells (RBCs), platelets, granulocytes, and liquid (not previously frozen) plasma. If the immune system of the recipient does not recognize and produce an immune response against the…

Posttransfusion Purpura

Posttransfusion purpura (PTP) is a rare complication of transfusion that most commonly occurs in previously pregnant women. PTP typically occurs 2–14 days after a transfusion of a blood product (most commonly a red blood cell [RBC] product), resulting in acute, profound thrombocytopenia (platelet count <10,000/μL). The incidence is thought to be 1 in 50,000–100,000 components transfused. The thrombocytopenia is secondary to high-titer platelet alloantibodies. Pathophysiology PTP…

Metabolic, Hypotensive, and Other Acute Reactions and Complications

Metabolic complications may occur when large volumes of blood products are transfused. The so-called lethal triad of massive transfusion, including acidosis, hypothermia, and coagulopathy will be discussed in this chapter. Other complications of massive transfusion will be reviewed, including hyperkalemia, hypoglycemia, hypocalcemia from citrate in transfused products, and other metabolic abnormalities associated with hypothermia. Hypotensive reactions and transfusion-associated dyspnea will also be discussed. Metabolic Complications of…

Septic Transfusion Reactions

Transfusion of bacterially contaminated blood products may result in no symptoms, bacterial infection, sepsis, or death in the recipient. Bacterial pathogens have emerged as most common cause of transfusion-transmitted infections. Incidence of septic transfusion reactions (STRs) varies with type of platelet product. STR is under recognized and underreported, and high level of suspicion should be maintained in certain patient populations. Significant improvement in bacterial safety of…

Transfusion-Related Acute Lung Injury

Incidence The incidence of transfusion-related acute lung injury (TRALI) and deaths due to TRALI has decreased substantially over the past decade, as TRALI mitigation strategies have been implemented. In 2006, 35 TRALI-related fatalities were reported to the FDA. These accounted for more than 50% of all transfusion-related fatalities, with 60% of the cases being attributed to plasma products. In contrast, only 12 TRALI fatalities that met…

Transfusion-Associated Circulatory Overload

Incidence TACO is estimated to occur in up to 1% of transfusions, with higher rates reported in studies using active surveillance methodologies. For several reasons, TACO is likely one of the most underreported transfusion complications to hospital transfusion. A retrospective Medicare database review of over 2 million transfusions showed that patient characteristics such as age (greater than 85 years), history of heart failure, female sex, white…

Delayed Hemolytic Transfusion Reactions

Delayed hemolytic transfusion reactions (DHTRs) typically occur 3–10 days after red blood cell (RBC) transfusion that appear to be serologically compatible. These reactions occur in patients who have been alloimmunized to minor RBC antigens during previous transfusions and/or pregnancies; pretransfusion testing fails to detect these alloantibodies due to their low titer. After reexposure to antigen-positive RBCs, an anamnestic response occurs, with rapid rise in antibody titer.…

Acute Hemolytic Transfusion Reactions

Acute hemolytic transfusion reactions (AHTRs) may occur when either incompatible RBCs or large amounts of incompatible plasma are transfused, which can lead to antibody–antigen binding in the recipient. AHTRs can lead to minimal hemolysis with no clinical sequelae, or can result in brisk hemolysis, induction of disseminated intravascular coagulation (DIC), hypotension, and shock, followed by renal failure and/or death. Incidence Studies from the REDS III database…

Allergic Transfusion Reactions

Allergic reactions are common reactions to blood transfusions. On one end of the spectrum, typical mild allergic transfusion reactions (ATRs) consist of isolated, pruritic/urticarial lesions and occur during or within 2 hours of transfusion. On the other end of the spectrum, anaphylaxis is an acute, systemic allergic reaction that is characterized most significantly by hypotension and/or respiratory compromise. Anaphylaxis typically occurs early after transfusion has started.…