Funciones de enfermería en los procederes de aféresis / Nursing functions in cell therapy procedures

Introducción: Con el paso de los años, la profesión de enfermería ha ganado terreno en diferentes áreas de la medicina y su acción ha llegado a esferas que se creía exclusivas de otros profesionales del sector de la salud, como la Medicina Transfusional y Terapia celular. Objetivo: Describir las funciones de enfermería en los procederes de aféresis. Análisis y síntesis de la información: El trabajo de enfermería se basa en la aplicación de la metodología para la implementación de los cuidados que realiza. El intercambio directo con la persona permite identificar sus necesidades, facilita planear, controlar, ejecutar y evaluar las actividades que se realizan en la práctica diaria. Dentro del área de la Medicina Transfusional el accionar de enfermería es fundamental, ya que puede intervenir en diferentes fases del proceso de la donación de sangre, realiza la centrifugación del componente a obtener, transfunde o implanta componentes sanguíneos y atiende las reacciones adversas del individuo. Conclusiones: La acción de enfermería en la actividad de aféresis para diferentes procedimientos es primordial para preservar la salud del donante y el paciente, así como en la creación o modificación de protocolos de trabajo con mayor eficiencia, eficacia y efectividad en base a los conocimientos y la experiencia en este campo lo que genera una espiral de desarrollo continuo que obliga a la constante actualización en el tema.

Introduction: With the step of the years, the infirmary profession has won land in different areas of the medicine and its action has arrived to spheres that it was believed they were exclusive of other professionals of the sector of the health, as the Medicine Transfusional and cellular Therapy. Objective: to describe the nursing functions in the aphaeresis procedures. Analysis and synthesis of the information: The infirmary work is based on the application of the methodology for the implementation of the cares that he/she carries out. The direct exchange with the patient allows to identify its necessities, as well as it facilitates to drift, to control, to execute and to evaluate the activities that are carried out in the daily practice. Inside the area of the transfusion medicine working of infirmary is fundamental, since it can intervene in different phases of the process of the donation of blood, he/she carries out the centrifugation of the component to obtain, it transfuses or it implants sanguine components and he/she assists the patient's adverse reactions. Conclusions: The nurse action in the aphaeresis activity for different procedures is primordial to preserve the donor's health and the patient, as well as in the creation or modification of work protocols with bigger efficiency, effectiveness and effectiveness based on the knowledge and the experience in this field what generates a hairspring of continuous development that he/she forces to the constant bring up to date in the topic.

Lipoprotein apheresis in patients with familial hypercholesterolemia: a single center research / 中华心血管病杂志

Objective: We evaluated the safety and efficacy of lipoprotein apheresis (LA) in patients with familial hypercholesterolemia (FH) who can't reach low-density lipoprotein cholesterol(LDL-C) target goals with the maximal tolerated dose of lipid-lowering agents. Methods: This was a retrospective cross-sectional study. Between February 2015 and November 2019, patients with FH who were admitted in Fuwai hospital and treated with LA were consecutively enrolled. Based on intensive lipid-lowering agents, these patients received LA by double filtration plasma pheresis (DFPP) method. The changes of lipid levels such as LDL-C and lipoprotein(a)[Lp(a)] were compared before and after LA treatment, and the changes of immunoglobulin (Ig) concentration and LA-related adverse effects were also discussed. Results: A total of 115 patients with FH were enrolled in this study, of which 8 cases were homozygous FH and 107 cases were heterozygous FH. The age was (43.9±12.2) years and there were 75 (65.2%) males, and 108 (93.8%) with coronary artery disease. For pre-and immediately after LA treatment, the LDL-C was (5.20±2.94) mmol/L vs. (1.83±1.08) mmol/L, Lp(a) concentration was 428.70(177.00, 829.50)mg/L vs. 148.90(75.90, 317.00) mg/L (P<0.001), with a decrease of 64.2% and 59.8% respectively. The levels of IgG and IgA measured 1 day after LA treatment were both in the normal range and IgM concentration was below the reference value, the reductions of which were 15.1%, 25.0% and 58.7% respectively (P<0.001). Six patients had mild symptoms of nausea, hypotension dyspnea and palpitation, the symptoms were relieved by symptomatic treatment. Conclusion: For patients with FH who do not achieve LDL-C target goal with the maximal tolerated lipid-lowering agents, especially those with elevated Lp(a) levels, LA, which can significantly further reduce LDL-C and Lp(a) levels, is an effective and safe option.

Procederes de aféresis en el Instituto de Hematología e Inmunología / Apheresis procedures at the Institute of Hematology and Immunology

Introducción: en los últimos decenios el interés por las aféresis se ha incrementado debido a que los avances tecnológicos han puesto a disposición de los profesionales de la salud equipamiento dotado de especificidad, seguridad, efectividad y rapidez para la realización de estos procederes en función de la transfusión y la terapéutica. Objetivo: presentar la experiencia acumulada en el Instituto de Hematología e Inmunología en la realización de los diferentes tipos de aféresis. Métodos: se realizó un estudio descriptivo retrospectivo que incluyó a todos los pacientes a los que se les realizó algún proceder de aféresis, en el período comprendido entre enero de 2008 y diciembre de 2013. Se analizaron las variables: datos generales del paciente, centro de procedencia, modalidad de aféresis empleada, método que se empleó y enfermedades que requirieron el proceder. Resultados: se realizaron 3 332 procederes de aféresis, 1 057 de producción con prevalencia de las tromboféresis que representó el 96,68 por ciento. De las 1 078 aféresis terapéuticas realizadas, el primer lugar correspondió a las plasmaféresis con el 26,5 por ciento, seguida de las exanguinotransfusiones (15,8 por ciento). Se realizaron, además, 1 197 aféresis de células mononucleares y plaquetas para su empleo en la Medicina Regenerativa. Conclusiones: los resultados de este primer trabajo muestran el desarrollo paulatino de las aféresis en la institución, tanto de producción como terapéutica, que por una parte promueven la producción de componentes por aféresis, lo que pone a disposición de médicos y pacientes necesitados de hemocomponentes con mayor calidad y seguridad para el tratamiento sustitutivo; y por otra, aporta información sobre las posibilidades reales de esta alternativa terapéutica para algunas enfermedades(AU)

Introduction: in recent decades, interest in apheresis has increased due to advances in technology that have made them available to health professionals with access to specific equipment, safety, effectiveness and speed to perform these procedures in terms of transfusion and therapeutics. Objective: to present the experience gained at the Institute of Hematology and Immunology in performing different types of apheresis. Methods: adescriptive retrospective study was performed which included all patients who underwent an apheresis procedure between January 2008 and December 2013. Variables were: patient´s general data, the establishment of provenance, method where analyzed apheresis was performed, method used, and diseases requiring the proceeding. Results: 3 332 apheresis proceedings were done : 1 057 for production with thrombopheresis prevalence which ranked 96,68 percent. Of the 1 078 therapeutic apheresis performed, the first place went to plasmapheresis with 26,5 percent, followed by exchange transfusions (15,8 percent); 1 197 apheresis of mononuclear cells and platelets to be used in regenerative medicine were also conducted. Conclusions: the results of this preliminary study show the gradual development in the use of apheresis procedures in our institution, with both production and therapy aims, which not only allows the diffusion of production of components by apheresis which provides physicians and patients in need of blood products with higher quality and security replacement therapy, but also provides knowledge about the actual possibilities for alternative therapy in some diseases(AU)

Identificación de células madres hematopoyéticas fetales y de adultos: mitos y realidades de los trasplantes / Identification of fetal and adults hematopoietic stem cells: myths and realities of the transplants

Las cédulas madres y hematopoyéticas son células indiferenciadas con una amplia capacidad de proliferación y de autorrenovación; están presentes en medula ósea (1%-3%) y en sangre (0,1%), identificándose por la expresión del marcador CD34. Pueden ser movilizadas desde la médula ósea a la sangre después de quimioterapia o con citoquinas, En este estudio se identificaron células madres en sangre de fetos, neonatos y adultos. Se analizaron 278 muestras de sangre de fetos de 17-32 semanas, neonatos, y en productos de aféresis de células madres de pacientes con enfermedades malignas. La cantidad de células CD34 ± disminuyó con el aumento de la edad gestacional de 6,10% a 1,03%. De estas células se obtuvo la formación de colonias granulocíticas y eritrocíticas en cultivos. En sangre de cordón se obtuvieron 0,86 ± 0,33% células CD34+. Se analizan las indicaciones y resultado de trasplantes de médula ósea y de sangre de cordón en diferentes patologías. Hasta ahora no existe indicación médica para el uso de células madres autólogas de sangre de cordón en leucemias infantiles, ni en enfermedades genéticas. En infarto del miocardio no se han obtenido resultados satisfactorios con los protocolos clínicos evaluados, mientras que en daño neurológico, el uso de células madres permanece todavía como una aproximación experimental.

Hematopoietic stem cells are undifferentiated cells with high proliferative rate and autorenovation; they are found in bone marrow (1%-3%) and blood (0.1%), being identified by the expression of the marker CD34. They may be mobilized from bone marrow (B.M.) into the blood after chemotherapy or cytokine treatment. In this study, stem cells were identified in fetal and adult blood. Two hundred and seventy eigh blood samples were analyzed; they were obtained from fetuses (17-32 weeks-old), neonates, and in the products from apheresis performed to patients with malignancies. The amount of CD34+ cells decreased as the gestational age increased (6.10% to 1.03%). These cells grew in culture to produce granulocytic and erytrocytic colonies. In cord blood CD34+ cell were identified (0,86% ± 0,33%). Indications and results of bone marrow and cord blood stem cell transplants in different pathologies are analyzed. The transplant of allogeneic cord blood stem cells in patients not having a compatible donor is the worldwide approved indication for this procedure. No satisfactory results has been obtained in cases of myocardial infarct. The treatment of neurological damage remains experimental.

Efecto de los leucocitos sobre la lesión por almacenamiento en plaquetas de aferesis / Effect of leukocytes on the storage lesion in apheresis platelet

En el Banco de Sangre , las plaquetas sufren una serie de cambios físicos, metabólicos y fisiológicos que se denominan "lesión por almacenamiento" (LA), que depende de varios factores: métodos de preparación del concentrado, tipo de bolsa utilizada, concentración de plaquetas, número de leucocitos presentes en la unidad y acumulación de citoquinas. Todos ellos podrían producir activación plaquetaria y así afectar la calidad del producto, lo cual se reflejaría en una menor sobrevida de las plaquetas transfundidas. Basándose en lo anterior, se plantea que la remoción precoz de leucocitos aminoraría la LA en los concentrados plaquetarios (CPs) obtenidos por aféresis. Se estudiaron veinte CPs obtenidos mediante dos métodos de aféresis que difieren en el número de leucocitos residuales que permanecen en el producto final; un CP leucoreducido (Cobe Spectra) y otro estándar (Baxter CS 3000 plus). Las determinaciones se realizaron el día cero (prealmacenamiento) y al quinto día de almacenamiento. La evaluación de la LA incluyó marcadores de menbrana plaquetaria: p-selectina (CD62-P), glicoproteína Ib (CD42b), fosfatidilserina (Ax V.), factor tisular (CD142), formación de micropartículas (MPs), los cuales se analizaron por citometría de flujo, y citoquinas liberadas por los leucocitos y/o plaquetas activadas (IL-1. IL-6,FNT y RANTES), las cuales se analizaron por ELISA. El principal marcador de activación de las plaquetas (p-selectina) se encontró significativamente aumentado en los CP leucorreducidos (P: 0.001) y en los obtenidos en forma estándar (p: 0.02). La expresión de GPIb disminuyó significativamente solo en las plaquetas no leucorreducidas (p: 0.01). En relación a la actividad procoagulante de las plaquetas, se observó un aumento significativo en la expresión de fosfatidilserina sobre la cara externa de la membrana (p: 0.019) y de MPs plasmáticas (p: 0.025) solo en las plaquetas leucorreducidas y un muy leve aumento de la expresión de factor tisular...

Under Blood Bank storage conditions, platelet undergo a series of physical, metabolic and physiological changes that are denominated "platelet storage lesion" (PSL). This condition depends on several factors: the platelets number and the methodology used for the preparations of platelet concentrates (PC), type of storage bag, the number of leukocytes present in the cell unit, cytokines release, among others. All these factors may produce platelet activation and thus affect the quality of the product, which would be reflected in a shorter survival of the transfused platelets. Based on the previous knowledge, we hypothesized that early removal of leukocytes from the apheresis concentrate will diminish platelets "activation/lesion" during storage. We studied twenty PC obtained by two methods of apheresis that differed in the number of residual leukoreduced PC (Cobe Spectra) and a standard PC (3000 Baxter CS extra). The determinations were made at day zero (pre-storage) and at the fifth day of storage. The evaluation included markers present in platelets membrane, such as, p-selectin (CD62-P), glycoprotein Ib (CD42b), phosphatydilserine expression (PS). Tissue Factor (CD142) and microparticles (MPs) generation, that were analyzed by flow cytometry. Cytokines released by leucocytes or activated platelet (IL-1). IL-6, TNF and RANTES), were analysed by the ELISA technique. The most important marker of platelets activation, CD62-P, was significantly more increased in leukoreduced CP (P: 0.001) than in the standard method (p: 0.02). The expression of GPIb diminished significantly only in non-leukoreduced platelets (p: 0.01). With regard to the procoagulant activity of platelets, a significant increase in the PS expression was observed on the external face of the platelet membranes (p: 0.019) and on MPs (p: 0.025) only in leukoreduced preparations, changes that were accompanied by a very slight increase of tissue factor expression (p: 0.055). The determinations...

Evolución de las prestaciones de Aféresis en el Hospital Posadas / Apheresis evolution in Posadas Hospital

Se analiza la evolución de las presentaciones de Aféresis en nuestro servicio a la luz de un cambio actitudinal operado en un momento del desarrollo del mismo, alcanzando niveles de crecimiento importantes y una proyección aún mayor para el futuro inmediato, constituyendo un aporte para el arsenal terapéutico disponible para toda la comunidad médica.

Effect of different apheresis techniques on stem cell yield in autologous peripheral blood stem cell [PBSC] transplant patients

Peripheral blood progenitor cells [PBSC] have been extensively used to restore haematopoiesis after myeloablative chemotherapy. Large volume leukapheresis [LVL] was defined as the processing of greater than 3 volumes of blood at one setting, by which more hematopoietic progenitor cells are mobilized to the peripheral blood. The aim of this work was to study the effect the use of large and small apheresis techniques on stem cell yield in patients undergoing autologous PBSC transplantation. In this study 41 PBSC transplant patients were evaluated to assess the effect of use of small and large volume apheresis techniques on the transplantation process. The study included 17/41 cancer breast cases, 22/41 lymphoma cases and 2/41 leukemia patients. Small volume apheresis was performed in 9/41 [22%] of patients for whom 33 sessions of apheresis were performed while large volume apheresis technique was used in 32/41 [78%] of patients in 60 apheresis sessions. Comparing the outcome of these techniques showed that patients subjected to large blood volume apheresis technique showed a significantly higher mean yield when compared to small blood volume apheresis, [p<0.05]. Assessment of relation between number of mobilizations needed for the patient and chemotherapy potency revealed significant relation as heavily treated patients needed more mobilization rounds [p<0.05]. Yield of CD34 positive cells was affected by the number of mobilization rounds. Patients who needed a single round of mobilization showed a significant higher stem cell yield than with 2 rounds of mobilization [P.<0.01].Correlation study in this work revealed significant positive correlation between CD34+ cell yield [CD34+ cells x 10[6]/kg] and absolute CD34+ cell number in peripheral blood before harvest [precount] using the large volume technique with [r value = 0.87] and [p value < 0.01] while this significant correlation was not detected using small volume technique. Another significant positive correlation was found between CD34+ cell yield [CD34+ cells x 10[6]/kg] and the volume of blood processed during apheresis [r value=0.57] and [p<0.05]. Comparing the blood picture counts before and after harvesting using the large volume techniques, there was a significant difference between preharvest and postharvest mean hemoglobin and hematocrit [P <0.05 for each]. Assessment of effect of small volume on pre and postharvest blood picture counts revealed no significant difference between any of the counts before and after harvesting

Aplicaçäo clínica de filtros leucocitários / Clinical applications of leukocyte filters

A presença de leucócitos nos produtos hemoterápicos alogênicos transfundidos tem sido associada à ocorrência de determinadas reaçöes transfusionais, tais como a reaçäo transfusional febril näo-hemolítica, a aloimunizaçäo e refratariedade à transfusäo de plaquetas, a doença enxerto-versus-hospedeiro, e a efeitos imuno-modulatários. Além disso, os leucócitos podem ser vetores de transmissäo de agentes infecciosos, tais como o CMV, o HTLV-I/II e o EBV. Tem sido postulado que a remoçäo dos leucócitos em hemocomponentes mediante uso de filtros leucocitários pode prevenir a ocorrência dessas reaçöes. Entretanto, a eficácia clínica da desleucotizaçäo permanece sem definiçäo. Tem sido sugerido que a remoçäo de 1 log(10) de leucócitos previne a reaçäo transfusional näo-hemolítica, a remoçäo de 2 log(10) pode prevenir a transmissäo de viroses, enquanto que a remoçäo de maior ou igual 3 log(10) pode ser necessária para a prevençäo de aloimunizaçäo plaquetária. Entretanto, devido à carência de estudos que analisem apropriadamente as vantagens do uso clínico rotineiro dos filtros, permanecem sem completa definiçäo quais säo as reais indicaçöes clínicas para o uso de hemocomponentes desleucotizados; quais säo os graus de desleucotizaçäo necessários para prevenir as diferentes reaçöes; e se a remoçäo dos leucócitos deve ser realizada antes ou após o armazenamento de hemocomponente. Dessa maneira, somente estudos clínicos prospectivos poderäo definir o custo-benefício da aplicaçäo clínica de filtros leucocitários em hemoterapia.

Erythrocyte depletion of human umbilical cord blood using dextran sedimentation.

We report on the results of a study using high molecular weight dextran for depletion of red blood cells (RBCs) from cord blood. Our technique achieved efficient RBC depletion by sedimentation without a significant loss in haemopoietic stem cells. Cord blood units were fractionated for erythrocyte depletion by unit gravity sedimentation in 3 per cent high molecular weight dextran. Dextran sedimentation enabled recovery of more than 80 per cent of the total nucleated cells present and 100 per cent mononuclear cell (MNC) recovery as compared to unfractionated cord blood. A four-fold increase in the colony forming unit-granulocyte macrophage (CFU-GM) number per 2 x 10(5) cells was observed after dextran treatment suggesting that this step also resulted in the enrichment of stem cells.

Is there a role for leukocyte depletion filters to remove Trypanosoma cruzi infection from donor blood?

First and third generation leukocyte filters were used to filter blood units inoculated with trypomastigote forms of Trypanosoma cruzi. After blood filtration an aliquot of preor post-filtered blood was infected in isogenic mice. Infection evolution was followed by microscopic parasite count, indirect immunofluorescence and histopathological examination. All the animals that received pre-filtered blood (n = 27) accquired infection, while 26 percent of the mice injected with post-filtered blood (n = 27) were apparently not infected. A trend for late onset and peak of the parasitaemia was also observed among infected animals that received post-filtered blood (p<0.05). Additionally, the apparently non-infected mice also tested negative for both indirect immunofluorescence and histopathological examination. The results of this study, though very preliminary, suggest that that leukocyte filters might help to improve the safety of blood with regard to Trypanosoma, cruzi transmission.

Sistema "top and bottom (opti-press)": uma nova alternativa para preparo de componentes sanguíneos pobres em leucócitos / \"Top and bottom (opti-press)\" system: a new way to preparation of leukocytes poor blood components

O alto número de leucócitos presentes em componentes sanguíneos tem causado diversos problemas técnicos e clínicos para a hemoterapia atual. O sistema "Top and Bottom" para preparo de plaquetas nos permite obter concentrado de glóbulos e plaquetas pobres em leucócitos a partir de uma doaçäo de sangue total. O sangue é centrifugado a 3560 g por 10 minutos, colocado no aparelho Opti-Press (marca registrada) para separaçäo dos glóbulos, plasma e "buffy-coat". Após liberaçäo da sorologia e tipagem, é realizado assepticamente o "pool" de mesmo ABO de 3 a 6 "buffy-coats". Este pool é centrifugado a 2280 g por 5 minutos para separaçäo do sobrenadante rico em plaquetas, que é transferido para bolsa PL-732 e estocado por 5 dias após coleta. Os resultados obtidos apresentaram uma remoçäo de 80 por cento de leucócitos no concentrado de glóbulos (6,4 + 4,1 x 10(8) leucócitos totais finais) e 85 por cento de reduçäo de leucócitos no concetrado plaquetário (0,2 + 0,2 x 10(8) leucócitos). A recuperaçäo plaquetária näo foi inferior ao encontrado no sistema tradicional (69 por cento x 70 por cento respectivamente). O volume plasmático obtido (264,0 + 25,6 mL) foi significantemente superior ao obtido pelo PRP (194,8 + 27,1 mL) (p < 0,05). Os valores obtidos no controle de qualidade durante estocagem dos "pools" de plaquetas foram considerados ideais para boa qualidade de preservaçäo. Apesar de alguns problemas, como perda de aproximadamente 25,0 mL de hemácias e aumento de custo operacional, pensamos que os produtos obtidos estäo mais concordantes com as reais necessidade dos pacientes.

Aféreses / Apheresis

Os procedimentos de aféreses säo realizados com objetivos terapêuticos ou para a obtençäo de hemoderivados. Podem ser realizados por técnicas artesanais ou através de equipamentos automatizados. Neste capítulo, discutem-se as principais indicaçöes para a realizaçäo destes procedimentos

Aféresis clínica: métodos e indicaciones / Clinical apheresis: methods and indications

Se señala que los últimos 15 años han sido testigos de logros y refinamientos cientificotécnicos en el campo de la aféresis terapéutica. Cerca de un centenar de enfermedades y situaciones clínicas determinadas, fundamentalmente con patogenia inmunológica, han sido tratadas mediante estos procedimientos. Se realiza un breve recuento de sus modalidades, aplicaciones y reacciones adversas asociadas y de otros aspectos que pueden resultar de interés para los investigadores y los clínicos