Effect of different lipid apheresis methods on plasma polyunsaturated fatty acids.

Lipoprotein apheresis has been shown to improve the cardiovascular outcome in patients with atherosclerotic disease and therapy-refractory hypercholesterolemia or elevated lipoprotein (a) (Lp(a)). An elevated intake of omega-3 polyunsaturated fatty acids such as eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) has also been associated with a reduced cardiovascular risk. However, until now only little is known about the effect of apheresis treatment on the levels of omega-6 and omega-3 polyunsaturated fatty acids (n-6 PUFA and n-3 PUFA) in patients. Using gas chromatography (GC) the present study analyzed the content of n-6 and n-3 PUFA as well as saturated fatty acids and monounsaturated fatty acids in the plasma of 20 patients with hyperlipidemia undergoing regular lipoprotein apheresis procedures in direct pre- and post-therapy measurements. Lipoprotein apheresis uniformly reduced the concentrations of arachidonic acid (AA), EPA and DHA fatty acids analyzed in the plasma. However, the three different apheresis methods analyzed (heparin precipitation, membrane filtration and direct absorption) had different effects on the fatty acid profile in the plasma. We found that heparin precipitation and direct absorption apheresis procedures led to a significant decrease of plasma n-3 and n-6 PUFA by 40-50%. In contrast, patients undergoing membrane filtration apheresis, levels pre- and post-apheresis did not change significantly, with AA and EPA being only reduced by approximately 10% while levels of DHA were maintained pre- and post-apheresis. In contrast, total triglyceride levels were lowered most potently by membrane filtration apheresis. In summary, heparin precipitation and direct absorption apheresis approaches significantly lowered polyunsaturated fatty acids in plasma, while membrane filtration did not. This might have implications for cardiovascular and inflammatory risk/benefit profiles associated with n-6 and n-3 PUFA levels in the body.

[Apheresis Techniques]. / Tecniche di Aferesi.

Apheresis therapies play an important role in the treatment of many pathologies, both as first-line and rescue therapies after drug failure or drug toxicity and, furthermore, when it is important to reach a therapeutic goal in a short time. Apheresis devices have evolved at an astounding rate over the last decades. Therapeutic apheresis are usually part of a treatment plan, so, a patient-centered approach to select the most appropriate treatment for each patient, balancing personal preferences, medication interferences and technological availability can significantly influence the choice of the protocol to be used. But, if the wide diversity of apheresis treatments may offer a tailored-patient approach, it can also create concerns on the right decision about the most appropriate protocol. Therapeutic apheresis - whose purpose is to cure diseases due to abnormality of blood cells or to toxicity of plasma substances - and, productive apheresis - whose purpose is to produce autologous or allogeneic therapeutic hemocomponents - are widely known as plasma-treatments and cytapheresis. The elementary techniques in apheresis are well represented by three physical separation methods of blood components: 1. differential centrifugation; 2. membrane filtration; 3. adsorption of proteins or cells, from whole blood or from plasma already separated. Starting from these three processes, several apheretic techniques have been developed to ensure, in expert hands, excellent therapeutic efficacy together with a low profile of adverse events.

In Vitro Evaluation of the Fresenius Kabi CATSmart Autotransfusion System.

Use of autotransfusion systems to collect, wash, and concentrate shed blood during surgical procedures is a widely used method for reducing postoperative anemia and the need for blood transfusions. The aim of this study was to evaluate the CATSmart Continuous Autotransfusion System wash program performance with small (200 or 700 mL) and large volumes (1,000 mL) of shed blood and to determine non-inferiority of the CATSmart to the C.A.T.S plus system. Human whole blood was collected in citrate phosphate dextrose, diluted, and divided into two aliquots to be processed as a pair using the C.A.T.S plus and CATSmart systems with their corresponding wash programs: low-volume, high quality/smart, or emergency wash. Final packed red cell product was analyzed for red blood cell (RBC), white blood cell, and platelet counts; hemoglobin; hemolysis; RBC recovery rates; and elimination of albumin, total protein, and potassium. The mean hematocrit (HCT) after processing with CATSmart and C.A.T.S plus systems were 59.63% and 57.71%, respectively. The calculated overall RBC recovery rates on the CATSmart and C.A.T.S plus systems were 85.41% and 84.99%, respectively. Elimination of albumin (97.5%, 98.0%), total proteins (97.1%, 97.5%), and potassium (92.1%, 91.9%) were also calculated for the CATSmart and C.A.T.S plus systems. The CATSmart and C.A.T.S plus systems both provided a high-quality product in terms of HCT, protein elimination, and hemolysis rates across the range of tested shed blood volumes and all wash programs. The study was able to confirm the CATSmart is non-inferior to the C.A.T.S plus system.

Spectra Optia® for Automated Red Blood Cell Exchange in Patients with Sickle Cell Disease: A NICE Medical Technology Guidance.

The Spectra Optia® automated apheresis system, indicated for red blood cell exchange in people with sickle cell disease, underwent evaluation by the National Institute for Health and Care Excellence, which uses its Medical Technologies Advisory Committee to make recommendations. The company (Terumo Medical Corporation) produced a submission making a case for adoption of its technology, which was critiqued by the Newcastle and York external assessment centre. Thirty retrospective observational studies were identified in their clinical submission. The external assessment centre considered these were of low methodological and reporting quality. Most were single-armed studies, with only six studies providing comparative data. The available data showed that, compared with manual red blood cell exchange, Spectra Optia reduces the frequency of exchange procedures as well as their duration, but increases the requirement for donor blood. However, other clinical and patient benefits were equivocal because of an absence of robust clinical evidence. The company provided a de novo model to support the economic proposition of the technology, and reported that in most scenarios Spectra Optia was cost saving, primarily through reduced requirement of chelation therapy to manage iron overload. The external assessment centre considered that although the cost-saving potential of Spectra Optia was plausible, the model and its clinical inputs were not sufficiently robust to demonstrate this. However, taking the evidence together with expert and patient advice, the Medical Technologies Advisory Committee considered Spectra Optia was likely to save costs, provide important patient benefits, and reduce inequality, and gave the technology a positive recommendation in Medical Technology Guidance 28.

Fat removal during cell salvage: an optimized program for a discontinuous autotransfusion device.

BACKGROUND: Fat in wound blood observed in orthopedic or cardiac surgery might pose a risk for fat embolism during blood salvage. Fat removal was optimized in the washing process. STUDY DESIGN AND METHODS: In an experimental study blood from fresh donations was adjusted to a hematocrit (Hct) of 25% and an admixture of 1.25% human tissue fat. This blood was processed with the cell salvage device XTRA in a modified program mode. Volumetric quantification of fat was performed after centrifugation of blood samples in Pasteur pipettes. From the volumes, the Hct levels and the concentrations of fat and other variables elimination rates and RBC recovery were calculated. RESULTS: Pretests showed wash volume, wash flow, and process interruptions affecting fat elimination. With the new optimized fat elimination program Pfat removal rate of fat increased to 98.5 ± 0.9% for the 225-mL bowl. The product had a mean Hct of 48.7 ± 1.2% and a RBC recovery rate of 93.5 ± 2.3%. The program conserved the high elimination rates for albumin, heparin, potassium, and free plasma hemoglobin (98.8, 99.3, 95.3, and 94.9%, respectively). Similar high fat removal was also observed with bowls of smaller size, namely, 98.1% for the 175-mL bowl and 98.2% for the 125- and the 55-mL bowls. With test blood of Hct 10% a mean fat elimination of 99.6 ± 01% was observed. CONCLUSIONS: A special program modification Pfat involving extra washing and RBC concentration steps significantly improves fat removal by the Latham bowl-based autotransfusion device XTRA, thus yielding results equivalent to the continuous cell salvage system.

Granulocyte and Monocyte Adsorption Apheresis for Generalized Pustular Psoriasis: Therapeutic Outcomes in Three Refractory Patients.

Generalized pustular psoriasis (GPP) is a type of neutrophilic dermatosis that is sometimes resistant to medications. In patients with neutrophilic skin diseases, granulocyte and monocyte adsorption apheresis (GMA) has been demonstrated to selectively and efficiently eliminate myeloid-lineage leukocytes from the peripheral blood. We evaluated the efficacy and safety of repeated GMA therapy in three refractory GPP patients. Three GPP patients refractory to previous therapies received weekly GMA with five sessions per course, which was repeated when the symptoms reappeared. The efficacy was assessed by the disease severity scores 2 weeks after each course of GMA. The GPP severity scores of all three patients were reduced in all courses (N = 9); they were reduced by more than 3 points in six courses and by 2 points in three courses. After the first GMA course, the GPP severity scores were reduced by more than 3 points in all three patients. On average, the GPP severity scores were reduced by 4.67 and 3.67 points after the first course and repeated courses, respectively. The severity of edema and pustules were particularly improved in all patients and no adverse effects were observed. GMA showed efficacy for the treatment of refractory GPP patients as a non-pharmacologic intervention without any associated adverse effects, and was particularly effective in the first course, but also effective in the subsequent courses.

Use of an autologous blood recovery system during emergency pericardiocentesis in the electrophysiology laboratory.

INTRODUCTION: Emergency pericardiocentesis during electrophysiology procedures is often associated with significant aspiration of pericardial blood, requiring transfusion. We sought to assess the feasibility of urgent use of an autologous blood recovery system in the electrophysiology laboratory to autotransfuse blood aspirated from the pericardium. METHODS AND RESULTS: We retrospectively analyzed Mayo Clinic electrophysiology records for patients who had ablation procedure-related pericardial effusions requiring emergency pericardial drainage during an 8-month period. An autologous blood recovery system was used during pericardiocentesis to separate and clean packed red blood cells from the pericardial aspirate. These cells were returned acutely to the patient intravenously. The procedural safety, aspirated and autotransfused volumes, and efficacy of this approach were evaluated. During the study period, nine patients underwent pericardial drainage with autotransfusion using a cell-salvage instrument during electrophysiology procedures. The mean aspirated volume was 1,078 mL, with a mean autotransfused volume of 390 mL. For four patients, all with aspirated volumes of 1,100 mL or less, autotransfusion alone was sufficient to maintain hemodynamic stability and avoid allogeneic transfusion. One patient required surgical intervention because of ongoing pericardial bleeding. The ablation procedure was completed after aspiration in two patients. No procedural complications related to the use of the cell-salvage system occurred. CONCLUSION: Autologous blood recovery during pericardiocentesis is safe, convenient, and feasible. With early use it may decrease or eliminate the need for allogeneic blood transfusion and, in selected cases, may permit completion of the ablation procedure.

The Italian SIdEM registry for apheresis: an overview of the 2005 statistics.

Data collection on apheresis activities in Italy throughout 2005 including techniques, types of blood cell separators, clinical indications and adverse effects was performed by means of a standardized questionnaire. These data provided by 83 Apheresis Units from 16 Italian regions, albeit rough, are sufficiently informative, mainly in comparison with previous surveys on these statistics (1997 and 2000). In 2005 a total number of 204,746 apheresis procedures were carried out, with a clear-cut prevalence of apheresis production (87.7%), performed by 66 out of 83 Apheresis Units (79.5). Lombardy, Veneto and Tuscany were the most active regions for therapeutic apheresis (51.1% of the total national procedures). An increasing number in extracorporeal photochemotherapy as compared to the 2000 national survey (3,386 vs. 704 procedures) is the most striking observation to emerge from the 2005 data collection on therapeutic apheresis in Italy. Adverse effects, predominantly mild ones (i.e., paresthesia due to citrate-induced hypocalcemia), occurred in 0.12% of apheresis production and 6.04 of therapeutic sessions, particularly in the course of peripheral blood stem cell collection (20.79%), as already reported in the 2000 national survey.

Processing of stored packed red blood cells using autotransfusion devices decreases potassium and microaggregates: a prospective, randomized, single-blinded in vitro study.

The aim of the study was to compare the potential of autotransfusion devices to reduce non-infectious complications related to transfusion of long-stored packed red blood cells (PRBC; n= 57), such as changes in electrolytes, blood cells and the load of free microaggregates. Following a baseline measurement, a blood pool of three PRBC was divided into three equal volumes and washed with either the Haemonetics Cell Saver (HCS) or the continuous autotransfusion system (C.A.T.S), using the quality (CATS(quality)) and emergency (CATS(emergency)) mode. After the washing procedure, measurements for electrolytes, blood cells and free microaggregates were repeated (n= 19 each). Compared with baseline, the investigated autotransfusion devices reduced the median load of potassium (baseline: 52 mEq L(-1); HCS: 4 mEq L(-1); CATS(quality): 4 mEq L(-1); CATS(emergency): 17 mEq L(-1); each P < 0.001), restored a physiologic electrolyte balance and significantly decreased the load of leucocytes, glucose and protein. Whereas the quantity of microaggregates was not reduced by HCS, CATS(emergency) decreased the load of cell fragments below 7.8 microm (P < 0.05 vs. baseline). Using CATS(quality) decreased the load of cell fragments not only to a diameter below 7.8 microm (P < 0.001 vs. baseline) but also of microaggregates between 7.8 and 17.6 microm (P < 0.05 vs. baseline). In situations where long-stored PRBC have to be transfused, the procedure described here may be feasible to reduce clinically relevant side effects, i.e. hyperkalaemia and microvascular obstruction secondary to free cell fragments. This approach could be especially useful in patients undergoing massive transfusion and/or suffering from renal failure.

Differences in platelet growth factor release and leucocyte kinetics during autologous platelet gel formation.

Three commercial systems for whole blood separation were compared to obtain the buffy coat composed of platelet-rich plasma (BC-PRP) and leucocytes . These samples of the buffy coat were used to make a platelet gel (PG), which was used to measure platelet growth factor (PGF) release, to perform a white blood cell (WBC) count and to measure myeloperoxidase (MPO) release from WBCs. Aliquots of whole blood obtained from ten volunteers were distributed either to a blood cell separator (The Electa Cell-Separator, E-CS) or to a tabletop centrifuge (Gravitational Platelet Sequestration System, GPS) to prepare the BC-PRP. The third system combines the BC-PRP production by E-CS with a micro porous filter (Autologous Growth Factor filter, AGF) to enrich for the BC-PRP. Autologous thrombin was used to activate the BC-PRP and to prepare the PG and subsequently to degranulate the platelet concentrate. Platelet-derived growth factor-AB and transforming growth factor-beta1 were present in high levels after thrombin activation of the E-CS or GPS prepared samples. However, the AGF prepared samples released their growth factors before thrombin activation. The WBCs were significantly increased with each of the three systems. Contrary to the AGF, no leucocyte degranulation occurred with the E-CS or GPS prepared samples, based upon the low MPO concentrations in the BC-PRP. The three types of apparatus had different harvesting capacities for collecting the enriched platelets and the release of high concentrations of PGF. When the E-CS and GPS, but not the AGF, were used, low levels of MPO were maintained in the PG, which potentially contributes to antimicrobial properties of platelet gel at the site of application.

Clinical experience with the delivery of thawed and washed autologous blood cells, with an automated closed fluid management device: CytoMate.

BACKGROUND: Washing out of thawed autologous grafts, before reinfusion in poor-prognosis cancer patients who undergo high-dose chemotherapy, is desirable. The procedure allows for the reduction of infused dimethyl sulfoxide (DMSO) quantities and the performance of biologic controls on the infused cell product. STUDY DESIGN AND METHODS: Three-hundred four patients were treated with intensified chemotherapy and autologous transplantation at a single institution. Fifty-four of them received washed cell products, because three or more bags were to be reinfused. The recently available, closed, automated, and current good manufacturing practice-compliant device (CytoMate, Baxter Oncology) was used for this purpose. RESULTS: The performances of the device were similar to previously reported results, with greater than 75 percent CD34+ cell recovery. Neutrophil and platelet (PLT) recoveries were similar in the group of patients receiving washed cells and in the group of patients for whom cell products were extemporaneously thawed at the bedside. Adverse events that are typically reported after DMSO infusion were significantly less frequent and less severe in patients who received washed cells. Finally, the nurse staff on the transplant ward reported a decreased workload and more satisfactory procedure when infusing washed cell products. CONCLUSION: The CytoMate device allows for a significant reduction in DMSO infusion, with a diminished frequency and severity of immediate side effects and does not compromise neutrophil or PLT engraftment.

Quality of red blood cells using the Dideco Electa autotransfusion device.

The purpose of this study was to evaluate the quality of washed, concentrated red blood cells (RBCs) produced by the new Electa autotransfusion device from Cobe Cardiovascular (Dideco). Blood was collected intraoperatively in 16 patients undergoing cardiac surgery for whom routine cell savage was being used and then washed using the Electa. According to the manufacture's protocol. 125-mL bowls were used in the standard wash program. Reservoir and washed RBCs were analyzed for platelets (PLTs), leukocytes (WBCs), potassium (K+), and plasma-free hemoglobin (PFH) removal, as well as, hematocrit (Hct) and RBC recovery. The Electa cell saver produced a product with an average Hct of 58+/-5% and a RBC recovery rate of 87+/-10%. Its removal of waste products resulted in the washout of 54+/-18% WBCs, 87+/-6% PLTs, 91+/-4% K+, and 77+/-17% PFH. The Electa produces a good-quality washed RBC product that is comparable with other autotransfusion devices on the market.

Apheresis techniques for collection of peripheral blood progenitor cells.

The combination of effective mobilisation protocols and efficient use of apheresis machines has caused peripheral blood progenitor cells (PBPC) transplantation to grow rapidly. The development of apheresis technology has improved over the years. Today PBSC procedures have changed towards systems to minimise operator interaction and to reduce the collection of undesired cells such as polymorphonuclear cells and platelets using functionally closed, sterile environments for PBSC collection in keeping with Good Manufacturing Practice guidelines. Blood cell separators with continuous flow technique allow the processing of more blood than intermittent flow devices resulting in higher PBSC yields. Large volume leukapheresis with the processing of 3-4-fold donor's/patient's blood volume can increase the number of collected progenitor cells. Therefore, intermittent flow cell separators are indicated if only single vein access is available. Anticoagulant induced hypocalcaemia is an often observed side effect in long lasting PBPC harvesting and monitoring of electrolytes should be performed especially at the end of the apheresis procedure to supplement low levels of potassium, calcium or magnesium. Refinement and improvement of collection techniques continue to add to the armamentarium of current approaches for cancer and non-malignant conditions and will enable future strategies.

Cytokine levels after transfusion of washed wound drainage in total knee arthroplasty: a randomized trial comparing autologous blood and washed wound drainage.

Forty patients undergoing total knee arthroplasty (TKA) were prospectively randomized to autologous blood transfusion or retransfusion of washed wound drainage. The wound drainage was washed using a dynamic disk separation chamber. Interleukin (IL)-1 beta, IL-6, IL-8, and tumor necrosis factor (TNF) alpha blood levels were measured prior to epidural anesthesia and at 0, 30, 60, and 120 minutes after initiation of the transfusion. Washed wound drainage contained significantly higher amounts of IL-6 (P < .05) and IL-8 (P < .05) than predonated autologous blood. No significant difference was found for IL-1 beta (P = .28) and TNF-alpha (P = .14). The patients' IL-6 and IL-8 blood levels increased in both groups within 2 hours after the transfusion. This increase was correlated to the time interval between surgery and transfusion (P < .05) and was not significantly different between both groups. No correlation was found between the increase in patients' cytokine levels and the amount of washed wound drainage transfused. According to these results, the increase in IL-6 and IL-8 after transfusion is related to the surgical trauma response and not the transfusion protocol.

Quality of red blood cells using autotransfusion devices: a comparative analysis.

Cell salvage devices are routinely used to process and wash red blood cells (RBCs) shed during surgical interventions. Although the principle theory of cell saving is the same, the actual process to achieve this is very different from one device to another. The purpose of this study was to compare the quality of washed, concentrated RBC produced by five very different cell-saving devices, specifically the Cobe BRAT 2, Medtronic Sequestra 1000, Haemonetics Cell Saver 5, Medtronic Autolog, and the Fresenius CATS. Reservoir and washed red blood cells were analyzed for hematocrit (Hct), platelets (PLT), leukocytes (WBC), potassium (K+), heparin, plasma-free hemoglobin (PFH), RBC mass recovery and recovery rate. The Haemonetics and BRAT 2 had the highest RBC recovery. All devices adequately removed heparin and potassium. The Medtronic Autolog had the highest removal of platelets and PFH; whereas, the BRAT had the lowest. Although the Autolog had the highest leukocyte removal, leukocytes were not adequately washed out by any of the autotransfusion devices. In conclusion, although all cell-saving devices use the same theory of centrifugation, the actual quality of the washed RBC product differs widely from one device to another.

A questionnaire: will plateletpheresis donors accept multicomponent donation?

BACKGROUND AND OBJECTIVES: New technological developments make it possible to collect red blood cells (RBC) by apheresis which provides standardised products and has the potential for improved RBC quality. The purpose of this study was to evaluate the donors' opinion about the multicomponent donation procedure. MATERIAL AND METHODS: For evaluating the donors' opinion about this new apheresis technique we compiled a questionnaire. The questionnaire was given to all single needle actual plateletpheresis donors (n = 133) that donated platelets in our Institute during February-March 2001. The questionnaire contained 12 questions related to: (1) general information about previous donations of our donors and (2) donors' opinion about multicomponent donation. After implementation of multicomponent donation in December 2001 the data of the questionnaire were compared with the actual opinions of the donors about the procedure. RESULTS: The mean age of the donors was 38.1 +/- 9.1 years. The median number of previous platelets donations of the interviewed donors was 30. The majority of donors (92.4%) were willing for multicomponent donation. In the same time the majority of donors (74.8%) were willing to donate multicomponents four times per year. The different donation time was not an argument for the donors for the multicomponent donation, while the reduction of incidence of transfusion transmitted diseases was a motivation for them. The decrease of hemoglobin and the side effects caused by possible iron-supplementation therapy were found acceptable from most of our donors. Approximately 74% of the donors thought that the donation of a second component should result in better remuneration whereas 20% of them believed that the remuneration should be unchanged. Seventy-five RBC units were concurrently collected with platelets since December 15th, 2001. Six donors (7.4%) were unwilling to donate an additional RBC unit. CONCLUSION: Acceptance and disacceptance rates were almost equal after the implementation of multicomponent donation and at the time point when the interview was performed. The majority of donors was highly motivated to donate multicomponents, by these means we were able to increase our RBC supply and to improve standardization of our products.

Levels of inflammatory markers in the blood processed by autotransfusion devices during cardiac surgery associated with cardiopulmonary bypass circuit.

Intraoperative blood salvage devices allowing a reinfusion of red blood cells (RBCs) after processing of shed blood and stagnant blood in the mediastinal cavity are more and more used to reduce homologous blood requirements in cardiac surgery with cardiopulmonary bypass (CPB). As the proinflammatory activity of the shed blood also contributes to morbidity during CPB, we conducted a prospective study in order to examine the quality of autologous blood before and after processing with five different devices [BRAT2, Sequestra, Compact Advanced, Cell Saver 5 (CS5), Continuous Autologous Transfusion System (CATS)]. All systems resulted in an excellent haemoconcentration, ranging from 53.7% (Compact) to 68.9% (CATS). The concentrations and elimination rates of several inflammatory markers [IL-1beta, IL-2, IL-8, TNFalpha, myeloperoxidase (MPO), elastase] were examined. Except for the Sequestra, an important increase in concentration of IL-1beta (between 30% and 220%) has been observed after processing with each device. In contrast, the attenuation rate of IL-6 and TNFalpha (95%) was optimal for all investigated blood salvages systems. Regarding IL-8, only the CATS and CS5 systems were able to attenuate this biological parameter with an excellent efficacy. The rate of attenuation in MPO and elastase, as markers of leukocyte activation, was higher than 80% for all devices. In conclusion, the different RBC washing systems tested in this study resulted in a significant attenuation of the inflammatory response. Increased levels of IL-1beta after processing remained, however, unclear. According to the type of protocol, based on inlet haematocrit, fill and wash speeds, and wash volumes, small variations in reducing the inflammatory response have been observed from one device to another.