Rheotherapy for vascular disorders.

Patients with vascular disorders are seldom offered apheresis in he management of their symptoms. In this article we review the different apheretical techniques used in these situations.

Hypertriglyceridemia: apheretic treatment.

Patients with extremely high triglyceride levels and associated lipemia are at high risk for acute pancreatitis. Two factors can increase triglyceride-rich lipoproteins; one is overproduction and other is a defect in clearance. Either mechanism can cause hypertriglyceridemia and both may exist simultaneously. Causes can be either primary or secondary. Plasmapheresis is efficacious for severe Hypertriglyceridemia in patients who have not responded to previous therapies. We have treated 15 cases of hypertriglyceridemia complicating the course of patients receiving Cyclosporin A after bone marrow transplantation. Five patients were treated with plasmapheresis, the other ten with cascade filtration. The removal rate for triglycerides was 58.0% for patients treated by cascade filtration and 63.5% for patients treated by plasmapheresis. The removal rates for triglycerides were low possibly as a consequence of early saturation of the filter.

Hypercholesterolemia and LDL apheresis.

Several trials have assessed the link between low-density lipoprotein cholesterol (LDL) and the development of coronary heart disease (CHD). LDL apheresis provides an effective role in treating patients with familial hypercholesterolemia (FH) and in preventing the progression of coronary artery disease (CAD). Five different techniques of LDL apheresis are in current use: immunoadsorption (IMA), dextran sulphate-cellulose adsorption (DSA), heparin extracorporeal LDL precipitation system (HELP), double filtration plasmapheresis (DFPP) or lipidfiltration and direct adsorption of lipoprotein using hemoperfusion (DALI). All methods are efficient,but their cost restricts LDL apheresis to the treatment of FH. Indications could include other diseases, but controlled trials are still lacking.

Lepromatous vasculitis successfully treated by plasma exchange (PE).

Vascular involvement is presently considered a "common pathway" in a number of diseases that is mediated by circulating immune complexes (CIC). CIC are found in the circulation when the disease is active and in single patients their level may parallel disease activity. Lepromatous leprosis is characterized by the presence of CIC and deposits of immunoglobulins and complement in vascular lesions of the different organs and an Arthus-like mechanism is considered as the basis for the clinical picture. The same mechanism is considered to play an essential pathophysiologic role in Lucio's phenomenon, which is characterized by lymphohistiocytic vascular infiltrates with or without thrombosis and secondary cutaneous infarction. Lepromatous vascular involvement is mediated by CIC whose antigen composition is known, the same as it is with HCV mediated cryoglobulinemia, HBV positive panarteritis nodosa, rheumatoid vasculitis, or Wagner's granulomatosis, which are usually treated by PE [1-3]. PE has been employed for lepromatous vasculitis since 1979 [4] and other cases have been successfully treated afterwards [5,6]. We report on another patient successfully treated by plasma exchange.

PCR testing for HCV in anti-HCV negative blood donors involved in the so called HCV +ve post-transfusion hepatitis.

UNLABELLED: Although it is infrequent, post-transfusion HCV infection may occur if the donors blood is collected in the window period between exposure and anti-HCV detectability by ELISA testing. STUDY DESIGN: In these last years, despite of routine application of anti-HCV testing, our blood transfusion center has been involved in 53 cases of alleged post-transfusion HCV hepatitis and look-back programs were set up with the goal of finding out the donors possibly involved in viral transmission. Most of these patients were hematological cases with multiple transfusions given because of aplastic anemia (3 cases), leukemia with or without bone marrow transplantation (5/4 cases) but necessitating long-term platelet support, leukemia and solid cancer patients undergoing autologous PBSC transplantation (3/4 cases) and TTP (2 cases). Only 32 patients were of the simple medical or surgical type, 9 transfused because of cardiac or vascular surgery, 8 because of spine surgery, 5 for different diseases and 5 for different types of cancer surgery. Donor's infectivity was determined by ELISA anti-HCV testing, by recombinant immunoblotting assay, and by nucleic acid testing. RESULTS AND CONCLUSION: No donors out of 267 traced of a total of 359 involved was found with anti-HCV seroconversion, or positive on PCR testing. This suggests that the responsibility for HCV transmission can only hypothetically be related to blood or blood components and that other transmission routes should be found out.

Multicomponent collection (MCC) with the latest hemapheresis apparatuses.

BACKGROUND: Collection of multiple products including plasma, packed red blood cells (PBRC) and double units of platelets, is increasingly improving donor utilisation and decreasing blood transfusion costs. Total apheresis is the new trend in blood banking and both industry and physicians are progressively expanding their involvement in this field. During 1998, at our hemapheresis unit, we used three new apparatuses for multicomponent collection (MCC). These apparatuses vary in terms of principle, operation and specific capabilities, and thus knowledge of them is essential to match their characteristics with plateletapheresis needs. STUDY DESIGN: We reviewed all MCCs carried out in 1998 with MCS+, Trima and Excel-Pro cell separators. These apparatuses were evaluated in terms of platelet yield, white blood cell (WBC) contamination, efficiency per minute, platelet activation, and PBRC product quality. RESULTS: The three machines are compared in the following table [table in text]. CONCLUSIONS: MCC with the new apparatuses is well accepted by donors and personnel. There are no risks for the donors and, excluding ACD reactions and/or vaso/vagal attacks at the beginning of procedures, no severe reaction was seen. The quality and quantity of platelet products are good. When PRBC or a second platelets unit are collected, the cost of the kit is covered by this double product.

Erythrothrombocytapheresis and plasmathrombocytapheresis with storage in T-sol of platelets collected by the new Amicus cell separator.

The Amicus cell separator is the latest apparatus introduced into the international market for high-yield, low WBC contamination and short-procedure time thrombocytapheresis. In its original configuration the apparatus collects platelets for subsequent resuspension in plasma and no collection of PRBC can be carried out along with thrombocytapheresis. In this paper we present the results of plasma-thrombocytapheresis and erythro-thrombocytapheresis after the adaptation of the Amicus to the collection and storage of platelets in a non-plasma medium and the concurrent collection of PRBC. From our study it is concluded that PRBC collection doesn't modify the quality of the platelet product obtained from random donors (platelets pre-count 263x10e3/microliter) in terms of yield which is 4.6x10e11 platelets, WBC contamination (1.3x10e5) or procedure time (63 +/- 26 min.). The quality of the platelet products is satisfactory too, as measured by aggregation induced by collagen and ristocetin or by the substantial stability of membrane glycoproteins (CD62-63-51-36-42B). The concentrate had an average content of 58.8 g of hemoglobin per bag, a final volume of 376 +/- 13 ml, (after the addition of 100 ml of SAG-M) and a normal mechanic and osmotic fragility.

PBSC collection from G-CSF primed donors.

Peripheral blood stems cells (PBSCs) have been used in autologous transplantation as an alternative to bone marrow-derived cells. Recently, PBSCs have been collected from healthy donors after priming with G-CSF and used for allogeneic transplantation. We have a comparatively large experience with PBSC collection in autologous and allogeneic settings. The five cell separators we employ are: the CS3000 plus, AS 104, Excel, Cobe Spectra and MCS 3p. These machines appear to have different efficacies but no studies have been carried out on this topic. In a prospective study we have randomly assigned donors to different cell separators to evaluate their efficiency. Twenty-five donors underwent the procedure and 50 leukaphereses were carried out. Donors were given 5 micrograms kg-1 d-1 of recombinant human G-CSF for 3 days and 10 micrograms kg-1 d-1 for 4 days subcutaneously. Leukaphereses were performed on days 6 and 7 of G-CSF administration. The results of our study show that a total value of CD34+ cells ranging from 48.44 x 10(6) to 270.37 x 10(6) can be collected from donors with a white cell count ranging from 40.50 x 10(3) microL-1 to 51.34 x 10(3) microL-1 and mononuclear cells ranging from 16.42 to 20.37%. The Excel and the MCS 3p seem to differ from the other machines in terms of higher CD34+ cell collection efficiency. The Excel appears to be even more efficient than the MCS 3p, but this may not reflect reality because the Excel processes 12 L of blood while the MCS 3p employs an 8 L procedure. All the machines showed satisfactory results in terms of yield and quality of the harvests.

Intraoperative blood salvage (IOBS) in cardiac and vascular surgery.

The extensive application of IOBS has permitted a great reduction in the use of homoglous transfusion which presently represents the largest field of application of autologous systems. In cardiac and vascular surgery, IOBS is particularly useful to the goal of preventing the transmission of viral disorders and other adverse effects related to homologous transfusions. The apparatuses for IOBS may also be used to perform hemodilution and sequestration of a desired amount of platelet rich plasma. The appropriate usage of drugs in perioperative period and the promotion of hemostasis with IOBS are important costituents for the correct transfusional management of the patient. The feasibility and safety of IOBS is known and in expert hands it is an optimal method for the transfusional treatment of surgical patients.

Single-donor platelet concentrates produced along with packed red blood cells with the Haemonetics MCS 3p: preliminary results.

There has been an increasing interest in recent years over the qualitative superiority of single-donor platelets in the management of hemato-oncologic patients. The reasonable desire of both patients and physicians to limit the risks of transfusion along with the need for limiting the costs involved in this kind of therapy have led to application of multicomponent donations both in terms of double platelet concentrates and double products such as red blood cells (RBC) and platelets from the same donor. Single donor platelets and RBC have been collected in a semi-automated mode and only the very recent introduction of the Haemonetics MCS 3p with its SDP/RBC protocol provides a totally closed-system automated protocol for this combined collection. Twenty procedures have been carried out so far at our unit. In a mean of 87 minutes (6-7 passes), a mean of 3.1 x 10(11) platelets were collected along with approximately 220 mL of packed RBC. The leukocyte contamination of the platelet product was in the range of 0.4-1.1 x 10(7) (99% lymphocytes), and the quality of platelets was very satisfactory as measured by the hypotonic shock response, aggregation induced by ADP, collagen and ristocetin, morphology score, and membrane glycoproteins modifications. Equally satisfactory was the quality of the RBC concentrate, suspended in 80 mL of SAG-M, with a total hemoglobin (Hb) content approaching 55 g as compared to the normal Hb content of a standard RBC concentrate that is approximately 62 g.(ABSTRACT TRUNCATED AT 250 WORDS)

Donors thrombocytapheresis with last generation cell separators.

An exciting, fast moving and promising field remains the use of plasma-free synthetic medium for platelet storage (10, 11), that along with the potential for getting more plasma for therapeutic needs, might also improve the quality of stored platelets. Addition of acetate to solution, may be the way to obtain these results. An astonishing fact is that citrate remains the only anticoagulant for platelet collection, and remains as well the only real cause of donor discomfort during thrombocytapheresis.

Plasma exchange: the cost/benefit ratio and the critical revision of indications.

The number of conditions that can benefit from Plasma-Exchange (PE) continues to grow. We have recently added to the list the Cyclosporin-A induced hypertrygliceridemia and myoglobinuric acute renal insufficiency. Such as any therapeutic measure for PE, four evolutive phases can be recognized: the discovery and research, the confirmation of indications, the routine applications and the decline, when new more powerful tools are offered by culture or technology. We have participated in the first three phases during the last 20 years. Not necessarily all experiences were favourable. Nonetheless, we feel that, for the time being, a hemapheresis unit is an absolute necessity for a medium - sized hospital even if only therapeutic procedures are carried out. The phase four, decline of interest and applications, cannot be foreseen. Finally the ability of PE to shorten substantially the length of hospital stays along with the ease with which procedure can be performed on ambulatory patients, substantiate a favourable cost/benefit ratio for this therapeutic modality.

The organization of the autotransfusion-perioperative blood salvage at San Martino Hospital.

Autologous transfusion is playing an important role in modern transfusion medicine. At San Martino hospital we use a combination of manual and mechanical techniques in order to improve autotransfusion procedures, control the hypertransfusion and avoid waste. Our autotransfusion program has determined a 55% reduction in the red cell concentrates used (from 42,000 in 1985 down to 19,400 in 1992). Proper training, cultural improvements and new applications on autotransfusion procedures will permit a better use of blood with less transfusion related complications, until a suitable substitute for blood will be available.

Excel: a new cell separator in its very first clinical application.

BACKGROUND: The evolution of technology has been one of the most interesting features that has accompanied thrombocytapheresis throughout the years. In this presentation we report on the preliminary results obtained with Excel, a third-generation cell separator that is presently in its early experimental phase. MATERIAL AND METHODS: So far only 15 thrombocytapheresis procedures, 2 of which of the single-needle type, were carried out on 15 healthy donors processing 4 liters of blood (2.8 liters in single needle). RESULTS AND CONCLUSIONS: The results were satisfactory since the average platelet yield was 4.7 x 10(11). The leukocyte contamination was 0.8 x 10(6) and the RBC contamination 0.4 x 10(7). The platelet efficiency per minute was 6.5 x 10(9), and the run time average 72 min. As to the quality of the product the very first results of platelet aggregation, relative to pre-apheresis, were 78% in response to ADP 6 microM; 106 and 102% in response to collagen 4.5 micrograms/ml and ristocetin 1.5 mg/ml, respectively. Essentially no platelet aggregates were found in the platelet products (Wu-Hoak ratio: 0.91).