View source for Apheresis

{{Short description|Medical techniques to separate one or more components of blood}}
{{About||the linguistic term|Apheresis (linguistics)}}
{{redirect-distinguish|Pheresis|Phoresis}}
{{Infobox interventions |
  Name        = Apheresis |
  Image       = Image:Apheresis.svg |
  Caption     = Whole blood enters the centrifuge (1) and separates into plasma (2), leukocytes (3), and erythrocytes (4). Selected components are then drawn off (5). |
  ICD10       = |
  ICD9        = |
  MeshID      = D016238 |
  OtherCodes  = |
}}

'''Apheresis''' ([[wikt:ἀφαίρεσις|ἀφαίρεσις]] (''aphairesis'', "a taking away")) is a [[medical technology]] in which the [[blood]] of a person is passed through an apparatus that separates one particular [[blood constituent|constituent]] and returns the remainder to the circulation.  It is thus an [[extracorporeal]] therapy.

One of the uses of apheresis is for collecting [[hematopoetic stem cells|hematopoietic stem cells]].<ref>{{Cite book|title=Official CPC Certification Study Guide|last=Katherine|first=Abel|publisher=Delmar Cengage Learning |isbn=978-1-285-42799-7 |oclc=1073648099 |author2=American Academy of Professional Coders |year=2013|pages=128}}</ref>
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== Method ==

Depending on the substance that is being removed, different processes are employed in apheresis. If separation by [[density]] is required, [[centrifugation]] is the most common method. Other methods involve absorption onto beads coated with an absorbent material<ref>{{Cite journal |last1=Fuchs |first1=Kornelius |last2=Rummler |first2=Silke |last3=Ries |first3=Wolfgang |last4=Helmschrott |first4=Matthias |last5=Selbach |first5=Jochen |last6=Ernst |first6=Friedlinde |last7=Morath |first7=Christian |last8=Gauly |first8=Adelheid |last9=Atiye |first9=Saynab |last10=Stauss-Grabo |first10=Manuela |last11=Giefer |first11=Mareike |date=2022 |title=Performance, clinical effectiveness, and safety of immunoadsorption in a wide range of indications |journal=Therapeutic Apheresis and Dialysis |volume=26 |issue=1 |pages=229–241 |doi=10.1111/1744-9987.13663 |pmc=9291474 |pmid=33914397}}</ref> and filtration.<ref>{{cite journal |vauthors=Hirano R, Namazuda K, Hirata N |title=Double filtration plasmapheresis: Review of current clinical applications |journal=Ther Apher Dial |volume=25 |issue=2 |pages=145–151 |date=April 2021 |pmid=32558286 |doi=10.1111/1744-9987.13548 }}</ref>

The centrifugation method can be divided into two basic categories:<ref>{{cite journal |vauthors=Lambert C, Gericke M, Smith R, Hermans C |title=Plasma extraction rate and collection efficiency during therapeutic plasma exchange with Spectra Optia in comparison with Haemonetics MCS+ |journal=J Clin Apher |volume=26 |issue=1 |pages=17–22 |date=2011 |pmid=21312255 |doi=10.1002/jca.20271 }}</ref>

=== Continuous flow centrifugation ===

Continuous flow centrifugation (CFC) historically required two [[venipunctures]] , as "continuous" means the blood is collected, spun, and returned simultaneously. Newer systems can operate with a single venipuncture by collecting blood in a vessel and alternating between drawing and returning it through the same needle, while the centrifuge continuously processes the blood held in the vessel.<ref>{{cite patent |country=US | number=7108672| status=patent| title=Extracorporeal blood processing methods and apparatus }}</ref> The main advantage of this system is the low extracorporeal volume (calculated by volume of the apheresis chamber, the donor's [[hematocrit]], and total blood volume of the donor) used in the procedure, which may be advantageous in the elderly and for children.{{citation needed|date=November 2021}}

=== Intermittent flow centrifugation ===

Intermittent flow centrifugation (IFC) works in cycles, taking blood, spinning/processing it and then giving back the unused parts to the donor in a [[Bolus (medicine)|bolus]]. The main advantage is a single venipuncture site. It does require a larger extracorporeal volume and takes significantly longer to perform the procedure via IFC. As a result, it is less commonly used for therapeutic purposes and is more frequently found in Donation Center settings.<ref>{{Cite web |title=Apheresis |url=https://www.transfusions.org/p/apheresis.html |access-date=2022-10-24 |language=en}}</ref> To stop the blood from [[Coagulation|coagulating]], [[anticoagulant|an anticoagulant]] is automatically mixed with the blood as it is pumped from the body into the apheresis machine.<ref>{{cite journal |vauthors=Vurro F, Merolle L, Marraccini C, Parisi M, Canovi L, Erta B, Santachiara A, Bonvicini L, Giorgi Rossi P, Baricchi R, Pertinhez TA |title=Quantitative assessment of the anticoagulant in plasma units collected by plasmapheresis |journal=Transfusion |volume=59 |issue=6 |pages=2113–20 |date=June 2019 |pmid=30875439 |doi=10.1111/trf.15244 }}</ref>

=== Centrifugation variables ===

The centrifugation process itself has four variables that can be controlled to selectively remove desired components. The first is spin speed and bowl diameter, the second is "sit time" in the centrifuge, the third is solutes added, and the fourth is not as easily controllable: plasma volume and cellular content of the donor. The result in most cases is the classic sedimented blood sample with the [[Red blood cells|RBCs]] at the bottom, the [[buffy coat]] of platelets and [[White blood cells|WBCs]] ([[lymphocytes]], [[granulocytes]], [[monocytes]]) in the middle and the plasma on top.<ref name=Vrielink23>{{cite journal |vauthors=Vrielink H, Neyrinck MM |title=Basics of apheresis and equipment |journal=Transfus Apher Sci |volume=62 |issue=2 |pages=103671 |date=April 2023 |pmid=36870905 |doi=10.1016/j.transci.2023.103671 }}</ref>

== Types ==

[[Image:Blood donation needle.jpg|thumb|480px|Disinfect, insert the cannula, pull out the cannula, and dress the wound. The blue pressure cuff is controlled by the platelet apheresis machine in newer models.]]

There are numerous types of apheresis.

=== Donation ===

Blood taken from a healthy donor can be separated into its parts during [[blood donation]], where the needed component is collected and the unharvested components are returned to the donor. [[Fluid replacement]] is usually not needed in this type of collection.  In many countries, apheresis donors can donate platelets more often than those donating whole blood. There are several categories of component collections:
* [[Plasmapheresis]] – [[blood plasma]]. Plasmapheresis is useful in collecting FFP (fresh frozen plasma) of a particular ABO group.  Commercial uses aside from FFP for this procedure include immunoglobulin products, plasma derivatives, and the collection of rare WBC and RBC antibodies.
[[File:Fenwal Erythropheresis machine for plasmapheresis.jpg|thumb|A Fenwal Erythropheresis machine is being used for plasmapheresis.]]
* [[Erythrocytapheresis]] – [[red blood cells]].  Erythrocytapheresis is the separation of [[erythrocytes]] from whole blood.  It is most commonly accomplished using the method of centrifugal sedimentation.  The automated red blood cell collection procedure for donating erythrocytes is referred to as 'Double Reds' or 'Double Red Cell Apheresis.'<ref>[http://www.cc.nih.gov/dtm/dtm_double_red_cell.htm dtm double red cell<!-- Bot generated title -->] {{webarchive |url=https://web.archive.org/web/20070705090407/http://www.cc.nih.gov/dtm/dtm_double_red_cell.htm |date=July 5, 2007 }}</ref>
* [[Plateletpheresis]] (thrombapheresis, thrombocytapheresis) – [[platelet|blood platelets]]. Plateletpheresis is the collection of platelets by apheresis while returning the RBCs, WBCs, and component plasma. The yield is normally the equivalent of between six and ten random platelet concentrates. Quality control demands the platelets from apheresis be equal to or greater than 3.0 × 10<sup>11</sup> in number and have a pH of equal to or greater than 6.2 in 90% of the products tested and must be used within five days.
* [[Leukapheresis]] – [[leukocytes]] (white blood cells). Leukopheresis is the removal of [[Granulocyte|PMN]]s, basophils, eosinophils for transfusion into patients whose PMNs are ineffective or where traditional therapy has failed.  There is limited data to suggest the benefit of [[granulocyte transfusion]].  The complications of this procedure are the difficulty in collection and short shelf life (24 hours at 20 to 24&nbsp;°C).  Since the "buffy coat" layer sits directly atop the RBC layer, HES, a sedimenting agent, is employed to improve yield while minimizing RBC collection.  Quality control demands the resultant concentrate be 1.0 × 10<sup>10</sup> granulocytes in 75% of the units tested and that the product be irradiated to avoid graft-versus-host disease (inactivate lymphocytes).  Irradiation does not affect PMN function.  Since there is usually a small amount of RBCs collected, ABO compatibility should be employed when feasible.<ref>{{cite journal |vauthors=Lodermeier MA, Byrne KM, Flegel WA |title=Red blood cell sedimentation of Apheresis Granulocytes |journal=Transfusion |volume=57 |issue=10 |pages=2551–2 |date=October 2017 |pmid=28815621 |pmc=5656404 |doi=10.1111/trf.14251 }}</ref>
* Stem cell harvesting – [[hematopoietic stem cells]].  Circulating peripheral blood stem cells (PBSCs) are harvested to use in [[peripheral stem cell transplantation]] following administration of a mobilizing agent, such as granulocyte colony stimulating factor (G-CSF).
* Lymphapheresis – [[lymphocytes]].  Lymphocytes are harvested to use in manufacture of [[CAR T cell]] products for T-cell-based immunotherapies.<ref>{{cite journal |vauthors=Yamanaka I, Yamauchi T, Henzan T, Sakoda T, Miyamoto K, Mishima H, Ono H, Koga Y, Nakashima Y, Kato K, Miyamoto T, Mizuno S, Ogawa Y, Ohga S, Akashi K, Maeda T, Kunisaki Y |title=Optimization of lymphapheresis for manufacturing autologous CAR-T cells |journal=Int J Hematol |volume=114 |issue=4 |pages=449–458 |date=October 2021 |pmid=34275066 |doi=10.1007/s12185-021-03191-x }}</ref>

==== Donor safety ====
* Single use kits – Apheresis is done using single-use kits, so there is no risk of infection from blood-contaminated tubing or centrifuge. Blood does not contact the device and during the separation, blood does not exit the kit.<ref name=Vrielink23/>
* Reinfusion – At the end of the procedure, the remaining blood in the kit is given back to the donor with a process called 'reinfusion'.
* Immune system effects – "the immediate decreases in blood lymphocyte counts and serum immunoglobulin concentrations are of slight to moderate degree and are without known adverse effects. Less information is available regarding long-term alterations of the immune system".<ref>{{cite journal |doi=10.1002/jca.2920020112 |title=Apheresis donor safety – changes in humoral and cellular immunity |year=1984 |last1=Strauss |first1=Ronald G. |journal=Journal of Clinical Apheresis |volume=2 |pages=68–80 |pmid=6536660 |issue=1|s2cid=25890912 }}</ref>

===== Kit problems =====

Two apheresis kit recalls were:
* Baxter Healthcare Corporation (2005), in which "pinhole leaks were observed at the two-omega end of the umbilicus (multilumen tubing), causing a blood leak."<ref>{{cite web|url=https://www.fda.gov/CbER/recalls/baxaphe013105.htm |title=Recall of Amicus Apheresis Kits, Baxter Healthcare Corporation |website=[[Food and Drug Administration]] |access-date=2008-12-20 |url-status=dead |archive-url=https://web.archive.org/web/20090117033956/https://www.fda.gov/cber/recalls/baxaphe013105.htm |archive-date=2009-01-17 }} "Recall of Amicus Apheresis Kits, Baxter Healthcare Corporation", US FDA, Jan 31 2005</ref>
* Fenwal Incorporated (2007), in which there were "two instances where the [[acid-citrate-dextrose|anticoagulant citrate dextrose]] (ACD) and saline lines were reversed in the assembly process. The reversed line connections may not be visually apparent in the monitor box, and could result in excessive ACD infusion and severe injury, including death, to the donor."<ref>{{Cite web|url=https://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm053390.htm|archive-url=https://web.archive.org/web/20090709195045/http://www.fda.gov/BiologicsBloodVaccines/SafetyAvailability/Recalls/ucm053390.htm|url-status=dead|archive-date=July 9, 2009|title=Recall of CS3000 Apheresis Kits|date=June 21, 2007|website=[[Food and Drug Administration]]}}</ref>
<!--* Sri lanka expired kits – " top Health Ministry officials accompanied UNP parliamentarian Jayalath Jayawardena to the Centre, on his request, and found 44 expired apheresis kits, allegedly damaged, in two rooms close to its director's office."<ref>[http://sundaytimes.lk/080817/News/sundaytimesnews_12.html  More bluffs and blunders in bloody mess, By Kumudini Hettarachchi, August 17, 2008, ''The Sunday Times'']</ref> -->

===== Donor selection =====

People who do not use a drug that may prevent blood donation, who do not have the risk of the carrier of a disease, and who have suitable vascular structure may be apheresis donors. For apheresis platelet donation the donor's pre platelet count should be above 150 x 10^9/L. For apheresis plasma donation, the donor's total protein level should be greater than 60 g/L. For double red cell apheresis, donors of either gender require a minimum hemoglobin level of 14.0 g/dl.<ref>{{cite journal |vauthors=Boulton F |title=The 13% rule. Comments |journal=Transfusion Today |date=2007 |volume=71 |pages=7–9}}</ref>

===== Plasticizer exposure =====

Apheresis uses plastics and tubing, which come into contact with the blood. The plastics are made of [[PVC]] in addition to additives such as a [[plasticizer]], often [[DEHP]]. DEHP leaches from the plastic into the blood, and people have begun to study the possible effects of this leached DEHP on donors as well as transfusion recipients.<ref>{{cite journal |vauthors=Larsson L, Sandgren P, Ohlsson S, Derving J, Friis-Christensen T, Daggert F, Frizi N, Reichenberg S, Chatellier S, Diedrich B, Antovic J, Larsson S, Uhlin M |title=Non-phthalate plasticizer DEHT preserves adequate blood component quality during storage in PVC blood bags |journal=Vox Sang |volume=116 |issue=1 |pages=60–70 |date=January 2021 |pmid=32918773 |doi=10.1111/vox.12982 |doi-access=free }}</ref>
* "current risk or preventive limit values for DEHP such as the RfD of the US EPA (20 μg/kg/day) and the TDI of the European Union (20–48 μg/kg/day) can be exceeded on the day of the plateletpheresis. ... Especially women in their reproductive age need to be protected from DEHP exposures exceeding the above mentioned preventive limit values."<ref>{{cite journal |doi=10.1007/s00204-005-0004-x |title=Intravenous exposure to di(2-ethylhexyl)phthalate (DEHP): Metabolites of DEHP in urine after a voluntary platelet donation |year=2005 |last1=Koch |first1=Holger M. |last2=Bolt |first2=Hermann M. |last3=Preuss |first3=Ralf |last4=Eckstein |first4=Reinhold |last5=Weisbach |first5=Volker |last6=Angerer |first6=Jürgen |journal=Archives of Toxicology |volume=79 |issue=12 |pages=689–93 |pmid=16059725|bibcode=2005ArTox..79..689K |s2cid=743051 }}</ref>
* "Commercial plateletpheresis disposables release considerable amounts of DEHP during the apheresis procedure, but the total dose of DEHP retained by the donor is within the normal range of DEHP exposure of the general population."<ref>{{cite journal |doi=10.1046/j.1537-2995.2003.00479.x |title=Donor exposure to the plasticizer di(2-ethylhexyl)phthalate during plateletpheresis |year=2003 |last1=Buchta |first1=Christoph |last2=Bittner |first2=Claudia |last3=Höcker |first3=Paul |last4=Macher |first4=Maria |last5=Schmid |first5=Rainer |last6=Seger |first6=Christoph |last7=Dettke |first7=Markus |s2cid=34539126 |journal=Transfusion |volume=43 |issue=8 |pages=1115–20 |pmid=12869118}}</ref>
* The Baxter company manufactured blood bags without [[DEHP]], but there was little demand for the product in the marketplace
<!-- * Some apheresis products are now manufactured in China. <ref>http://nigale.en.alibaba.com/offerdetail/203354126/Sell_Single_use_Apheresis_Plasma_Separating_Kit.html {{Bare URL inline|date=May 2022}}</ref> -->
* "Mean DEHP doses for both plateletpheresis techniques (18.1 and 32.3 μg/kg/day) were close to or exceeded the reference dose (RfD) of the US EPA and tolerable daily intake (TDI) value of the EU on the day of the apheresis. Therefore, margins of safety might be insufficient to protect especially young men and women in their reproductive age from effects on reproductivity. At present, discontinuous-flow devices should be preferred to avert conceivable health risks from plateletpheresis donors. Strategies to avoid DEHP exposure of donors during apheresis need to be developed."<ref>{{cite journal |doi=10.1016/j.ijheh.2005.07.001 |title=Di(2-ethylhexyl)phthalate (DEHP) exposure of voluntary plasma and platelet donors |year=2005 |last1=Koch |first1=Holger M. |last2=Angerer |first2=Jürgen |last3=Drexler |first3=Hans |last4=Eckstein |first4=Reinhold |last5=Weisbach |first5=Volker |journal=International Journal of Hygiene and Environmental Health |volume=208 |issue=6 |pages=489–98 |pmid=16325559|bibcode=2005IJHEH.208..489K }}</ref>

=== Therapy ===

[[Image:Platelet apheresis.jpg|thumb|480px|The assembly (A–D), operation (E) and disassembly (F) of the platelet apheresis machine, which can be configured to separate other components as well]]
<!--:''Please refer to the individual apheresis methods for use in diseases''-->

The various apheresis techniques may be used whenever the removed constituent is causing severe symptoms of disease. Generally, apheresis has to be performed fairly often, and is an invasive process. It is therefore only employed if other means to control a particular disease have failed, or the symptoms are of such a nature that waiting for medication to become effective would cause suffering or risk of complications.  For autoimmune diseases in which apheresis is effective, it is used not as a standalone treatment, but rather in conjunction with therapies that reduce production of autoantibodies.
* [[Plasma exchange]] – removal of the liquid portion of blood to remove harmful substances.  The plasma is replaced with a replacement solution.
* [[LDL apheresis]] – removal of [[low density lipoprotein]] in patients with [[familial hypercholesterolemia]].
* [[Lipoprotein(a)]] (Lp(a) apheresis<ref name="CDCLp(a)">{{cite web |title=Lipoprotein (a) |url=https://www.cdc.gov/genomics/disease/lipoprotein_a.htm |website=[[CDC]] Office of Science (OS), Office of Genomics and Precision Public Health |date=5 July 2022 |publisher=[[U.S. Department of Health & Human Services]] |access-date=14 September 2022}}</ref>
* [[Photopheresis]] – used to treat [[graft-versus-host disease]], [[cutaneous T-cell lymphoma]], and [[transplant rejection|rejection in heart transplantation]].
* Immunoadsorption with Staphylococcal [[protein A]]-agarose column – removal of allo- and autoantibodies (in autoimmune diseases, transplant rejection, hemophilia) by directing plasma through protein A-agarose columns. Protein A is a cell wall component produced by several strains of Staphylococcus aureus which binds to the Fc region of IgG.
* [[Leukoreduction|Leukocytapheresis]] – removal of malignant white blood cells in people with leukemia and very high white blood cell counts causing symptoms.
* [[Erythrocytapheresis]] – removal of erythrocytes (red blood cells) in people with [[iron overload]] as a result of [[Hereditary haemochromatosis]].  This process is also used for [[exchange transfusion]] in severe malaria, or in sickle cell patients with specific indications such as acute chest syndrome or stroke. 
* [[Thrombocytapheresis]] – removal of platelets in people with symptoms from extreme elevations in platelet count such as those with [[essential thrombocythemia]] or [[polycythemia vera]].

==Indications==
[[File:Platelets collected by using apheresis.jpg|thumb|right|Platelets collected by using apheresis at an [[American Red Cross]] donation center]]

===ASFA categories===

In 2023,<ref>{{cite journal |last1=Connelly-Smith |first1=Laura |last2= Alquist|first2= Caroline|last3= Aqui|first3= Nicole|last4= Hofmann|first4= Jan|last5= Klingel|first5= Reinhard|last6= Onwuemene |first6= Oluwatoyosi|last7= Patriquin|first7= Christopher |last8= Pham|first8= Huy|last9= Sanchez|first9= Amber|last10= Schneiderman|first10= Jennifer|last11= Witt|first11= Volker|last12= Zantek|first12= Nicole|last13= Dunba|first13= Nancy |display-authors=5 |date=2023 |title= Guidelines on the Use of Therapeutic Apheresis in Clinical Practice — Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Ninth Special Issue. |journal=The Journal of Clinical Apheresis |volume=38 |issue=2 |pages=77–278 |doi=10.1002/jca.22043 |pmid=37017433 }}</ref> the [[American Society for Apheresis]] published the 9th Special Edition of [[Evidence-based medicine|evidence based guidelines]] for the practice of Apheresis Medicine.  These guidelines are based upon a systematic review of available scientific literature.  Clinical utility for a given disease is denoted by assignment of an '''ASFA Category''' (I – IV).  The quality and strength of evidence are denoted by standard [[Evidence-based medicine#GRADE working group|GRADE]] recommendations. ASFA Categories are defined as follows:
* '''Category I''' for disorders where therapeutic apheresis is accepted as a first line treatment,
* '''Category II''' for disorders where therapeutic apheresis is accepted as a second-line treatment,
* '''Category III''' for disorders where the optimal role of therapeutic apheresis is not clearly established and
* '''Category IV''' for disorders where therapeutic apheresis is considered ineffective or harmful.


===Diseases and disorders===
Only diseases (or mentioned special conditions thereof) with ASFA category I or II are displayed in '''bold''', with category I being <u>underlined</u> in addition.

{|class="wikitable"
! Disease !! Special condition
!colspan=2| [[ABO-incompatible transplantation|ABO-incompatible]] [[hematopoietic stem cell transplantation]]
| [[Plasmapheresis]] || II
|-
!rowspan=3| [[ABO-incompatible transplantation|ABO-incompatible]] solid [[organ transplantation]]
| '''Kidney'''|| rowspan="3" | [[Plasmapheresis]] || II
|-
| '''Heart (<40 months of age)'''|| II
|-
| Liver ([[perioperative]]) || III
|-
!colspan=2| [[Acute disseminated encephalomyelitis]]
| [[Plasmapheresis]] || II
|-
!colspan=2| [[Acute inflammatory demyelinating polyneuropathy|<u>Acute inflammatory demyelinating polyneuropathy</u>]]
| [[Plasmapheresis]] || I
|-
|colspan=2| [[Acute liver failure]] || [[Plasmapheresis]] || III
|-
| [[Age-related macular degeneration]] (AMD) || Dry AMD || [[Rheopheresis]] || III
|-
|colspan=2| Systemic [[amyloidosis]] || [[Plasmapheresis]] || IV
|-
|colspan=2| [[Amyotrophic lateral sclerosis]] || [[Plasmapheresis]] || IV
|-
!rowspan=3| [[Anti-neutrophil cytoplasmic antibody]]-associated [[rapidly progressive glomerulonephritis]]
| Dialysis dependence|| rowspan="3" | [[Plasmapheresis]] || III
|-
| Diffuse alveolar [[hemorrhage]] (DAH)|| III
|-
| Dialysis independence || III
|-
!rowspan=3| [[Goodpasture syndrome]]
| '''<u>Dialysis independence</u>'''|| rowspan="3" | [[Plasmapheresis]] || I
|-
| '''<u>Diffuse alveolar hemorrhage (DAH)</u>'''|| I
|-
| Dialysis dependence and no DAH || III
|-
!rowspan=2| [[Aplastic anemia]] or [[pure red cell aplasia]]
| [[Aplastic anemia]] ||rowspan=2| [[Plasmapheresis]] || III
|-
| '''[[Pure red cell aplasia]]''' || II
|-
!rowspan=2| [[Autoimmune hemolytic anemia]]
| [[Warm antibody autoimmune hemolytic anemia]] ||rowspan=2| [[Plasmapheresis]] || III
|-
| '''[[Cold agglutinin disease]], life-threatening'''|| II
|-
!rowspan=2| [[Babesiosis]]
| '''<u>Severe</u>'''|| rowspan="2" | [[Erythrocytapheresis]] || I
|-
| '''High-risk population'''|| II
|-
|colspan=2| [[Burn]] with [[Shock (circulatory)|circulatory shock]] || [[Plasmapheresis]] || IV
|-
!rowspan=3| [[Heart transplant]] with allograft
| '''<u>Prophylaxis of rejection</u>'''|| rowspan="2" | [[Photopheresis]] || I
|-
| '''Treatment of rejection'''|| II
|-
| '''<u>Treatment of antibody-mediated rejection</u>'''|| [[Plasmapheresis]] || I
|-
!colspan=2| [[Catastrophic antiphospholipid syndrome|<u>Catastrophic antiphospholipid syndrome</u>]]
| [[Plasmapheresis]] || I
|-
!colspan=2| [[Rasmussen's encephalitis]]
| [[Plasmapheresis]] or [[immunoadsorption]] || II
|-
!colspan=2| [[Chronic inflammatory demyelinating polyneuropathy|<u>Chronic inflammatory demyelinating polyneuropathy</u>]]
| [[Plasmapheresis]] || I
|-
|colspan=2 rowspan=2| [[Coagulation factor]] inhibitors || [[Immunoadsorption]] || III
|-
| [[Plasmapheresis]] || III
|-
!rowspan=2| [[Cryoglobulinemia]]
| '''<u>Severe/symptomatic</u>'''|| [[Plasmapheresis]] || II
|-
| '''Secondary to [[Hepatitis C]]'''|| [[Immunoadsorption]] || II
|-
!rowspan=2| [[Cutaneous T cell lymphoma]]: [[mycosis fungoides]] or [[Sézary disease]]
| '''<u>Erythrodermic</u>'''|| rowspan="2" | [[Photopheresis]] || I
|-
| Non-erythrodermic || III
|-
|colspan=2 rowspan=2| [[Dermatomyositis]] or [[polymyositis]] || [[Plasmapheresis]] || IV
|-
| [[Leukapheresis]] || IV
|-
| [[Dilated cardiomyopathy]] || [[New York Heart Association Functional Classification|NYHA class]] II-IV || [[Immunoadsorption]] or [[plasmapheresis]] || III
|-
!rowspan=3| [[Familial hypercholesterolemia]]
| '''<u>Homozygotes</u>'''|| rowspan="2" | [[LDL apheresis]] || I
|-
| '''Heterozygotes'''|| II
|-
| '''Homozygotes with small blood volume'''|| [[Plasmapheresis]] || II
|-
! [[Focal segmental glomerulosclerosis]]
| '''<u>Recurrent</u>'''|| [[Plasmapheresis]] || I
|-
!rowspan=2| [[Graft-versus-host disease]]
| '''Skin'''|| rowspan="2" | [[Photopheresis]] || II
|-
| Non-skin || II
|-
! [[Hemolytic disease of the fetus and newborn]]
| '''Before intrauterine transfusion availability'''|| [[Plasmapheresis]] || III
|-
|colspan=2| [[Hereditary haemochromatosis]] || [[Erythrocytapheresis]] || III
|-
!rowspan=3| [[Hemolytic–uremic syndrome]] (HUS)
| '''Atypical HUS due to mutations in complement factor genes'''|| rowspan="3" | [[Plasmapheresis]] || II
|-
| '''<u>Atypical HUS due to [[factor H]] autoantibodies</u>'''|| I
|-
| Typical HUS, or diarrhea-associated HUS || III
|-
!rowspan=2| [[Leukocytosis]]
| '''<u>[[Leukostasis]]</u>'''|| rowspan="2" | [[Leukapheresis]] || III
|-
| Prophylaxis of leukostasis || III
|-
!rowspan=2| [[Hyperviscosity]] in [[monoclonal gammopathy]]
| '''<u>Treatment of symptoms</u>'''|| rowspan="2" | [[Plasmapheresis]] ||rowspan=2| I
|-
| '''<u>Prophylaxis in [[rituximab]]</u>'''
|-
|colspan=2| Immune thrombocytopenic purpura || [[Plasmapheresis]] || IV
|-
|colspan=2| [[Immune complex]]-type of [[rapidly progressive glomerulonephritis]] || [[Plasmapheresis]] || III
|-
|colspan=2| [[Inclusion body myositis]] || [[Plasmapheresis]] or [[leukapheresis]] || IV
|-
!colspan=2| [[Inflammatory bowel disease]]
| [[Leukapheresis]] || II
|-
!rowspan=3| [[Kidney transplantation]]
| '''<u>Antibody-mediated rejection</u>'''|| rowspan="3" | [[Plasmapheresis]] || I
|-
| '''<u>Desensitization in living donor in positive crossmatch due to donor specific HLA antibody</u>'''|| I
|-
| High [[Panel-reactive antibody|PRA]] and cadaveric donor || III
|-
!colspan=2| [[Lambert–Eaton myasthenic syndrome]]
| [[Plasmapheresis]] || II
|-
! [[Lung transplantation]]
| '''Allograft rejection'''|| [[Plasmapheresis]] || II
|-
! [[Malaria]]
| '''Severe'''|| [[Erythrocytapheresis]] || II
|-
!rowspan=2| [[Multiple sclerosis]]
| '''Acute [[inflammatory demyelinating diseases of the central nervous system]], unresponsive to steroids'''|| rowspan="2" | [[Plasmapheresis]] || II
|-
| Chronic progressive || III
|-
!rowspan=2| [[Myasthenia gravis]]
| '''<u>Moderate to severe</u>'''|| rowspan="2" | [[Plasmapheresis]] || I
|-
| '''<u>Pre-[[thymectomy]]</u>'''|| I
|-
!colspan=2| [[Myeloma cast nephropathy]]
| [[Plasmapheresis]] || II
|-
|colspan=2| [[Nephrogenic systemic fibrosis]] || [[Photopheresis]] or [[Plasmapheresis]] || III
|-
!colspan=2| [[Neuromyelitis optica]]
| [[Plasmapheresis]] || II
|-
!rowspan=2| [[Venom]]s, [[poisoning]] and [[overdose]]
| '''[[Mushroom poisoning]]''' ||rowspan=2| [[Plasmapheresis]] || II
|-
| Other || III
|-
| [[Paraneoplastic syndrome]] || Neurologic || [[Plasmapheresis]] or [[immunoadsorption]] || III
|-
| [[Pancreatitis]] || Secondary to [[hypertriglyceridemia]] || [[Plasmapheresis]] || III
|-
!rowspan=3| [[Polyneuropathy]] due to [[monoclonal gammopathy]]
| '''<u>IgG, IgA or IgM</u>'''|| rowspan="2" | [[Plasmapheresis]] || I
|-
| [[Multiple myeloma]] || III
|-
| IgG/IgA or IgM || [[Immunoadsorption]] || III
|-
!colspan=2| <u>[[PANDAS]] and [[Sydenham's chorea]]</u>
| [[Plasmapheresis]] || I
|-
|colspan=2 rowspan=2| [[Pemphigus vulgaris]] || [[Plasmapheresis]] || IV
|-
| [[Photopheresis]] || III
|-
!colspan=2| [[Refsum disease]]
| [[Plasmapheresis]] || II
|-
|colspan=2| [[Polycythemia vera]] or [[erythrocytosis]] || [[Erythrocytapheresis]] || III
|-
|colspan=2| [[POEMS syndrome]] || [[Plasmapheresis]] || IV
|-
|colspan=2| [[Post-transfusion purpura]] || [[Plasmapheresis]] || III
|-
|colspan=2| [[Psoriasis]] || [[Plasmapheresis]] || IV
|-
! [[Rheumatoid arthritis]]
| '''Refractory'''|| [[Immunoadsorption]] || II
|-
|colspan=2| [[Schizophrenia]] || [[Plasmapheresis]] || IV
|-
|colspan=2 rowspan=2| [[Systemic scleroderma]]
| [[Plasmapheresis]] || III
|-
| [[Photopheresis]] || IV
|-
|colspan=2| [[Sepsis]] with [[multi-organ failure]] || [[Plasmapheresis]] || III
|-
!rowspan=4| [[Sickle cell disease]]
| '''<u>Acute [[stroke]]</u>'''|| rowspan="4" | [[Erythrocytapheresis]] || I
|-
| '''[[Acute chest syndrome]]''' || II
|-
| '''Prophylaxis of stroke or transfusional [[iron overload]]'''|| II
|-
| [[Multi-organ failure]] || III
|-
|colspan=2| [[Stiff-person syndrome]] || [[Plasmapheresis]] || IV
|-
!rowspan=2| [[Systemic lupus erythematosus]]
| '''Severe, such as [[cerebritis]] or [[diffuse alveolar hemorrhage]]'''|| rowspan="2" | [[Plasmapheresis]] || II
|-
| [[Nephritis]] || IV
|-
!rowspan=2| [[Thrombocytosis]]
| '''Symptomatic'''|| rowspan="2" | [[Plateletpheresis]] || II
|-
| Prophylactic || III
|-
!rowspan=3| [[Thrombotic microangiopathy]], drug-associated
|
* '''<u>[[Ticlopidine]]</u>'''
|rowspan=3| [[Plasmapheresis]] || I
|-
|
* [[Cyclosporine]]
* [[Tacrolimus]]
* [[Clopidogrel]]
| III
|-
|
* [[Gemcitabine]]
* [[Quinine]]
| IV
|-
|colspan=2| [[Thrombotic microangiopathy]], [[hematopoietic stem cell transplantation]]-related
| [[Plasmapheresis]] || III
|-
!colspan=2| [[Thrombotic thrombocytopenic purpura|<u>Thrombotic thrombocytopenic purpura</u>]]
| [[Plasmapheresis]] || I
|-
|colspan=2| [[Thyroid storm]] || [[Plasmapheresis]] || III
|-
! [[Wilson's disease]]
| '''<u>Fulminant hepatic failure with hemolysis</u>'''|| [[Plasmapheresis]] || I
|}

== Fluid replacement during apheresis ==

When an apheresis system is used for therapy, the system is removing relatively small amounts of fluid (not more than 10.5 mL/kg body weight). That fluid must be replaced to keep correct intravascular volume. The fluid replaced is different at different institutions. If a [[Volume expander#Types|crystalloid]] like [[normal saline]] (NS) is used, the infusion amount should be triple what is removed as the 3:1 ratio of normal saline for plasma is needed to keep up [[oncotic pressure]]. Some institutions use [[human serum albumin]], but it is costly and can be difficult to find. Routine use of [[fresh frozen plasma]] (FFP) is not generally appropriate because of the dangers including citrate toxicity (from the anticoagulant), [[ABO incompatibility]], [[infection]], and allergic reactions.  However, FFP should be used in cases of [[thrombotic thrombocytopenic purpura]] or patients at high risk of bleeding.

== See also ==
* [[Leukoreduction]]
* [[Plasmapheresis]]
* [[Venipuncture]]
* [[Pediatric Apheresis]]

== References ==
{{reflist}}

== External links ==
* {{cite web |title=Double Red Cells by Apheresis |date= |work=NIH Blood Bank: Types of Donations |publisher=NIH Clinical Center |url=https://www.cc.nih.gov/blooddonor/donationtypes/red_cells.html}}
* [https://www.apheresis.org American Society for Apheresis]
* [https://web.archive.org/web/20050408114722/http://medlib.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BBAPHER.html WebPath] Apheresis page.
* [https://web.archive.org/web/20041205170749/http://medlib.med.utah.edu/WebPath/TUTORIAL/BLDBANK/BBPROC.html WebPath] Blood Donation and Processing
* [https://web.archive.org/web/20081103014400/http://www.thebloodconnection.org/blood_products.aspx#platelets Donating Platelet Apheresis: Facts and the FAQ]

{{transfusion medicine}}

[[Category:Hematology]]
[[Category:Medical treatments]]
[[Category:Nephrology procedures]]
[[Category:Transfusion medicine]]
[[Category:Extracorporeal procedures]]