Michelle Vauthrin

Is group A thawed plasma suitable as the first option for emergency release transfusion? (CME).

Group AB plasma, which lacks anti‐A and anti‐B isohemagglutinins, is issued for emergency transfusion when a patients ABO group is unknown, but the relative scarcity of group AB blood donors limits its availability. We sought to establish a thawed plasma inventory to improve the rapid availability of plasma in the emergency release setting but were concerned about potential wastage of group AB plasma.

Prospective surveillance of D- recipients of D+ apheresis platelets: alloimmunization against D is not detected

Recent retrospective studies indicate that D− recipients of D+ apheresis platelets (PLTs) are not alloimmunized to D. Our hospital policy is to offer RhIG to D− women of childbearing age who received D+ apheresis PLTs but not to other D− recipients of D+ apheresis PLTs. We instituted prospective surveillance of the D− recipients who were not given RhIG.

Safety and efficacy of autologous hemopoietic progenitor cell collection in tandem with hemodialysis in multiple myeloma with myeloma cast nephropathy

Autologous hemopoietic progenitor cell (HPC) collection is the most frequent indication for an apheresis procedure in patients with multiple myeloma, up to 10% of whom may also require hemodialysis because of myeloma kidney. We investigated whether HPC collection could be performed in tandem with hemodialysis, to avoid extra outpatient visits for extracorporeal procedures, without compromising the efficacy of the hemodialysis, the HPC collection efficiency (CE) or patient safety. Four dialysis‐dependent patients with multiple myeloma underwent 5 large volume leukapheresis HPC collections in tandem with hemodialysis. Under our protocol, all of the blood processed through the apheresis instrument was dialyzed against a standard calcium‐rich bath prior to being returned to the patient, therefore no supplemental calcium was needed. No significant changes in pulse rate (P = 0.625) or mean arterial pressure (P = 0.188) were noted between the start and end of the procedures. The patients exhibited no signs or symptoms of hypocalcemia or other adverse effects. Calculated urea reduction ratios ranged between 62.5 and 73.9%, and HPC CE was between 53 and 84% for 4 of the 5 procedures, indicating that there was no compromise of either procedure when performed in tandem. Ionized calcium measured at the beginning, midpoint and end of every procedure did not change (P = 0.954). The two patients who proceeded to autologous HPC transplant engrafted on Days 11 and 10, respectively. We conclude that autologous HPC collection can safely be performed in tandem with hemodialysis without compromising the efficacy of dialysis, HPC CE, or patient safety. J. Clin. Apheresis 29:83–89, 2014.

Automated red blood cell exchange for acute drug removal in a patient with sirolimus toxicity.

Sirolimus is an immunosuppressant used to prevent graft versus host disease in allogeneic hematopoietic stem cell transplant recipients. It has a large volume of distribution (12 ± 7.5 l/kg) and within the intravascular space ∼95% of it is bound to red blood cells. Because of potential toxic effects at high trough levels, therapeutic drug monitoring is recommended for sirolimus. We present a case of severe hepatic dysfunction due to Hepatitis B and sirolimus toxicity, in a 51‐year‐old male stem cell transplant recipient. An automated red cell exchange decreased his blood sirolimus level from 22.6 to 10.3 ng/ml (55% reduction) and improved his liver enzymes. Re‐equilibration of sirolimus from other compartments to the blood necessitated a series of four red cell exchanges, after which the sirolimus level was 4.7 ng/ml. Although the patient ultimately succumbed to multiorgan failure, red cell exchange may be considered for acute removal of sirolimus in selected patients. J. Clin. Apheresis 30:367–370, 2015.

Physiological measurements corroborate symptomatic improvement after therapeutic leukapheresis in a pregnant woman with chronic myelogenous leukemia

Therapeutic leukapheresis can control the white blood cell count (WBC) of pregnant women with chronic myelogenous leukemia (CML) who have hyperleukocytosis without leukostasis. The medical justification for this treatment has not been objectively documented. We report a 27‐year‐old woman, diagnosed with CML at 10‐week gestation, who developed severe dyspnea on exertion. A workup that included chest CT and echocardiography with a bubble study detected no cardiopulmonary pathology to explain her symptoms, and thus she was referred for leukapheresis. Prior to her first leukapheresis, which lowered her WBC from 154 × 103/μL to 133 × 103/μL, her oxygen saturation (SpO2) on room air decreased from 98 to 93% during 100 feet of slow ambulation and she was dyspneic. Just after the leukapheresis, her dyspnea on exertion was much improved and her SpO2 remained at 98% with repeat ambulation. Spirometry and lung volume studies obtained before and after her first leukapheresis demonstrated 32 and 31% improvements in forced vital capacity and forced expiratory volume in 1 s respectively, a 25% increase in functional residual capacity, and a 142% improvement in expiratory reserve volume. Residual volume decreased by almost 20%. Three times in a week, leukapheresis was continued until her WBC was controlled with interferon α‐2b approximately 4 weeks later. Her dyspnea had completely resolved. She gave birth by elective caesarean section to a healthy boy at 32 weeks. Corroboration of symptom relief by leukapheresis with physiological data may justify such treatment in pregnant patients with CML. J. Clin. Apheresis 31:393–397, 2016.

Automated red blood cell exchange in preparation for filgrastim mobilization of autologous peripheral blood hematopoietic progenitor cells in a patient with sickle cell anemia

Increasing survival of patients with sickle cell anemia (SCA) well into adulthood results in a rising likelihood of developing hematological malignancy. High‐dose chemotherapy with autologous hematopoietic progenitor cell (HPC) rescue is standard of care for several hematological malignancies, but the risk of severe or life‐threatening vaso‐occlusive phenomena during filgrastim mobilization of HPC for collection poses a potential barrier to this approach. We report the use of automated red cell exchange in preparation for filgrastim mobilization in a patient with homozygous SCA. Red cell exchange was repeated just prior to high‐dose chemotherapy to mitigate the need for red cell transfusion during bone marrow reconstitution. The patient experienced no vaso‐occlusive phenomena throughout the entire episode of care and did not become iron overloaded. This approach should be considered for all patients with homozygous or compound heterozygous sickle cell disease who are candidates for auto‐HPC rescue therapy.

A liquid calcium+vitamin D3 supplement is effective prophylaxis against hypocalcemic toxicity during apheresis platelet donation

Hypocalcemic toxicity, because of return of citrate anion to the donor, is the major toxicity of apheresis platelet donation. Oral calcium carbonate, given prophylactically at the start of donation, has shown limited ability to alleviate this toxicity. We examined whether repeated prophylactic doses of calcium carbonate, or of a liquid preparation containing calcium citrate, calcium phosphate, and vitamin D3, would be more effective at preventing symptoms of hypocalcemic toxicity. Symptoms were reported by 48% of donors who received no prophylaxis and 60% of donors who received 1000 mg of oral calcium carbonate at the start of, and every 20 minutes during, donation (P = 0.711). Only 19.2% of donors who received the liquid preparation (1000 mg calcium, 1000 IU vitamin D3) reported symptoms (P = 0.040 versus no prophylaxis, P = 0.039 versus calcium carbonate). This difference was not because of gender, weight, age, or blood volume of the donor. Neither calcium preparation prevented a measurable fall in plasma ionized calcium during donation. We conclude that liquid calcium citrate/calcium phosphate/vitamin D3 provides effective prophylaxis against hypocalcemic toxicity during platelet donation, however it does not prevent a fall in plasma ionized calcium.

Therapeutic plasma exchange performed in tandem with hemodialysis without supplemental calcium in the apheresis circuit

Therapeutic plasma exchange (TPE) and hemopoietic progenitor cell (HPC) collection are apheresis procedures that can safely be performed in tandem with hemodialysis. Despite the return of citrate‐anticoagulated blood to the patient during HPC collection, it is not necessary to administer supplemental calcium during these procedures because the ionized calcium concentration is restored as the returning blood passes through the dialyzer. It is not known whether this applies to TPE, in which a mixture of blood and pharmaceutical albumin, an avid binder of plasma ionized calcium, is returned to the patient through the dialyzer. We report on three dialysis‐dependent patients who required TPE and underwent tandem treatments without supplemental calcium in the apheresis circuit. Overall, ionized calcium fell 4–12% (P = 0.0.024) and patients reported no symptoms of hypocalcemic toxicity. Tandem hemodialysis/TPE can be performed without supplemental calcium in the apheresis circuit. J. Clin. Apheresis 32:154–157, 2017.

Therapeutic apheresis using a mononuclear cell program to lower the microfilaria burden of a 23-year-old African woman with loiasis.

Apheresis has been used to lower the parasite burden of patients with Loa loa infection, but there are no reports regarding how to do this using modern, continuous flow equipment with a currently available program. A 23‐year‐old female refugee from Cameroon with known Loa loa infection presented to our Emergency Department with acute mental status changes and a picture of encephalitis. Lumbar puncture revealed Loa loa in her cerebrospinal fluid. Her midday blood microfilaria count was 15,000/mL. Because treatment with diethylcarbamazine was under consideration, we were asked to lower her parasite burden using apheresis. One single 2‐total blood volume apheresis using the mononuclear cell program (without hydroxyethyl starch) on a COBE® Spectra Apheresis System decreased the microfilarial load from 15,000/mL to 10,666/mL, a 29% reduction. J. Clin. Apheresis 32:200–202, 2017.

Prophylactic infusion of calcium gluconate to prevent a symptomatic fall in plasma ionized calcium during therapeutic plasma exchange: A comparison of two methods

We compared two methods of calcium gluconate infusion to maintain plasma ionized calcium ([Ca2+]) during therapeutic plasma exchange (TPE) performed using the Spectra Optia Apheresis System. Method A, our legacy method, consisted of adding 5 mL of 10% calcium gluconate to each 500 mL bottle of 5% albumin replacement fluid. Method B used an accessory IV infusion of calcium gluconate (2 g in 50 mL of 0.9% NaCl starting at 25 mL/h). Plasma [Ca2+] was measured at 20‐minute intervals, and symptoms of hypocalcemia were recorded during TPE. Baseline [Ca2+] was the same (P = 0.616), as was total acid citrate dextrose Formula A used (P = 0.865), with either method. TPE with method A used 2.62 ± 0.52 g of calcium gluconate vs 1.13 ± 0.27 g with method B (P < 0.001). [Ca2+] remained stable with method A (P = 0.251), but fell on average by 5% with method B (P < 0.05). Hypocalcemic symptoms were reported in 0 of 23 TPE with method A and 2 of 24 TPE with method B. We conclude that both methods A and B prevent a symptomatic fall in plasma [Ca2+] during TPE. Method B requires significantly less calcium gluconate than does method A.