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Therapeutic apheresis provides a means to rapidly alter the composition of blood components. It can be a valuable and safe initial treatment of a number of illnesses associated with quantitative and/or qualitative abnormalities of blood cells or plasma. Cell depletions are useful in symptomatic thrombocythemia and hyperleukocytosis, or to provide autologous or allogeneic stem and progenitor cells for hematopoietic reconstitution or immunocytes for immunomodulation. Plasma exchange is useful in certain paraproteinemias, antibody-mediated disorders, and toxin-mediated diseases. It also can be used to replace a deficient plasma constituent. Red cell exchange is used primarily for severe manifestations of sickle cell disease. Selective extraction techniques are available for immunoglobulin G and low-density lipoprotein, and modulation of certain immune responses is possible with photopheresis. Adverse effects with current techniques are infrequent and usually mild.

Acronyms and Abbreviations

Acronyms and abbreviations that appear in this chapter include: ADAMTS13, von Willebrand cleaving metalloproteinase; ALL, acute lymphocytic leukemia; AML, acute myelogenous leukemia; ANCAs, antineutrophil cytoplasmic antibodies; BPC, blood progenitor cell; CML, chronic myelogenous leukemia; CTCL, cutaneous T-cell lymphoma; HLA, human leukocyte antigen; HPA, human platelet alloantigen; Ig, immunoglobulin; LDL, low-density lipoprotein; MNC, mononuclear cell; SPS, stiff person syndrome; TTP, thrombotic thrombocytopenic purpura.

Therapeutic apheresis comprises a set of related techniques in which the amount or composition of a blood component is manipulated for a therapeutic purpose, usually with a continuous-flow centrifugal blood separation instrument. Available techniques are divided into three main categories: blood cell depletion, blood component exchange, and blood component modification (Table 26–1). Cell-depletion procedures usually target excess platelets or leukocytes. These procedures currently are undertaken almost exclusively for hematologic diseases. Similar techniques adapted for autologous or allogeneic leukocyte donation provide cells for transplantation and/or immunotherapy. Blood component exchanges target plasma or red cells. Plasma exchange is beneficial in a number of antibody-mediated conditions, many of which are not usually considered hematologic diseases. Specialized techniques have been developed for online selective extraction of certain individual constituents, such as immunoglobulin (Ig) G and low-density lipoproteins (LDLs), from plasma separated by an apheresis instrument, and for photochemical modification of separated lymphocytes (photopheresis).

Table 26–1. Therapeutic Apheresis Techniques

The goal of therapeutic apheresis is usually therapeutic depletion. Candidate entities for therapeutic depletion should be pathogenic and susceptible to meaningful depletion by apheresis. The latter provision implies that a substantial portion of the total body burden is intravascular and that the half-life is relatively long. In practice, this limits utility to blood cells and large, slowly catabolized plasma proteins, such as immunoglobulins and LDLs.1...

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