plasma therapy training presentation
TRANSCRIPT
Asahi Kasei Medical Asahi Kasei Medical
Plasma Therapy Plasma Therapy Training ProgrammeTraining Programme
Asahi Kasei MedicalAsahi Kasei Medical
Biomembrane DialysersBiomembrane Dialysers
Polysulfone DialysersPolysulfone Dialysers
Polyacryronitrile HemofiltersPolyacryronitrile Hemofilters
Hemodialysers & FiltersHemodialysers & Filters
Blood Transfusion FiltersBlood Transfusion Filters Leukocyte Reduction FiltersLeukocyte Reduction Filters
Apheresis DevicesApheresis Devices
Plasma SeparatorPlasma Separator
Plasma Component SeparatorsPlasma Component Separators
Immunoadsorption ColumnsImmunoadsorption Columns
Plasma Perfusion ColumnPlasma Perfusion Column
Hemoperfusion ColumnHemoperfusion Column
Asahi Kasei MedicalAsahi Kasei Medical
Biomembrane Dialysers
Polysulfone Dialysers
Polyacryronitrile Hemofilters
Hemodialysers & Filters
Blood Transfusion Filters Leukocyte Reduction Filters
Apheresis DevicesApheresis Devices
Hemoperfusion ColumnHemoperfusion Column
Plasma Perfusion ColumnPlasma Perfusion Column
Immunoadsorption ColumnsImmunoadsorption Columns
Plasma Component SeparatorsPlasma Component Separators
Plasma SeparatorPlasma Separator
Apheresis Devices - 1Apheresis Devices - 1
Plasma SeparatorPlasma Separator
- Plasmaflo OP-05 Plasmaflo OP-05
- Cell-free separation of plasmaCell-free separation of plasma
- Treatment of various diseases, Treatment of various diseases,
auto-immune, neurological, etc.auto-immune, neurological, etc.
- Separated plasma can be further treatedSeparated plasma can be further treated
Plasma Component SeparatorsPlasma Component Separators
- Cascadeflo ECCascadeflo EC
- Removal of pathogens by secondary filtrationRemoval of pathogens by secondary filtration
- Purified plasma can be returned to patientPurified plasma can be returned to patient
- Treatment of various diseases, autoimmune,Treatment of various diseases, autoimmune,
neurological, etc.neurological, etc.
Apheresis Devices - 2Apheresis Devices - 2
Immunoadsorption ColumnsImmunoadsorption Columns
- TR-350, PH-350 for treatment of various diseases,TR-350, PH-350 for treatment of various diseases,
autoimmune, neurological, etc.autoimmune, neurological, etc.
Plasma Perfusion ColumnPlasma Perfusion Column
- BR-350 for treatment of liver diseases BR-350 for treatment of liver diseases
and intoxicationsand intoxications
Hemoperfusion ColumnHemoperfusion Column
- Cellsorba for whole blood perfusionCellsorba for whole blood perfusion
- Removal of LeucocytesRemoval of Leucocytes
- Treatment of IBDTreatment of IBD
Plasma TherapyPlasma Therapy 1902 1902 Washing and return of blood from uraemic patientWashing and return of blood from uraemic patient
1944 1944 Frequent plasma separation possible – plasma Frequent plasma separation possible – plasma
required during the warrequired during the war
1952 1952 Manual plasmapheresis first used therapeuticallyManual plasmapheresis first used therapeutically 1965 1965 First continuous flow cell separator – buffy coat First continuous flow cell separator – buffy coat
removal possibleremoval possible 1970's 1970's Plasma exchange for Goodpastures / MGPlasma exchange for Goodpastures / MG
1980's 1980's Plasmapheresis programmes for routine collection Plasmapheresis programmes for routine collection
of blood productsof blood products 1990’s 1990’s Treatment of plasma componentsTreatment of plasma components
2000’s 2000’s Improvement in whole blood technologies to replace Improvement in whole blood technologies to replace
some plasma treatmentssome plasma treatments
Plasma TherapyPlasma Therapy
REMOVAL OF ANTIBODIESREMOVAL OF ANTIBODIES
Allo-antibodies e.g. Anti - Rh(D)Allo-antibodies e.g. Anti - Rh(D) Auto-antibodies e.g. M.G., Goodpastures Disease.Auto-antibodies e.g. M.G., Goodpastures Disease. Immune Complexes e.g. SLEImmune Complexes e.g. SLE
REMOVAL OF EXCESSIVE OR ABNORMAL SUBSTANCES REMOVAL OF EXCESSIVE OR ABNORMAL SUBSTANCES
ParaproteinsParaproteins
Cholesterol in HypercholesterolaemiaCholesterol in Hypercholesterolaemia
REMOVAL OF TOXINS REMOVAL OF TOXINS
Protein-bound Drugs / ToxinsProtein-bound Drugs / Toxins
Mushroom PoisonsMushroom Poisons
Plasma ExchangePlasma Exchange
Double FiltrationDouble Filtration
ImmunoadsorptionImmunoadsorption
Removal of pathogenic substance by replacing Removal of pathogenic substance by replacing
plasma with the same volume of fresh frozen plasma with the same volume of fresh frozen
plasma (FFP) or substitution fluidplasma (FFP) or substitution fluid
Plasma TherapyPlasma Therapy
CentrifugationCentrifugation Continuous or IntermittentContinuous or Intermittent
More common in Haematology DepartmentsMore common in Haematology Departments
Citrate Anti-coagulationCitrate Anti-coagulation
Membrane SeparationMembrane Separation Continuous (Usually) or IntermittentContinuous (Usually) or Intermittent
More common in Nephrology DepartmentsMore common in Nephrology Departments
Heparin Anti-coagulationHeparin Anti-coagulation
Plasma ExchangePlasma Exchange
Component collection:Component collection: Peripheral Blood Stem CellsPeripheral Blood Stem Cells (CD34+) for bone marrow transplant, Lymphocytes, Platelets, (CD34+) for bone marrow transplant, Lymphocytes, Platelets,
Therapeutic Procedures:Therapeutic Procedures: Plasma Exchange, Plasma Exchange,
Therapeutic Red Cell applications, Cellular DepletionsTherapeutic Red Cell applications, Cellular Depletions
e.g. Haemonetics e.g. Haemonetics MCSMCS
CentrifugationCentrifugation
e.g.e.g. Gambro BCT Gambro BCT COBE SpectraCOBE Spectra
AdvantagesAdvantages Can be used to prepare cell subsetsCan be used to prepare cell subsets
e.g. Granulocytes, Plateletse.g. Granulocytes, Platelets
DisadvantagesDisadvantages Possible cell/platelet lossPossible cell/platelet loss Reactions to Citrate anticoagulantReactions to Citrate anticoagulant
CentrifugationCentrifugation
Membrane SeparationMembrane Separation
Blood returned to patientBlood returned to patient
Substitution Substitution Fluid Fluid
RequiredRequired
Plasma Separation MembranePlasma Separation Membrane
The large pores of the membrane The large pores of the membrane allow plasma, proteins and allow plasma, proteins and pathogens to pass through and pathogens to pass through and be discarded. be discarded. Cells and platelets are retained. Cells and platelets are retained. Substitution fluid is added and the Substitution fluid is added and the treated blood is returned to the treated blood is returned to the patient.patient.
Whole Blood from patientWhole Blood from patient
Separated PlasmaSeparated Plasma
AdvantagesAdvantages Cell-free plasmaCell-free plasma No Platelet lossNo Platelet loss Lower Protein lossLower Protein loss
DisadvantagesDisadvantages No collection of cell fractionsNo collection of cell fractions Reactions to membraneReactions to membrane
Membrane SeparationMembrane Separation
Circuit Diagram for Plasma ExchangeCircuit Diagram for Plasma Exchange
Plasma ExchangePlasma Exchange
Plasma is removed and discarded
Plasmaflo
Replacement fluid
Pump
Pump
PumpAnticoagulant
e.g. Patient Weight = 52 kg and Haematocrit = 40%e.g. Patient Weight = 52 kg and Haematocrit = 40%
11 ( 40 )( 40 )PPV = 52 x ----- x PPV = 52 x ----- x ( 1 - --------- ) ( 1 - --------- )
1313 ( 100 ) ( 100 )
= 2.4 Litres= 2.4 Litres
Treatment Volume:Treatment Volume: THEORETICALLY: 1 X PATIENT PLASMA VOLUME *THEORETICALLY: 1 X PATIENT PLASMA VOLUME *
PATIENTPATIENT 1 1 ( HAEMATOCRIT ) ( HAEMATOCRIT )PLASMAPLASMA = BODY WEIGHT x ----- x ( 1 - ------------------------ )= BODY WEIGHT x ----- x ( 1 - ------------------------ )VOLUMEVOLUME 13 13 ( 100 ) ( 100 )
* * AJUSTED IN ACCORDANCE WITH PATIENT'S CONDITION AND DOCTOR'S ADVICEAJUSTED IN ACCORDANCE WITH PATIENT'S CONDITION AND DOCTOR'S ADVICE
ACCESS:ACCESS:
Blood FlowBlood Flow 60 - 100 ml/min (Plasma Flow 20 - 30 ml/min) 60 - 100 ml/min (Plasma Flow 20 - 30 ml/min)
Double Lumen CatheterDouble Lumen Catheter Femoral or Subclavian VeinFemoral or Subclavian Vein
NeedleNeedle > 18G – Femoral, Subclavian or Brachial Vein> 18G – Femoral, Subclavian or Brachial Vein
ANTICOAGULATION:ANTICOAGULATION:
Heparin *Heparin * 2,000 - 3,000 Units at beginning of treatment2,000 - 3,000 Units at beginning of treatment
20 - 40 Units / kg per hour during treatment20 - 40 Units / kg per hour during treatment
* AJUSTED IN ACCORDANCE WITH PATIENT'S CONDITION AND DOCTOR'S ADVICE* AJUSTED IN ACCORDANCE WITH PATIENT'S CONDITION AND DOCTOR'S ADVICE
Access & AnticoagulationAccess & Anticoagulation
LOCATIONLOCATION
DIFFERENCESDIFFERENCES
METHODMETHOD
ANTI-COAGULATIONANTI-COAGULATION
EFFICIENCY FOR PLASMA EFFICIENCY FOR PLASMA PROTEIN /PROTEIN / REMOVALREMOVAL
MECHANISM OF SEPARATIONMECHANISM OF SEPARATION
CITRATECITRATE
CENTRIFUGATIONCENTRIFUGATION
HAEMATOLOGY, HAEMATOLOGY, BLOOD BANKSBLOOD BANKS
CELL COLLECTION POSSIBLECELL COLLECTION POSSIBLE
EQUALEQUAL
DENSITY : CENTRIFUGAL FORCEDENSITY : CENTRIFUGAL FORCE
MEMBRANEMEMBRANE
NEPHROLOGY, NEPHROLOGY, NEUROLOGYNEUROLOGY
HEPARINHEPARIN
CELL FREE PLASMACELL FREE PLASMA
EQUALEQUAL
SIZE : FILTRATIONSIZE : FILTRATION
Comparison of MethodsComparison of Methods
Plasma ExchangePlasma Exchange
Double FiltrationDouble Filtration
ImmunoadsorptionImmunoadsorption
Selective removal of large molecules or pathogenic Selective removal of large molecules or pathogenic
substances by filtration of separated plasmasubstances by filtration of separated plasma
Plasma TherapyPlasma Therapy
Plasma TherapyPlasma TherapyViral Contamination in Transfusion / Substitution ProductsViral Contamination in Transfusion / Substitution ProductsViral Contamination in Transfusion / Substitution ProductsViral Contamination in Transfusion / Substitution Products
Plasma ProductPlasma Product Transmitted Virus / Prion Transmitted Virus / Prion YearYear CountryCountry
i.v. Igi.v. Ig Hepatitis C Hepatitis C 19941994 GermanyGermany
Creutzfeld-JakobCreutzfeld-Jakob 19981998 GermanyGermany
Clotting FactorClotting Factor HIV HIV 19901990 GermanyGermany
Hepatitis BHepatitis B 19941994 GermanyGermany
Substitution Products Hepatitis ASubstitution Products Hepatitis A 19961996 GermanyGermany
Parvovirus B19Parvovirus B19 GermanyGermany
Creutzfeld-JakobCreutzfeld-Jakob 19981998 Canada/USA Canada/USA
AlbuminAlbumin Creutzfeld-Jakob Creutzfeld-Jakob 19981998 USAUSA
FFPFFP Parvovirus B19 Parvovirus B19 19991999 USAUSA
Plasma ProductPlasma Product Transmitted Virus / Prion Transmitted Virus / Prion YearYear CountryCountry
i.v. Igi.v. Ig Hepatitis C Hepatitis C 19941994 GermanyGermany
Creutzfeld-JakobCreutzfeld-Jakob 19981998 GermanyGermany
Clotting FactorClotting Factor HIV HIV 19901990 GermanyGermany
Hepatitis BHepatitis B 19941994 GermanyGermany
Substitution Products Hepatitis ASubstitution Products Hepatitis A 19961996 GermanyGermany
Parvovirus B19Parvovirus B19 GermanyGermany
Creutzfeld-JakobCreutzfeld-Jakob 19981998 Canada/USA Canada/USA
AlbuminAlbumin Creutzfeld-Jakob Creutzfeld-Jakob 19981998 USAUSA
FFPFFP Parvovirus B19 Parvovirus B19 19991999 USAUSA
Willkommen H, Anästhesiol Intensivmed Notfallmed Schmerzther 34: 497-500, 1999 and Dev Biol Stand 99: 131-138, 1999Willkommen H, Anästhesiol Intensivmed Notfallmed Schmerzther 34: 497-500, 1999 and Dev Biol Stand 99: 131-138, 1999FDA USA: fda.gov/opacom/7alerts.html: Product Recalls, Alerts, and Warnings, 2000FDA USA: fda.gov/opacom/7alerts.html: Product Recalls, Alerts, and Warnings, 2000
Second FilterSecond Filter
Double FiltrationDouble FiltrationWhole Blood from patientWhole Blood from patient
Separated Separated PlasmaPlasma
Blood returned Blood returned to patientto patient
Substitution Fluid
may be required
Substitution fluid may be added Substitution fluid may be added and the treated blood / plasma and the treated blood / plasma is returned to the patient. is returned to the patient. Purified Purified
PlasmaPlasma
First FilterFirst Filter
DiscardDiscard
The large pores of the first filter The large pores of the first filter membrane allow plasma, proteins membrane allow plasma, proteins and pathogens to pass through and and pathogens to pass through and into the second filter.into the second filter.
The second filter, of The second filter, of smaller pore size, smaller pore size, selectively removes selectively removes pathogenic substances pathogenic substances from the plasma.from the plasma.
Pathogenic substances and Pathogenic substances and some plasma are discarded.some plasma are discarded.
Circuit Diagram for Double FiltrationCircuit Diagram for Double Filtration
Double FiltrationDouble Filtration
Plasmaflo
Pump
Pump
Pump
Replacement fluid
Cascadeflo
Discard
Anticoagulant
AdvantagesAdvantages More selective than Plasma ExchangeMore selective than Plasma Exchange Returns purified plasma to the patientReturns purified plasma to the patient Minimal loss of patientMinimal loss of patient’’s own desirable non-s own desirable non-
pathogenic substancespathogenic substances Minimal Albumin lossMinimal Albumin loss Minimal substitution fluid required Minimal substitution fluid required –– no FFP no FFP Minimal risk of infection from substitution fluidsMinimal risk of infection from substitution fluids Reduces possible protein allergy to substitution fluidReduces possible protein allergy to substitution fluid Fibrinogen loss is small and regenerates within 48 Fibrinogen loss is small and regenerates within 48
hourshours
Double FiltrationDouble Filtration
DisadvantagesDisadvantages Semi-selectiveSemi-selective Some Some ““goodgood”” components of similar size components of similar size
and Molecular Weight to pathogen may and Molecular Weight to pathogen may also be lostalso be lost
Some Fibrinogen is lost, but loss is small Some Fibrinogen is lost, but loss is small and regenerates within 48 hoursand regenerates within 48 hours
Reactions to membrane Reactions to membrane
Double FiltrationDouble Filtration
PromotionPromotion Introduced most easily where Plasma Introduced most easily where Plasma
Exchange is already carried out Exchange is already carried out –– simple simple extension of the treatment principleextension of the treatment principle
Better long-term therapy for patients than Better long-term therapy for patients than Plasma Exchange or Drug therapyPlasma Exchange or Drug therapy
May need to establish links to other treating May need to establish links to other treating physicians e.g. immunologistsphysicians e.g. immunologists
Double FiltrationDouble Filtration
Plasma ExchangePlasma Exchange
Double FiltrationDouble Filtration
ImmunoadsorptionImmunoadsorption Selective adsorption of pathogenic substances from Selective adsorption of pathogenic substances from
separated plasmaseparated plasma
Plasma TherapyPlasma Therapy
BiologicalBiological Antigen Antigen –– Antibody Binding e.g. Anti-LDL Ab for LDL Antibody Binding e.g. Anti-LDL Ab for LDL Complement Binding e.g. C1q for Immune ComplexesComplement Binding e.g. C1q for Immune Complexes Fc Binding e.g. Protein A for Immune Complexes, IgG Fc Binding e.g. Protein A for Immune Complexes, IgG
PhysicochemicalPhysicochemical Hydrophobic e.g. Tryptophan and Phenylalanine for Hydrophobic e.g. Tryptophan and Phenylalanine for
Immune Complexes, RA Factor, Anti-AchR Antibodies, Immune Complexes, RA Factor, Anti-AchR Antibodies, Anti-DNA AntibodiesAnti-DNA Antibodies
Ionic e.g. Ion Exchange Resin for Bilirubin adsorptionIonic e.g. Ion Exchange Resin for Bilirubin adsorption
Affinity Type AdsorbentsAffinity Type Adsorbents
First FilterFirst Filter
Blood returned Blood returned to patientto patient
Purified PlasmaPurified Plasma
AdsorptionAdsorptionColumnColumn
ImmunoadsorptionImmunoadsorption
NoSubstitution
Fluid required
The treated blood / plasma The treated blood / plasma is returned to the patient. is returned to the patient.
Separated Separated PlasmaPlasma
Whole Blood from patientWhole Blood from patient The large pores of the first The large pores of the first filter membrane allow plasma, filter membrane allow plasma, proteins and pathogens to proteins and pathogens to pass through and into the pass through and into the adsorption columnadsorption column
The adsorption The adsorption column selectively column selectively removes pathogenic removes pathogenic substances from the substances from the plasma.plasma.
Circuit Diagram for ImmunoadsorptionCircuit Diagram for Immunoadsorption
ImmunoadsorptionImmunoadsorption
Plasmaflo
Pump
Pump
Immusorba
ParticleFilter
Anticoagulant
AdvantagesAdvantages More selective than Plasma ExchangeMore selective than Plasma Exchange Wide area of applicationWide area of application Selective removal based on Hydrophobic adsorptionSelective removal based on Hydrophobic adsorption Ligand is harmless, physiological Amino AcidLigand is harmless, physiological Amino Acid Returns purified plasma to the patientReturns purified plasma to the patient Minimal loss of patientMinimal loss of patient’’s own desirable non-pathogenic s own desirable non-pathogenic
substancessubstances No substitution fluid requiredNo substitution fluid required No risk of infection from substitution fluidsNo risk of infection from substitution fluids Eliminates possible protein allergy to substitution fluidEliminates possible protein allergy to substitution fluid Suitable for patients with protein allergySuitable for patients with protein allergy
ImmunoadsorptionImmunoadsorption
DisadvantagesDisadvantages Semi-selective Semi-selective Some Fibrinogen is lost, but loss is small and Some Fibrinogen is lost, but loss is small and
regenerates within 48 hoursregenerates within 48 hours
ImmunoadsorptionImmunoadsorption
PromotionPromotion Introduced most easily where Plasma Introduced most easily where Plasma
Exchange is already carried out Exchange is already carried out Better long-term therapy for patients than Better long-term therapy for patients than
Plasma Exchange or Drug therapyPlasma Exchange or Drug therapy May need to establish links to other treating May need to establish links to other treating
physicians e.g. immunologistsphysicians e.g. immunologists May need education programmeMay need education programme
ImmunoadsorptionImmunoadsorption
• Immune Thrombocytopenic Purpura (ITP)• Thrombotic thrombocytopenic purpura (TTPP) or hemolytic uremic syndrome (HUS)• AIDS-related ITP• Cryoglobulinemia with symptomatic hyperviscosity• Goodpasture’s syndrome in crisis• ABO-incompatible bone marrow transplant• Pure Red Cell Aplasia unresponsive to immunosuppressives• Myasthenia gravis causing severe disability• Chronic demyelinating gammopathy• Chronic relapsing polyneuropathy for severe, disabling, or life-threatening unresponsive to conventional therapy• Guillain Barre for severely ill patients (Grades 3-5)• Myeloma kidney• Waldenstrom’s macroglobulinemia• Refsum’s disease• Rheumatoid Arthritis • Severe bullous pemphigoid• Multiple Sclerosis• Severe sclerodema• Pemphigus• Polymyositis (cerebritis, myocarditis, nephritis, etc.)• Systemic Lupus Erythematosis• Lipid-apheresis / familial hypercholesterolemia / lipoprotein (a)• Chronic Idiopathic Demyelinating Polyneuropathy
Some ApplicationsSome Applications
More selective than Plasma ExchangeMore selective than Plasma Exchange
Better long-term therapy for patients than Better long-term therapy for patients than
Plasma Exchange or Drug therapyPlasma Exchange or Drug therapy
Wide are of applicationWide are of application
Easy to performEasy to perform
Plasma TherapyPlasma Therapy