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WHO ARE WE AND WHAT DO WE DO?
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• Pathology Department/BMT
• Transfusion Medicine
• Medical Director – Dr. Susan Roseff
• Asst. Medical Director – Dr. K Sanford
• Jenni Anderson RN, HP(ASCP)
• Susan Walker RN
• Monica Utley RN
• Louise Watlington RN
• Renee King RN
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Accreditation
AABB
CAP
FDA
FACT
JACHO
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What is Apheresis
• Greek Word meaning to remove or
separate.
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Bone Marrow : Function
•Production of red blood cells, white cells and platelets
•170 billion red cells/day
•70 billion granulocytes/day(neutrophils, eosinophils,
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basophils)
•175 billion platelets/day
•Capable of 5-10 fold increase in production
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Stem Cells: What are they?
Life begins with stem cells from a fertilized
egg.
First as unspecialized cells that become
specialized cells.
Embryonic stem cells
Fetal stem Cells
Umbilical Cord stem cells
Adult stem cells
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• Vast majority of cells in the body are
differentiated meaning they have taken on
specialized properties and functions and
have lost their ability to generate cells of
other types e.g. skin, lungs, heart, bones.
• There is another type of cells that are less
differentiated and can give rise to other cell
types and these are the stem cells.
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Hematopeotic Stem Cells
Capable of self renewal and production of a
defined set of differentiated progenitor cells.
Progenitor cells are multipotent with no capacity
of self-renewal which differentiate and
proliferate according to their pre-programmed
destiny – Common Myeloid Progenitor
Common Lymphoid Progenitor
Megakaryocyte / Erythrocyte
Progenitor
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Stem Cells Marker
•A CD34+ cell is a cell which had the CD34 antigen on its
•surface.
•This antigen is present on stem cells and colony
•forming units as well as some other cell types.
•This cell antigen is used as a surrogate marker for
•multipotent stem cells.
•“CD” refers to the “Cluster Designation” group of the
•surface antigen.
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CD34+
Multipotential Stem Cell
Committed Stem Cells
BFU-E
CFU-Meg
CFU-GM
CFU-G
CFU-Ba
CFU-Eo
CFU-E
CFU-Ms
CFU-B
CFU-T
CFU-M
CD4/CD8
B
T
Lymphocytes
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PBSC Collection: When to Begin ?
I see lots of CD-34
cells in your
future…
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G-CSF Stimulation: How does it work ?
Less than 0.01% in peripheral without stimulation.
G-CSF
Stem Cells
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Effects of Mozobil
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How do we mobilize stem cells ?
G-CSF
CD-34
Growth factor only
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Growth factor
+
post chemo
(Cy+ G-CSF)
G-CSF
CY
CD-34
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Chemo +Growth factor
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Requirements for Apheresis
Venous access
• Peripheral access? Smallest needle #17G
• DL Dialysis type catheter (Permacath)
• Dialysis shunts
• Femoral only for limited number of
procedures (peds)
• #8F and above for DL catheter for peds
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Central Line Catheter
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Centrifuge
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Platelets
(1040)
Lympocytes
(1050-1061)
Buffy Coat
Monocytes
(1065 - 1069)
Granulocyte
(1087 - 1092)
RBC
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Chasing after Stem Cells
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PBSCC: Procedure
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How long does the procedure take?
• Large Volume (24L) collection.
• On a good day 4.5 hrs collection.
• On a not so good day maybe 5 - 6 hrs.
• On a bad day longer than 6 hrs.
• Pediatric patients usually take about 2.5hrs if we
• have good access but may take a whole day
• for line placement.
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Donor Lymphocyte Infusion (DLI)
•DLI is the infusion of Donor Lymphocytes from the
donor of stem cell graft to the graft recipient for the
purpose of combating or preventing relapse of the
cancer the patient is receiving treatment for.
•Can collect upfront during SC harvest and use part of
the stem cells for DLI
•Recruit donor at later date for collection.
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Goal for collection? How do we know when we
have enough cells??
•BMT sends orders to Apheresis to collect depending on
what kind of transplant protocol.
•Single auto transplant usually requires 5x10E6 CD34+/Kg
•Tandem transplant 8 - 10 x 10E6 CD34+/kg.
•Collections may take from 1 to 10 days to collect depending
on peripheral CD34+ cell ct.
•Collection starts when peripheral CD34+ cells is >10 - 15/uL
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Side Effects during stem cell collection
•G-CSF side effects: headache, flu like symptoms, bone pain.
•Machine is primed with Saline and ACD-A (Citrate)
•Citrate is used to prevent clotting.
•Citrate ratio:10 -14 :1 depending on plt ct.
•Citrate binds free ionized calcium to prevent blood from
•clotting.
•Citrate toxicity quite common with perioral tingling,
•peripheral/facial tingling, nausea, vomiting.
•May progress to prolong Q-T interval
• Tetany if not corrected.
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QA Management
•Very much a part of Apheresis SC
collection
•Donor Screening/Eligibility
•Donor safety
•Product Collection - culture, viability,
product purity
•Pt Engraftment and Outcome, ongoing
audits
•Lots of long meetings with BMT
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What is photopheresis
• Photopheresis (ECP) is an immunomodulating therapy treatment using the
Therakos UVR® XTS instruments.
• First introduced for the treatment of CTCL
which is only FDA approved treatment.
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Clinical Indications for ECP
• Malignancy: CTCL (ASFA Category I)
• Graft Vs Host Disease
• Organ Rejection
• Autoimmune disorders:
Systemic Sclerosis
Rheumatoid Arthritis
SLE
Crohn’s Disease
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GVHD
• Can be acute and chronic
• Acute GVHD occurs 10-18% of patients who
receive allo HSCT despite prevention with
immunosuppressive agents usually happens
within 100days.
• Happens when donor T cells recognize
recipient HLA molecules as non self and react
against those tissues.
• Caveat is that it is these donor T-lymph's that
facilitate engraftment in the marrow as well as
the graft versus leukemia effect.
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Technical Aspects
• First phase: Leukopheresis
Harvesting of WC 3 to 6 cycles depending
on extracorporeal volume tolerance by
patients.
Buffy coat mononuclear cells diverted
into a temporary collection bag.
Pt’s RBCs and plasma returned to pt
End product of 260cc to over 300cc.
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Buffy coat
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Technical Aspects of Photoactivation
Phase
• Buffy coat cells incubated with 8-Mop
and pumped through photoactivation
chamber and exposed to UVA radiation
8-Methoxypsoralen (UVADEX) induce
mitochondrial damage of T cells.
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Photopheresis
• Photopheresis induces apoptosis of the
treated.
• Reinfused apoptotic cells generate
tolerogenic antigen presenting cells
which helps restore the immune system.
• Cross linking of double strand DNA of T
cells help disrupt their proliferation
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Treatment schedule for photophersis
• In acute GVHD who are refractory to steroid
and anti rejection meds we may be asked to do
3x weekly for 8 to 12 weeks then taper to 2x
weekly or every other week.
• Chronic GVHD may start with 2x every other
week for 3 to 6 months then taper.
• cGVHD can last for years. Some patients stay
on photopheresis for a long time.
• Last treatment to be discontinued.
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• Many Thanks to Dr. Torloni
• Dr. Susan Roseff
• Apheresis nurses
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