Apheresis and COVID-19 in intensive care unit (ICU)
Coronavirus disease 2019 (COVID-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Accumulating evidence suggests that the severity of COVID-19 is due to high levels of circulating inflammatory mediators including cytokines and chemokines leading to cytokine storm syndrome (CSS). Patients are admitted in ICU with severe respiratory failure, but can also develop acute renal failure and multi organ failure. Advances in science and technology have permitted the development of more sophisticated therapies such as hemoperfusion, and various blood purification devices, for the treatment of ARDS and septic shock. Adsorptive granulocyte and monocyte apheresis (GMA) is an extracorporeal circulation therapy designed for selective absorption of elevated and activated myeloid lineage cells, inducing immunomodulartory effects with decrease of inflammatory cytokines. It has been shown efficacy in inflammatory bowel disease and psoriatic arthritis. In Covid-19 it has been used in one case report in a patient having comorbidity ulcerative colitis. Apart from the control of the colitis there was an unexpected improvement of the pulmonary symptoms and the septic shocK.
Chapter 53 – The use of therapeutic apheresis in allergic and immunological diseases
A Practical Guide to the Evaluation, Diagnosis and Management of Allergic and Immunologic Diseases 2022, Pages 1527-1583
Apheresis is a term for a group of extracorporeal treatments in which blood is separated into its components, with some components being discarded and replaced or subsequently modified. The replacement fluids/cells or modified components, along with the remainder of the blood, are then returned to the patient. These procedures can alter the immune system, both humoral and cellular, and have been used to treat a variety of common and uncommon immunologic diseases beginning in the late 1950s. The basic background information important for understanding those apheresis procedures used to treat immunologic disorders as well as the important patient considerations are discussed. A synopsis of immunologic diseases treated with apheresis, based upon the American Society for Apheresis Guidelines for the use of apheresis in clinical practice, is provided including treatment schedules and “dosing,” patient evaluation and laboratory monitoring, and the proposed mechanism of action. Unique considerations for each treatment, such as their effects on patient management and concurrent therapies, are also discussed. Apheresis is a group of related therapies that can effectively treat several immunologic diseases with a growing but still a limited base of published evidence.
Vascular access in therapeutic apheresis: One size does not fit all
Background: Therapeutic apheresis has been used in treating hematological and non-hematological diseases. For a successful procedure, efficient vascular access is required. Presently, peripheral venous access (PVA), central venous catheterization (CVC), implantable ports, and arteriovenous fistulas (AVFs) are used. This review aims to evaluate different type of access and their pros and cons to help physicians determine the best venous access. Methods: The electronic search included PubMed and Google Scholar up to November 2020. The Mesh terms were apheresis, peripheral catheterization, central catheterization, and arteriovenous fistula. Results: A total of 228 studies were found through database searching. Two independent authors reviewed the articles using their titles and abstracts; 88 articles were selected and the full text was reviewed. Finally, 26 were included. The inclusion criteria were studies incorporating patients with any indication for apheresis. Conclusion: PVA has been promoted in recent years in many centers across the United States to lower the rate of complications associated with vascular access and to make this procedure more accessible. Several factors are involved in selecting appropriate venous access, such as the procedure’s duration and frequency, patient’s vascular anatomy, and staff’s experience. In short-term procedures, temporary vascular access like PVA or CVC is preferred. Permanent vascular access such as AVF, tunneled cuffed central lines, and implantable ports are more beneficial in prolonged treatment period but each patient has to be evaluated individually by apheresis team for the most appropriate method.
Apheresis: A cell-based therapeutic tool for the inflammatory bowel disease
Inflammatory Bowel Disease (IBD) is a hallmark of leukocyte infiltration, followed by the release of cytokines and interleukins. Disease progression to Ulcerative Colitis (UC) or Crohn’s Disease (CD) remained largely incurable. The genetic and environmental factors disrupt enteral bacteria in the gut, which hampers the intestinal repairing capability of damaged mucosa. Commonly practiced pharmacological therapies include 5-aminosalicylic acid with corticosteroids and tumor necrosis factor (TNF)-α. New interventions such as CDP571 and TNF-blocking RDP58 report the loss of patient response. This review discusses the non-pharmacologic selective granulocyte-monocyte-apheresis (GMA) and leukocytapheresis (LCAP) that have been proposed as treatment modalities that reduce mortality. GMA, an extracorporeal vein-to-vein technique, presents a strong safety profile case for its use as a viable therapeutic option compared to GMA’s conventional medication safety profile. GMA reported minimal to no side effects in the pediatric population and pregnant women. Numerous studies report the efficacious nature of GMA in UC patients, whereas data on CD patients is insufficient. Its benefits outweigh the risks and are emerging as a favored non-pharmacological treatment option. On the contrary, LCAP uses a general extracorporeal treatment that entraps leukocytes and suppresses cytokine release. It has been deemed more efficacious than conventional drug treatments, the former causing better disease remission, and maintenance. Patients with UC/CD secondary to complications have responded well to the treatment. Side effects of the procedure have remained mild to moderate, and there is little evidence of any severe adverse event occurring in most age groups. LCAP decreases the dependence on steroids and immunosuppressive therapies for IBD. The review will discuss the role of GMA and LCAP.
Concomitant granulocyte and monocyte adsorption apheresis accelerates clinical efficacy and mucosal healing of colonic lesions in patients with active Crohn’s disease
S. Yasukawa*, F. Hirai, Y. Takada, Y. Yano Fukuoka University Chikushi , Department of Gastroenterology, Chikushino, Japan
Concomitant GMA not only improved clinical outcome but also benefited treatment of colonic mucosal lesions in
patients with CD who showed resistance to other treatments.
Granulocyte and monocyte/macrophage apheresis for the treatment of immune-mediated inflammatory arthropathies: case reports
Carro Martínez AV, Montolio Chiva L, Robustillo Villarino M. Drugs Context. 2021;10:2021-8-5. https://doi.org/10.7573/dic.2021-8-5
Drug therapy of immune-mediated inflammatory arthropathies is not always satisfactory, and there is a risk of adverse events. Granulocyte and monocyte/macrophage apheresis (GMA) is a non-pharmacological therapeutic option that is beneficial and very well tolerated. GMA involves passing blood through a column with cellulose acetate beads to remove increased and activated myeloid lineage cells and improve the cytokine profile. The technique reduces pain and inflammation. We present four clinical reports that illustrate the clinical uses of GMA with the medical device Adacolumn® in patients with different backgrounds and immune-mediated inflammatory arthritis. The results were positive, and no adverse events were reported..
Cellular immune response triggered by granulocytoapheresis in ulcerative colitis patients under biological treatment
UEG WEEK VIRTUAL 2021
GMA induces specific immunoregulatory changes in leukocyte’s subpopulations. We confirm the depletion of the
monocytes with proinflammatory phenotype after GMA. Treg and B effector cells shift to a more immunotolerant phenotype. The emergence of subpopulations with the atypical immunofluorescence staining (CXCR3+CRTH2+) related to immature T cells support the immunomodulatory effects of GMA. These findings could help to understand the pathology of UC and to identify targeted immune subpopulations for treatment
S-05-05 Efficacy and safety of cytapheresis in elderly patients with ulcerative colitis (poster)
Remission induction was more challenging in elderly UC patients. However, CAP was safe and effective for remission induction as a non-pharmacological treatment, even in elderly UC patients, after the incorporation of practical measures. Optimized and contrived CAP is still useful as the sole or concomitant treatment.
Efficacy of apheresis as maintenance therapy for patients with ulcerative colitis in an open-label prospective multicenter randomised controlled trial
Makoto Naganuma, Yoko Yokoyama, Satoshi Motoya, Kenji Watanabe, Koji Sawada, Fumito Hirai, Takayuki Yamamoto, Hiroyuki Hanai, Teppei Omori, Takanori Kanai & Toshifumi Hibi, Journal of Gastroenterology volume 55, pages390–400 (2020)
Apheresis was well tolerated as maintenance therapy for UC although the cumulative clinical remission rate at 12 months was comparable between the apheresis and control groups.
Security of therapeutic apheresis in pediatrics. prospective study during 2018 in 171 apheresis sessions
Víctor López Baez, Pedro Arango Sancho, Yolanda Calzada Baños, Elena Codina Sampera, Ana Vinuesa Jaca, Lina Hernández Zúñiga, Álvaro Madrid Aris, Nephrology Dialysis Transplantation, Volume 35, Issue Supplement_3
The apheresis techniques in pediatrics had been presented with few complications in our center, none derived from vascular access, anticoagulation, infections or adverse effects due to use of replacement fluid. The training of medical and nursing staff is essential to identify risk situations. The use of protocols and international guidelines ensure safety in pediatrics.
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