Apheresis instrument settings influence infused absolute lymphocyte count affecting survival following autologous peripheral hematopoietic stem cell transplantation in non-Hodgkin's lymphoma: the need to optimize instrument setting and define a lymphocyte collection target.

Autograft absolute lymphocyte count (A-ALC) is an independent prognostic factor for survival after autologous peripheral blood hematopoietic stem cell transplantation (APHSCT) for non-Hodgkin's lymphoma (NHL). Factors enhancing A-ALC collections are unknown. We hypothesize that apheresis instrument settings could affect A-ALC. Data from 127 NHL patients collected from 15 January 1999 to 30 July 2004 using a single apheresis instrument (COBE Spectra (SP), Baxter Amicus (AM), and CS3000 Plus (CS)) were analyzed. The primary end point of the study was to assess the correlation between apheresis instrument settings and A-ALC. The secondary end point was to determine the effect of apheresis instrument on survival post-APHSCT. Patients collected using SP achieved higher A-ALC compared to AM (with modified settings) or CS (P<0.05) and demonstrated superior overall (OS) and progression-free survival (PFS) (P<0.03). Multivariate analysis demonstrated A-ALC and not the apheresis instrument as an independent prognostic factor for OS and PFS, cancelling the prognostic effect of the apheresis instruments observed in the univariate analysis. The survival advantage observed by SP was from the higher A-ALC collected compared to AM and CS. These data suggest that apheresis instrument settings should be optimized to collect CD34(+) cells as well as an A-ALC target, with direct impact on survival post-APHSCT.

Therapeutic plasma exchange: a paired comparison of Fresenius AS104 vs. COBE Spectra.

For therapeutic plasma exchange (TPE), continuous flow separators are known to be efficient as exemplified by Fresenius AS104 and COBE Spectra. The AS104 uses an interface monitoring system in the centrifuge during TPE, whereas Spectra uses computer algorithms to establish the plasma-cell interface. To determine the plasma collection efficiency (PLCE), anticoagulant (AC) volumes used, and platelets (PLT) lost of the AS104 and the Spectra, we performed a prospective paired comparison of 20 TPE (each machine). The study included 17 patients, 1.3 plasma volume exchanges (without AC), equal inlet rates, and AC ratio of 13:1. Processing times did not include reinfuse mode. Platelet loss was determined by sampling the collection bags. Inlet rates were between 60-110 ml/min. Diagnosis included peripheral neuropathies, TTP and cryoglobulinemia. The AS104 had significantly (P<0.0001) lower average whole blood processed (F:6,601 vs. S:8,584 ml), AC volume (F:532 vs. S:719 ml), and processing time (F:80 vs. S:102 minutes) than Spectra. The AS104 had significantly (P<0.0001) higher average plasma flow rates (F:53 vs. S:44 ml/minute), plasma collection efficiency (F:90 vs. S:69%), and platelet loss (F:2.0 vs. S:0.14 x 10(11) plt) than Spectra. Platelet loss correlated with inlet flow rate with the AS104 but not with the Spectra. The AS104 has a significantly higher collection efficiency than Spectra allowing it to remove the same amount of plasma in significantly less time, by processing significantly less blood, using significantly less AC, but removing significantly more platelets than Spectra.

Prospective comparison of plateletapheresis using four apheresis systems on the same donors.

To address the demand for higher plateletapheresis efficiency while maintaining consistent leukoreduction, manufacturers of apheresis systems have introduced new equipment or modifications to existing equipment. Using the same 20 donors, we compared the Fresenius AS104 (AS104), Fenwal Amicus, and COBE Spectra Version 7 Leukoreduction System (Turbo) to the COBE Spectra Version 5 Leukoreduction System (V5-LRS) and each other in regard to platelet (plt) collection efficiencies, processing times, and leukoreduction consistency. Using current pre-procedure platelet counts, target endpoints were set at 6-6.5 x 10(11) plt or 3.3-4.0 x 10(11) plt in up to 100 minutes processing time. Median platelet yields for V5-LRS, AS104, Amicus, and Turbo were 3.98, 3.63, 5.03, and 4.99 x 10(11) plt respectively; median collection efficiencies were 53, 46, 73, and 56% respectively; median collection rates were.049,.039,.065, and. 060 x 10(11) plt/minute respectively; double product frequencies were 35, 10, 40, and 30% respectively; and median processing times were 87, 92, 77, and 79 minutes, respectively. Amicus had a significantly higher collection efficiency and higher incidence of double products than all other systems. While AS104 had a significantly lower collection efficiency and lowest double product frequency than all other systems, Amicus and Turbo had significantly lower processing times than V5-LRS and AS104. AS104 leukoreduction was inconsistent, but V5-LRS, Amicus, and Turbo were consistently leukoreduced ((99.8% had <5 x 10(6) WBC at 95% confidence interval). The best overall performance was for the Amicus with Turbo a close second.

Plateletapheresis: instrumentation validation.

Plateletapheresis instrumentation validation is required to document that a new or modified instrument or technique is capable of consistently producing acceptable products at the production center using their equipment, personnel, and counting techniques even though the instrument or technique may already have FDA or equivalent approval for use. To pursue the process of validation, several questions need to be addressed: when is it required, what products are validated, what parameters are monitored, and how many products are required. Validation is required when a new instrument or technique (process) is used that could affect the quality of the product. According to the FDA, each apheresis system (e.g., Spectra LRS, Amicus) and each type of product (e.g., single, double, triple) need to be validated separately. Parameters to be validated vary, but usually platelet (plt) yield, white blood cell (WBC) content (if products are labeled "leukoreduced"), and 5-day storage pH are monitored. The number of procedures monitored is also quite variable, but we use 20 samples for highly variable parameters such as platelet yield and WBC content and five samples for less variable parameters such as 5-day storage pH. As an example, we validated the Fenwal Amicus (Baxter Biotech) for single apheresis platelet products. With 20 samples, we found that: 85% of the products contained > or = 3 x 10(11) plt (requirement was at least 75% contain > or = 3 x 10(11) plt); platelet concentration of all products was < or = 1.515 x 10(6) plt/microL (requirement was < or = 2.435 x 10(6) plt/microL), and WBC content was < 1 x 10(6) WBC in all products (requirement was all products contain < 5 x 10(6) WBC). In addition, in five samples, the 5-day storage pH was 6.89-7.25 (requirement was all products should be > or = 6.2 pH). Once validation is complete and acceptable, the process should be monitored on a regular basis using some form of process control. Statistical process control programs are available that can assist in documenting validation and ongoing process control. With the use of process validation and ongoing process control, the plateletapheresis center can assure that acceptable products are consistently being produced.

Plateletapheresis with a next generation blood cell separator.

Procedure time has been identified as the-most important element in apheresis platelet donor retention. Fenwal has developed a next generation apheresis system, the Amicus, with the intent of efficiently producing high platelet yields with low WBC content in much shorter processing times than currently available. This report describes the Amicus and presents results of a clinical trial of an Amicus prototype and a comparison to Fenwal CS 3000+. Thirty Amicus double-needle plateletapheresis procedures were evaluated. Average processing time was 61 +/- 16 min with 63% of the processing times < or = 60 min. The average preplatelet count was 246 +/- 46 x 10(3)/microliter, platelet yield 4.4 +/- 1.2 x 10(11) plt, collection efficiency 73 +/- 14%, platelet collection rate 0.075 +/- 0.016 plt x 10(11)/min and citrate toxicity incidence 3%. A comparison of double-needle procedures, 20 Amicus and 20 CS 3000+, showed that Amicus had significantly shorter (P < .05) processing times (64 +/- 17 vs. 86 +/- 10 min) and higher (P < .05) platelet collection rates (0.070 +/- 0.017 vs. 0.054 +/- 0.018 plt x 10(11)/min) but comparable (P < .05) platelet yields (4.4 +/- 1.4 vs. 4.7 +/- 1.0 x 10(11) plt). Comparison of 13 single and 13 double-needle Amicus procedures showed comparable (P < .05) processing times (71 +/- 13 vs. 65 +/- 18 min), platelet yields (4.7 +/- 1.0 vs. 4.6 +/- 1.5 x 10(11) plt), collection efficiency (74 +/- 7 vs 74 +/- 17%), and platelet collection rates (0.068 +/- 0.020 vs 0.072 +/- 0.018 plt x 10(11)/min). Using normal probability plots of WBC content at 95% confidence level. Amicus can provide products with < 5.0 x 10(6)WBC or < 1.0 x 10(6) WBC in 99.7% or 92.7% of collections, respectively, compared with 69.0% or 44.0%, respectively, for CS 3000+. We found Amicus was able to provide equivalent quantities of platelets with less WBC content in significantly shorter processing times than CS3000+ as well as shown encouraging results for single-needle procedures.

Plateletapheresis: comparison of processing times, platelet yields, and white blood cell content with several commonly used systems.

In this study we compare processing times and platelet yields of eight systems: five double-needle (DN)--Fenwal CS3000 Plus with interface offset (IO) of 6 (Fen 6) and IO of 10 (Fen 10), a prototype Fenwal Amicus (AM-DN), Spectra version 4 (Spec 4-DN) and version 5 with leukoreduction system (Spec 5-LRS); and three single-needle (SN) systems--Haemonetics MCS Plus (MCS+), prototype Amicus (AM-SN), and Spectra version 4 (Spec 4-SN). Twenty-five procedures from each of the systems (except AM-SN, N = 13) were compared; each system had comparable preprocedure platelet counts and similar endpoints. Five systems--MCS+, Fen 6, Fen 10 with leukoreduction filter (MCS + LRF), (Fen 6 LRF), (Fen 10 LRF), as well as AM-DN, and Spec 5-LRS--were compared for WBC content. P-selectin expression was compared in the MCS+; Fen-10 with A-35 (Fen 10-A35) and PLT-30 (Fen 10-PLT30) collection chambers; Spec 4-DN; and platelet-rich plasma. We found AM-DN (63 +/- 16 min) had a significantly lower average processing time than all other systems except AM-SN. Spectra 4-DN (5.6 +/- 1.7 x 10(11) Plt) produced significantly more platelets and had a significantly higher incidence of products > or = 6.0 x 10(11) (56%) and higher incidence of products > or = 6.6 x 10(11) Plt (32%) than all other systems. AM-DN (0.073 +/- 0.017 x 10(11) Plt/min) had a significantly higher collection rate than all other systems except AM-SN. The WBC content comparison indicated MCS+ with a filter; and AM-DN and Spectra 5-LRS without filters were capable of consistently (99.32-100%) producing products with < 5 x 10(6) WBC, but were less consistent (86.36-99.26%) at < 1 x 10(6) WBC. MCS+ and Fen 10-PLT30 had significantly (p < .05) less p-selectin expression than all other systems but not between each other. From the data in this study, if leukoreduced platelets were needed in the shortest processing time, the first and second choices would be Amicus-DN and Spectra 5-LRS, respectively.

Effects of whole blood flow rates on mononuclear cell yields during peripheral blood stem cell collection using Fenwal CS 3000 Plus.

It is generally assumed that using high whole blood flow rates (WBFR), 80 ml/min, during peripheral blood stem cell (PBSC) collection on the Fenwal CS 3000 Plus blood cell processor will result in higher yields of mononuclear cells (MNC) than using lower WBFR (50 ml/min). To test this assumption, we retrospectively studied 129 PBSC procedures on 17 patients in a multiple myeloma protocol comparing MNC yield, as well as red blood cell (RBC), granulocyte, and platelet (Plt) content, of four average WBFR groups. Standard PBSC procedures were performed using modified procedure 1, interface offset 100, anticoagulant (AC) ratio of 11:1, small volume collection chamber, and a processing time of 4 hours. After correcting for AC volume used, the volume processed was divided by 240 minutes to obtain the average WBFR. WBFRs were separated into 4 groups of 40-49, 50-59, 60-69, and 70-79 ml/min. When compared to the highest flow rate group (70-79 ml/min), the three lower flow rate groups had significantly higher MNC yields of 16.2 +/- 6.9, 13.1 +/- 5.1, and 11.5 +/- 4.7 x 10(9), respectively, as compared to 8.9 +/- 6.1 x 10(9) MNC for the 70-79 ml/min group. There was no significant difference in granulocyte yield which ranged from 1.6 +/- 2.1 to 4.5 +/- 4.8 x 10(9).(ABSTRACT TRUNCATED AT 250 WORDS)

Modifications to increase accuracy and consistency of anticoagulant delivery using the Fenwal CS3000 plus.

Consistent and accurate delivery of anticoagulant (AC) with the Fenwal CS3000 Plus has been difficult to maintain. We have modified and evaluated methods to deliver AC more accurately and consistently at a 11:1 ratio on the Fenwal CS 3000 Plus. Two modifications (shortened AC tubing, shortened AC tubing with modified drip chamber) and two unmodified methods (unmodified right-hand string, unmodified double string) were compared (n = 20 platelet apheresis procedures each), resulting in average AC ratios of 11.4 +/- 0.5, 11.2 +/- 0.4, 11.6 +/- 1.3, and 12.1 +/- 0.7:1, respectively. There was a significantly higher incidence of ratios within +/- 10% of 11:1 using the modified methods, 90% and 100%, versus the unmodified methods, 50% and 55%, respectively. Comparison of 36 plateletapheresis (each) using 15-, 30-, and 90-minute intervals in AC drip rate monitoring revealed no significant difference. However, the 30-minute interval had a better ratio, 11.4 +/- 1.0 versus 11.6 +/- 0.8 or 11.7 +/- 1.1, and higher frequency of 11 +/- 10%: versus 75% and 72% and was more practical to use than 15-minute interval; the 90-minute interval did require adjustments in 8% of the procedures. The use of a spring scale versus AC bag graduations (n = 75 plateletapheresis) to measure AC volume was significantly superior in measuring volume (343 +/- 64 versus 373 +/- 72 ml), ratio (11.2 +/- 1.5 versus 10.2 +/- 1.6), and ratios 11 +/- 10%:1 (71% versus 52%). For more accurate and consistent AC delivery with the Fenwal CS 3000 Plus, we recommend three courses of action: 1) Shorten the AC line and modify the AC drip chamber, 2) use a 30-minute interval to monitor AC drip rate and adjust only if off by more than 3 drops/15 sec, 3) use a spring scale rather than AC bag graduations to obtain more accurate measurement of AC volume used.

Therapeutic cytapheresis: continuous flow versus intermittent flow apheresis systems.

In this retrospective study, we compared two systems, continuous flow (CF) (COBE Spectra) versus intermittent flow (IF) (Haemonetics V-50, M-30), in performance of therapeutic plateletapheresis (TP: N = 49 each) and therapeutic leukapheresis (TL: N = 29 each). Pre- and post-procedure cell reductions, specificity of removal, volumes removed, and incidence of adverse reactions were compared. Standard procedures with minor modifications, starch with IF only, and 180 minutes blood processing time were used. The CF system had a significantly lower percent reduction of platelets during TP at 43 +/- 17% than IF at 53 +/- 19%. However, no significant difference was found between CF and IF in percent reduction of white blood cells during TL with 49 +/- 16% and 42 +/- 14%, respectively. The CF system had significantly less hemoglobin reduction (5 +/- 4% vs. 19 +/- 9%, respectively) and white blood cell reduction (13 +/- 15% vs. 27 +/- 17%, respectively) for TP than IF and lower (not significant) hemoglobin reduction (9 +/- 8% vs. 12.4 +/- 8.2%, respectively) as well as platelet reduction (27 +/- 18% vs. 35 +/- 19%, respectively) for TL. CF also had significantly less volume removed than IF during TP (559 +/- 97 vs. 883 +/- 304, respectively) and TL (710 +/- 134 vs. 1405 +/- 421 ml, respectively). Incidence of reactions was lower for CF than IF during TP (8% vs. 10%, respectively) and during TL (14% vs. 21%, respectively).(ABSTRACT TRUNCATED AT 250 WORDS)

Plateletpheresis: comparison of platelet yields, processing time, and white cell content with two apheresis systems.

Two apheresis systems (COBE Spectra and Fenwal CS-3000 Plus with TNX-6 chamber [CS-3000 Plus]) were compared by using their yield predictors and maximum processing times in regard to platelet yields and processing times (n = 200 each). Platelet yields (n = 50 each) and white cell (WBC) content (n = 20 each) from procedures using the current software revision (3.6) on the Spectra and various interface offset (IO) settings on the CS-3000 Plus were also compared. Significantly higher median platelet yields (4.88 [range, 1.84-9.97] vs. 4.57 [range, 2.82-9.20] x 10(11) platelets) and frequency of components with > or = 6.0 x 10(11) platelets (31.5 vs. 21.5%) were found with the Spectra. In the study with Spectra and the CS-3000 Plus IO settings, IO-10 and IO-13, overall, produced the most platelets, although the differences were not significant. All Spectra collections tested had < 5 x 10(8) WBCs, and, depending on the software revision, had either 85 percent (revision 3.6) or 100 percent (revision 2.5) of components with < 5 x 10(6) WBCs. To ensure that 100 percent of components contained < 5 x 10(8) WBCs when the CS-3000 Plus was used, IO settings of 10 or less were required, and to ensure components with < 5 x 10(6) WBCs, only IO-6 could be used. Spectra and CS-3000 Plus were capable of collecting large doses of platelets (up to the equivalent of 18 units) in processing times of 67 to 100 minutes with < 5 x 10(6) WBCs.

Plasma exchange versus an affinity column for cholesterol reduction.

The recent introduction of low-density lipoprotein (LDL)/very low-density lipoprotein (VLDL) selective-removal systems offers an alternative to plasma exchange (PE). For the last 10 years, we have treated a male homozygous hypercholesterolemia type IIA patient with PE using 5% normal serum albumin (NSA) replacement, PE using 6% hydroxyethyl starch (HES) replacement, single dextran sulfate cellulose bead affinity column (DSAC) (Kaneka LA-40), and double DSAC. This report compares the performance of these systems in cholesterol reduction (total, LDL+VLDL, and high-density lipoprotein [HDL] and their effect on the total protein, albumin, and hematocrit levels. The number of procedures and average volume of plasma treated using PE-NSA, PE-HES, 1-DSAC, and 2-DSAC were 113, 64, 15, 90 and 3,939, 3,270, 3,519, and 3,588 ml, respectively. The average pretreatment total cholesterol levels were baseline 864 mg/dL, PE-NSA 606 mg/dL, PE-HES 610 mg/dL, 1-DSAC 467 mg/dL, and 2-DSAC 395 mg/dL with plasma reductions of 59%, 57%, 47%, and 55%, respectively. Average LDL+VLDL plasma reductions were PE-NSA 58%, PE-HES 59% (N = 1), 1-DSAC 46%, and 2-DSAC 56%. Average HDL plasma reductions were PE-NSA 58%, PE-HES 69% (N = 1), 1-DSAC 5%, and 2-DSAC 17%. The average total cholesterol and LDL+VLDL reductions were comparable for both types of PE and the 2-DSAC system. The average HDL loss was 53% lower for the DSAC systems than for PE systems.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunoabsorption in an extracorporeal plasma perfusion system: in vitro studies.

A rechargeable plasma perfusion system developed to remove IgG immunoglobulins is described. Partially purified protein A was covalently bonded on two separate carriers, Sepharose 6MB and carboxyl acrylic beads. Plasma from a patient with IgG multiple myeloma was perfused through the Sepharose-protein A column, and this resulted in a maximum removal of 177% of the estimated removal capacity of the column. Plasma from the same source was perfused through the acrylic bead-protein A column and yielded an average of 220% of the estimated removal capacity of the column. In addition, plasma from a normal subject and from six patients with various autoimmune diseases was perfused through the Sepharose-protein A column, and varying percent removal was obtained. A detailed procedure for covalent coupling of purified protein A to carboxylated acrylic beads is also given.

Treatment of pruritus of cholestasis by plasma perfusion through USP-charcoal-coated glass beads.

The accumulation of bile acids has been implicated in the pathogenesis of pruritus of cholestasis. To study the effect of bile-acid depletion on pruritus, 8 patients with chronic cholestasis and intractable pruritus which had not responded to cholestyramine and/or phenobarbitone underwent plasma perfusion through USP-charcoal-coated glass beads. DSuring twenty-two perfusions, between 957 and 6100 ml of plasma were perfused through charcoal columns, resulting in the removal of 126-795 mumol of bile acids. The mean extraction of the perfused bile acids was 81%. After the perfusions, all patients had prompt relief of their pruritus, lasting from 24 h to 5 months. Although the clinical effect may be due to the removal of unidentified pruritogens other than bile acids, charcoal plasma perfusion may improve the quality of life of incapacitated patients with servere intractable pruritus of cholestasis.

Removal of plasma lipoproteins from circulating blood with a heparin-agarose column.

A method is described for the removal of cholesterol fractions by means of intermittent extracorporeal plasma circulation through a column containing heparin-treated agarose in the presence of calcium. The system allows plasma perfusion in one column while simultaneously recharging another. In vitro testing demonstrated its efficiency, and in vivo testing of a normal dog proved its feasibility. In vitro testing revealed a mean removal of 22% of low-density and very low-density lipoproteins combined. Animal testing did not produce any abnormalities in clinically significant parameters.