Therapeutic Apheresis Clinical Guidelines

RWJBarnabas Health through Blood Services at Robert Wood Johnson University Hospital, provides comprehensive, therapeutic apheresis for inpatients and same-day stay patients. Blood Services performs approximately 500 procedures annually.

• Core Services Provided: Plasma Exchange (TPE), Red Cell Exchange (RCE), Cytoreduction (Leukapheresis/Plateletpheresis), Extracorporeal Photopheresis (ECP), and HPC Harvest.
• Staffing: Procedures are performed by specialized apheresis nurses and supervised by Transfusion Medicine physicians.

Consultation & Referral Process

All procedures are performed by Transfusion Medicine (TM) specialists.

• Initial Contact: Call the Donor Program or the On-Call Fellow (see Contact section).
• Review: A TM physician will provide a formal consultation regarding clinical efficacy and scheduling.

II. Physician Responsibilities & Admission

1. Primary Attending: Responsible for the management of the underlying disease, admission orders, diet, and routine medications.
2. Transfusion Medicine (TM): Acts as a consulting service. TM physicians manage all procedural parameters, including extracorporeal volume, anticoagulation, and fluid replacement.
3. Required Documentation: Prior to acceptance, the referring physician must provide:
   • A comprehensive History & Physical (H&P).
   • Current labs (CBC, Electrolytes, Coagulation profile).
   • Explicit admission orders.

III. Critical Safety Protocols

• ACE Inhibitors: Hold for 24–48 hours prior to TPE. ACE inhibitors interfere with bradykinin degradation; combining them with TPE (especially with albumin or certain membranes) can trigger severe, atypical anaphylactoid reactions and profound hypotension.
• Vascular Access: Procedures are performed by expert nurses via peripheral veins or central venous access.

IV. Indication Categories (ASFA 2023)

The following common indications are categorized based on the strength of clinical evidence.

Category I: First-Line Therapy

Therapeutic apheresis is accepted as standard of care, either as primary or in conjunction with other first-line therapies.

1. Hematology: TTP (Thrombotic Thrombocytopenic Purpura), Sickle Cell Disease, Hyperviscosity Syndrome, severe Babesiosis, Catastrophic Antiphospholipid Syndrome (CAPS).
2. Neurology: Guillain-Barré Syndrome (AIDP), Myasthenia Gravis, CIDP (Chronic Inflammatory Demyelinating Polyneuropathy), NMDAR Encephalitis, Anti-MAG Neuropathy,
3. Renal & Rheumatology: Goodpasture Syndrome (Anti-GBM), Focal Segmental Glomerulosclerosis (FSGS), Renal Transplantation, Antibody-Mediated Rejection (AMR)), Catastrophic Antiphospholipid Syndrome (CAPS).

Category II: Second-Line Therapy. Therapeutic apheresis is accepted as a supportive or second -line treatment for:

Lambert-Eaton Myasthenic Syndrome, PANDAS (Severe Exacerbations, Multiple Sclerosis (Acute CNS Demyelination, steroid-refractory), Symptomatic Thrombocytosis/Leukostasis.

The optimum role of apheresis is not clearly established for other diagnosis; use is decided on a patient-by-patient basis. Consult with Transfusion Medicine for these cases or any other non- listed diagnosis.

V. Contact & Consultation

• Business Hours: Donor Program at (732) 235-8100 x 225 or 243.
• After Hours/Weekends: Call Hospital Operator at (732) 828-3000; page the Hematology/Oncology Fellow on call.