Therapeutic Apheresis Performed in Tandem with Dialysis and Left Ventricular Assist Devices

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1 Therapeutic Apheresis Performed in Tandem with Dialysis and Left Ventricular Assist Devices Vishesh Chhibber, MD Regional Medical Director, Transfusion Medicine Northwell Health, NY 1

2 Disclosure I have no actual or potential conflict of interest in relation to this presentation.

3 Objectives Various Tandem procedures performed Technical aspects of tandem procedures Details of tandem circuits Risks VS Benefits of tandem procedures Anticoagulation issues Calcium management

4 Tandem Procedures Performed ECMO and TPE- discussed previously Hemodialysis (HD) and TPE Hemodialysis and PBPC collection Continuous veno-venous hemodialysis (CVVHD) and TPE TPE performed in patients with a LVAD

5 Hemodialysis and TPE Why perform these procedures in tandem? May occasionally be necessary to perform both procedures urgently Convenience for patient Other benefits How to perform the procedures? Initiate HD and then start TPE Blood is diverted from arterial line of HD circuit and returned to a side port of the pre-pump low pressure plastic arterial chamber after apheresis performed Blood is then dialyzed and then returned to patient

6 Tandem Hemodialysis & Apheresis J Clin Apheresis 2014;29:83-89

7 Hemodialysis and PBPC collection Circuit/connections of HD and apheresis devices is identical to HD and TPE Initiate PBPC collection ASAP after initiation of HD to maximize the volume of blood able to be processed Higher apheresis flow rate preferred in patients undergoing HD and PBPC collection (heparin) PBPC collected prior to entering HD device Patients studied had no decrease in collection efficiency or efficiency of HD No delays in engraftment noted

8 Additional Considerations Informed consent from patient Consider fluid removal after apheresis complete in small or hypotensive patients May need to use plasma as (partial) replacement fluid during TPE May make dialysis team nervous Blood enters apheresis device prior to HD and all blood dialyzed post apheresis

9 CVVHD and TPE Often CVVHD can be held for 1-2 hours to perform TPE and then continued subsequently Patients are often hypotensive However, these two procedures have been performed in tandem

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11 Clin J Am Soc Nephrol Sep 5; 9(9):

12 TPE performed in patients with a LVAD Performed using independent vascular access for apheresis Patients may need desensitization prior to heart transplant TPE may also be performed during/just prior to transplant while the patient is on ECMO Number of LVADs being placed is increasing Anti-coagulation can be a significant challenge

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14 Risks of Tandem Procedures Higher extra-corporeal volume Hypotension Technical malfunction Need for skilled apheresis practitioner A problem with one procedure may result in having to abort the other procedure Anticoagulation of two circuits Possible interference

15 Anticoagulation for Tandem Procedures Dialysis Often use of heparin or no anticoagulation Some removal of heparin with TPE TPE anti-coagulation -can decrease citrate infusion rate -may not be necessary if heparin being used LVAD Anti-coagulation management is challenging Often on warfarin May be switched to heparin peri-operatively

16 Benefits of Tandem Procedures Able to perform both procedures in cases where both are needed urgently Decreased use of venous access Convenience for patient Efficiency of HD not compromised (urea reduction ratio) If HD performed in tandem with apheresis, supplemental Ca not necessary

17 Calcium Supplementation Zhao etal. J Clin Apheresis 2016;[Epub ahead of print]

18 Questions??? 18