Apheresis

APHERESIS

GOAL: To train fellows to acquire the level of competence necessary to provide service and consultation in apheresis. 

STRUCTURE:

The apheresis training is structured so that it provides maximum educational opportunities and includes one week of intensive training with Dr. Jan Hoffman at the Apheresis Care Group (ACG), followed by training at UCSF Medical Center Moffitt-Long Hospitals integrated with the 6-months Transfusion Service block, three weeks at UC Davis Medical Center in Sacramento, CA. Additional exposure to pediatric apheresis is accomplished through one week rotation with Dr. Shannon Kelly at Benioff Children’s Hospital and Research Center Oakland (BCHO).

DURATION:

  • ACG - Two weeks
  • UC Davis - Three weeks
  • UCSF - Variable

DIRECTORS:

ACG: Jan C. Hofmann, MD, MPH, MS
Medical Director
1700 California Street. Suite 350
San Francisco, CA 
E-mail: [email protected]
Phone: (415) 928-4642

UCSF: Lloyd Damon, MD
Professor
Department of Hematology and Oncology
Hematology and Blood and Marrow Transplant
400 Parnassus Ave., Fourth Floor
San Francisco, CA 94143
Email: [email protected]
Phone: (415) 353-2421

UC Davis: Grace Monis, MD, PhD
Therapeutic Apheresis and Hematopoietic Progenitor Cell Collection
UC Davis Health System
4400 V Street
Sacramento, CA 95820
Email: [email protected]
Phone: (916) 734-7347

BCH-Oakland: Shannon Kelly, MD, Director
Apheresis Program
Main Hospital
747 52nd Street
Oakland, CA 94609
Email: [email protected]
Phone: (510) 428-3372

SPECIFIC OBJECTIVES:

ACG ROTATION: This intensive introduction to apheresis with Dr. Jan Hoffman comprises of 80% didactic and 20% clinical cases over 5-10 days. Below is the curriculum example for a 7-day rotation:  

Day 1:

  • Overview: Apheresis Medicine Updates / Trends in Therapeutic Apheresis 
  • 2019 Apheresis and Transfusion Medicine (TM) Conferences 
  • Fundamentals of Therapeutic Apheresis (TA) 
  • Basics/specifics of Therapeutic Plasma Exchange (TPE) treatment 
  • Recommended MD apheresis orders (EPIC apheresis templates) 
  • 2019 ASFA TA Guidelines (7/19): understanding study design/grading and indication categories 
  • Autoimmune Neurologic Syndromes (GBS, MG, CIDP, MS, NMO, ATM, ADEM, NMDA-R encephalitis) 

Day 2:

  • Autoimmune Hematologic Diseases (acq TTP; TMA; infx-assoc. HUS; aHUS; CAPS; hyperviscosity synd.) 
  • Cytapheresis (WBC and Platelet Depletion in cellular hyperviscosity); (AML, ALL, CML-AT; ET) 
  • RBC Exchange (SCD; severe falciparum malaria); RBC depletion (PCV; hemachromatosis) 
  • Introduction to WBC collection 

Day 3:

  • WBC collection treatments/protocols/issues 
  • Vascular access (CVCs vs. peripheral lines vs. ports vs. AVF/AVGs) 
  • Ports (Vortex [Angiodynamics]; Powerflow port [Bard]; Tidal port [Norfolk Medical]) 
  • WBC cell (“immune surveillance”) therapies: progenitor cell therapies; therapeutic cancer vaccines (dendritic cell therapies); CAR-T cell/immune effector cell therapies. 

Day 4:

  • Autoimmune Renal Disorders (ANCA/anti-GBM vasculitis (PEXIVAS study); HCV-cryoglobulinemia; Myeloma/light chain cast nephropathy; FSGS; renal transplant AMR and desensitization; “immune tolerance” (persistent mixed chimerism). 
  • Other conditions: Cardiac transplant AMR; hypertriglyceridemic pancreatitis; HV-TPE in fulminant hepatic failure 

Day 5:

  • Cascade Plasmapheresis Procedures (LDL-Apheresis; IA column therapies (Adacolumn); Rheopheresis 
  • Specialized Procedures: Photopheresis; Adacolumn therapy 
  • Plasma-based research & Therapeutics: heterochronic parabiosis (“young plasma” studies; YBI; Ambrosia); Stanford’s PLASMA study; Grifol’s AMBAR alzheimer’s study. 
  • Other conditions: Thyroid storm/hyperthyroidism, TPE in sepsis (TAMOF); cold agglution disease; autoimmune retinopathy/B-DUMP; Sudden Sensorineural Hearing Loss (SSHL); PANDAS/PANS, etc. 

Day 6: Pediatric Apheresis: 

  • Overview & fundamentals 
  • Vascular access (peripheral access; central line selection (size)/placement; temporary CVCs vs. permcaths vs. ports vs. AV fistula). 
  • Pediatric Apheresis Math: ETBV, PV, RBCV, intracrit (calculations); pediatric formulas/equations 
  • Anticoagulation (ACD-A alone; ACD-heparin mixture; ACD-A and separate heparin drip); (WB:ACD ratio) - Pediatric Apheresis calc: ACD-A infusion rate; CaGluc preparation/infusion rate; inlet rate; fluid balance - Priming (NS prime; 5% albumin vs. RBC prime; diluted vs. undiluted RBC prime) - Fluid balance (ECV of different tubing sets of Cobe Spectra; Optia; Amicus); MD prescribed rinseback 
  • Adverse reactions associated with pediatric TA, and how to manage them (citrate toxicity, etc.) 
  • Pre-TA treatment labs/electrolyte monitoring (CBC, metabolic panel, Ca, Mg, other; serial ionized Ca) 
  • Typical pediatric apheresis MD orders (TPE; RBCX; WBC depletion; WBC/stem cell collection)
  • Pediatric case studies (work-up, MD orders, calculations of ECV, TBV, PV, FB; AC & Ca infusion rates): 
  • Pediatric Disease Management (using 2019 ASFA treatment guidelines for utilizing TA in pediatric patients): - Recurrent FSGS; Myasthenia Gravis, ADEM, PANDAS; acquired TTP, infx-assoc HUS, aHUS; Wilson’s Disease; thyroid storm; aplastic anemia; sepsis with multiorgan failure (TAMOF); renal and cardiac allograft rejection; ABOi solid organ transplantation. - Hyperleukocytosis (WBC depletion in AML & ALL) - Sickle cell disease (RBCX: acute exacerbations and chronic prophylactic RBCX treatment) - Ongoing patient cases 

Day 7:

  • Summary of Therapeutic Apheresis (key points) 
  • Strategies for developing and growing a TA program 
  • Quality program development & certification (AABB, FACT, etc.) 
  • TA Coding and Reimbursement (an introduction) 
  • 2019 ASFA TA Reimbursement Guide (on ASFA website) 
  • Telemedicine in Apheresis (including “peer-to-peer physician virtual consultation”, and “video-telephone”) 
  • Opportunities in TA (within one’s career) 
  • National TM & TA societies & committees (opportunities for involvement and/or leadership): ASFA; AABB; CAP; ISCT; ASH; ASBMT; ASN; other academic societies. 
  • Global Transfusion Standards: challenges and solutions in implementation Ethics and Transfusion Medicine (Ethical considerations for the apheresis provider: basic concepts and cases). 

UCSF, UC Davis and BCH-Oakland Rotations:

The UCSF (variable, integrated with the TS block), UC Davis (3 weeks) and BCH-Oakland Apheresis (2 days) rotations are mostly clinical based and their specific objectives overlap:

  1. Understand the principles of apheresis technology and therapeutic apheresis methods. 
  2. Demonstrate knowledge of evidence-based indications for therapeutic apheresis and practical aspects of apheresis procedures (appropriate replacement fluids, anticoagulant dosage, treatment schedules etc.).
  3. Demonstrate proficiency in assessing patients for suitability to undergo an apheresis procedure, consenting, ordering and monitoring them in various clinical situations.
  4. Understand common risk factors in therapeutic apheresis related to medications, such as ACE inhibitor use, anti-diabetic medications, antibiotics, anticoagulants, IVIG and rituximab.
  5. Obtain appropriate history and perform appropriate physical exam on apheresis patients. 
  6. Demonstrate knowledge and appropriate use of clinical and laboratory tests for the assessment and management of apheresis patients. 
  7. Show proficiency in oversight and management of patients undergoing apheresis treatment.
  8. Become competent in evaluating and managing common adverse events without supervision.
  9. Describe the process of HPC collection and the management of HPC donors.
  10. Communicate effectively with clinicians and house staff regarding necessary laboratory tests to perform before/after procedure, replacement fluids, calcium supplementation, adverse event prevention/treatment, and frequency/length of treatment.
  11. Develop an understanding of regulatory requirements applicable to therapeutic apheresis oversight, apheresis billing and reimbursement.