The use of fluid boluses to safely perform extracorporeal photopheresis (ECP) in low‐weight children: A novel procedure

Abstract

Apheresis procedures in small children are technically challenging and require special planning with attention to extracorporeal volume. Discontinuous procedures such as extracorporeal photopheresis (ECP) require additional consideration. Alternative methods to perform ECP have been utilized in small children that require manipulation of mononuclear cells outside the standard closed-loop system. We present a safe and feasible alternative to the procedure for children who weigh less than 40 Kg, while maintaining a closed loop, sterile system utilizing the UVAR XTS device. A retrospective chart review was performed analyzing the use of fluid boluses (normal saline in those between 20 and 40 Kg, 5% albumin in those under 20 Kg) before ECP. Eleven patients underwent 334 ECP procedures for acute and chronic graft-versus-host disease (n 5 9), and for prevention of graft-versus-host disease (n 5 2). Volumes of fluid boluses were calculated based on the expected extracorporeal volume during the first draw cycle. Treatments consisted of at least three draw cycles using the 125 mL bowl. The median weight was 28.5 Kg (range 19 to 39); nine of 11 required red cell transfusions to maintain adequate hematocrit. Complications attributed to ECP included tachycardia, dizziness, nausea, and hypotension; these occurred either in combination or isolation in 31% of the procedures and resolved following additional fluid boluses. Only three (0.8%) required early photoactivation due to these complications. The median time to completion of treatment was 2 h and 58 min (range 1:30 to 5:03). ECP is well tolerated in low-weight pediatric patients if hematocrit and hydration are carefully maintained. J. Clin. Apheresis 25:63-69, 2010. V V C 2010 Wiley-Liss, Inc.

Guidelines on the use of extracorporeal photopheresis

“…Several authors have pointed out that the use of ECP in children presents specific challenges, such as low bodyweight, vascular access, extracorporeal volume, metabolic and haematological problems, and psychological tolerance , Nevertheless, Messina and colleagues were able to treat patients with a bodyweight as low as 10 kg without significant side‐effects . Kanold and colleagues reported the follow‐up of paediatric patients with GVHD, with a particular emphasis on the technical aspects of ECP therapy .…”

“…The challenge of treating low‐bodyweight paediatric patients (as low as 15 kg) was also addressed in a study of patients with both aGVHD and cGVHD . In contrast to many groups that have used an ‘offline’, two‐stage technique for mononuclear cell collection and irradiation, this group reported the use of a sterile, closed‐loop procedure, in which patients received fluid boluses of normal saline or 5% albumin to boost blood volume before, and if needed during, ECP procedures.…”

An update on the clinical utility of extracorporeal photopheresis in the treatment of graft-versus-host disease

“…These were treated with normal saline flushes or TPA and required CVL change on two occasions. 59 Steroid sparing should be an important goal of secondline therapy, a feature that has not been consistently examined across ECP studies. One important consideration when using ECP especially for SR-cGVHD is the time needed to achieve an objective response.…”

“…In an effort to counteract the challenge of treating pediatric patients with low bodyweight (as low as 15 kg) for both aGVHD and cGVHD, Schneiderman et al 59 reported the use of a sterile, closed-loop procedure, where patients received fluid boluses of normal saline or 5% albumin to boost blood volume before and, if needed, during ECP procedures. The process was well tolerated by patients and therefore could extend the use of continuous-flow ECP to these patients with low body weight.…”

An automated mini buffy coat preparation method for use in mini extracorporeal photopheresis treatment of graft‐vs‐host‐disease in a low body weight pediatric patient

“…Conventional extracorporeal photopheresis (ECP) performed using apheresis devices has proven efficient for the treatment of acute and chronic graft‐vs‐host‐disease (GVHD) . The experimental modifications of the conventional ECP procedure have been developed, involving ECP‐treated allogeneic cells, ECP treated enriched or depleted cell populations, mini‐ECP, and cryopreservation of ECP‐treated cells .…”