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Blood prime for patients with single‐needle access requiring extracorporeal photopheresis: How to do and why it may be useful

Extracorporeal photopheresis (ECP) is an immunomodulation procedure that may be used as an adjunct therapy in patients with cutaneous T cell leukemia/lymphoma, graftversus-host-disease (GVHD), or rejection of a heart and/or lung allograft. In order to perform a safe ECP procedure, the extracorporeal volume (ECV) of the device, which is a mathematical function of both access mode and hematocrit (Hct), must not exceed 10–15% of the patient’s total blood volume (TBV) depending on the patient's comorbidities. Thus, due to immunosuppressive regimens and/or anemia, the ECV in relation to TBV for these patients may be too great to safely perform ECP. Additionally, many patients have only single-needle access which may increase the ECV needed for treatment. For example, over 70% of patients undergoing ECP at our institution have a single lumen line for access and many do not have suitable peripheral veins for a second access point. Thus, they may not be able to tolerate the ECV needed for ECP. In response to the need to still treat these patients, we modified a procedure to perform ECP with a blood prime on patients using single-needle access on the Therakos Cellex system (Mallinckrodt Pharmaceuticals, St. Louis, MO). A mock run based on the developed protocol (Table 1) was carried out successfully by our apheresis nursing staff before the procedure was performed on actual patients. Thus far, we have successfully performed six procedures on two patients who could not tolerate the ECV of the device without adverse events. The first patient was a 66-year-old female ( 45 kg, Hct typically <24%) receiving ECP for chronic rejection of her lung allograft. The second patient was a 15year-old female ( 35 kg, Hct typically <30%) receiving ECP for the treatment of GVHD after hematopoietic progenitor cell transplant. Of note, the patient only receives a minimal volume of red blood cells (RBCs) with this method, allowing their hemoglobin levels preand post-procedure to be similar. Nonetheless, since the patient will receive some RBCs, they are at risk for transfusion-related complications. In conclusion, we have developed and implemented a single-needle access blood prime for performing ECP on patients who could not otherwise tolerate the ECV of the Therakos Cellex system. Thus far, all patients tolerated the procedures well without any significant hemodynamic compromise.