APHERESIS

What is apheresis?

Certain conditions can be caused by an abnormal cell or component in the blood that may need removal. Apheresis is a “blood-washing” procedure in which your blood is passed through a device that separates it into various components, discards cells or pathologic components that are thought to be causing a disease or condition, and returns the remaining blood along with replacement fluid and normal cells.

There are two main reasons why patients may undergo apheresis. Apheresis can be done on donated blood given to a recipient or be therapeutic for patients with certain conditions that impact their blood or components within their blood.

There are two types of therapeutic apheresis methods: plasmapheresis and cytapheresis.¹ Plasmapheresis separates plasma (a light yellow liquid blood component containing proteins and antibodies) from the blood. In contrast, cytapheresis separates the blood into red blood cells, white blood cells, and platelets. Plasmapheresis typically removes autoantibodies or immune complexes, which the immune system makes in autoimmune disorders, infections, or certain cancers that target the body itself instead of a foreign invader. Cytapheresis is done to remove either excess components of cells or cells that are defective in some way. For instance, this can remove abnormally shaped red blood cells in patients with sickle cell disease.

How can apheresis help alleviate certain long COVID symptoms? 

Proposed mechanisms behind the chronic fatigue and post-exertional malaise of long-COVID include reduced blood flow to tissues, inflammation in the brain and other organs, and reactivation of different infectious agents or components.² Data has also shown that COVID can lead to the creation of autoantibodies and change components of the blood to make it more viscous and, thus, reduce blood flow.³ COVID can also cause a significant increase in lipid levels that can lead to long-term cardiovascular disease.

By removing these potential autoantibodies, lipids, and abnormal blood components, apheresis can improve blood flow and may, as a result, improve long-term COVID symptoms of chronic fatigue.

What evidence supports the use of apheresis for long COVID?

In a study done with patients in Germany who reported fatigue lasting for at least 12 months following COVID, 27 participants were treated with a therapeutic apheresis procedure that removed autoantibodies, inflammatory cytokines, certain lipids, and other molecules contributing to more viscous blood.² Patients were treated twice within a three-week interval, with each treatment lasting 114 minutes. Biomarkers for inflammatory factors, autoantibodies, lipids, and clotting factors were measured before and after apheresis. About 15% of participants did not feel better after six months following apheresis; however, most participants reported no symptoms after treatment, and 11% reported moderate improvement. The study found a significant reduction in these biomarkers in patients who reported a substantial improvement in their symptoms.

Several case reports have also found relief of long-COVID symptoms such as muscle or chest pain, vision and hearing problems, insomnia, and general quality of life using HELP (heparin-induced extracorporeal LDL/fibrinogen precipitation) apheresis.⁴ HELP apheresis dissolves microclots in the blood and removes proteins in the body that can contribute to clots.⁵

There currently needs to be randomized control trials investigating the use of apheresis for long COVID patients. The evidence behind apheresis for long COVID should be discussed with a provider if being considered for treatment.

What should you be aware of with apheresis?

Patients may experience fatigue, nausea, low blood pressure, or an allergic reaction during apheresis. Some patients may also feel tingling or numbness that subsides when the treatment is completed.⁶ One session may take 2 to 5 hours, depending on the type of apheresis done. Apheresis can be a long and costly procedure, and some insurance plans may not cover the treatment for long COVID.

References:

1)      Sarode R. Therapeutic Apheresis. Merck Manual. Sept 2022. Accessed November 5, 2023. https://www.merckmanuals.com/professional/hematology-and-oncology/transfusion-medicine/therapeutic-apheresis

2)      Achleitner M, Steenblock C, Dänhardt J, Jarzebska N, Kardashi R, Kanczkowski W, Straube R, Rodionov RN, Bornstein N, Tselmin S, Kaiser F, Bucher R, Barbir M, Wong ML, Voit-Bak K, Licinio J, Bornstein SR. Clinical improvement of Long-COVID is associated with reduction in autoantibodies, lipids, and inflammation following therapeutic apheresis. Mol Psychiatry. 2023 Jul;28(7):2872-2877. doi: 10.1038/s41380-023-02084-1

3)      Joob B, Wiwanitkit V. Blood viscosity of COVID-19 patient: a preliminary report. Am J Blood Res. 2021 Feb 15;11(1):93-95. PMID: 33796395.

4)      Heitmann J, Kreutz J, Aldudak S, Schieffer E, Schieffer B, Schäfer AC. A practical approach for the treatment of post-COVID symptoms. Herz. 2023 Jun;48(3):243-246. doi: 10.1007/s00059-023-05177-3

5)      Jaeger BR, Arron HE, Kalka-Moll WM, Seidel D. The potential of heparin-induced extracorporeal LDL/fibrinogen precipitation (H.E.L.P.)-apheresis for patients with severe acute or chronic COVID-19. Front Cardiovasc Med. 2022 Oct 11;9:1007636. doi: 10.3389/fcvm.2022.1007636

6)      Healthwise staff. Learning about apheresis. Kaiser Permanente. April 12, 2023. Accessed November 5, 2023. https://healthy.kaiserpermanente.org/health-wellness/health-encyclopedia/he.learning-about-apheresis.abs2246

Active Clinical Trials: Long COVID, apheresis | Card Results | ClinicalTrials.gov