Indications for aRCE
| Indication* . | Relevant literature or guidelines . |
|---|---|
| Acute stroke | RBC exchange (manual or automated) during management of initial stroke was associated with a lower stroke recurrence (21% [8/38]) compared to simple transfusion (57% [8/14])39 Category 1 recommendation by ASFA35 ** |
| Severe acute chest syndrome (ACS) | aRCE shown to reverse hypoxia within 24 hours in 5 patients.40 Comparison of simple transfusion and aRCE in 81 children with ACS showed aRCE was given in more severe cases, yet similar length of stay/clinical course was achieved when compared to less severe cases treated with simple transfusion.41 Suggested by ASH 2020 guidelines for SCD: transfusion support34 and is a category 2 recommendation by ASFA35 ** |
| Multiorgan failure | No randomized trials, but small case series suggest improved outcomes with RBC exchange transfusion.42,43 Of note, recent case reports describe improvement with plasma (rather than RBC) exchange.44-46 |
| Prophylactic preoperative transfusion if hemoglobin >9 g/dL | Transfusion is indicated prior to surgery for patients with SCD due to high risk of perioperative complications in this population. A randomized trial demonstrated that a conservative regimen to achieve hemoglobin 10 g/dL was as effective as an aggressive regimen to decrease HbS <30%,47 therefore aRCE should be used only in patients with high baseline hemoglobin who cannot receive simple transfusion. Suggested by ASH 2020 guidelines for SCD: transfusion support34 |
| Long term chronic transfusion therapy | aRCE suggested by ASH 2020 guidelines for SCD: transfusion support34 and category 1 recommendation by ASFA.35 |
| Indication* . | Relevant literature or guidelines . |
|---|---|
| Acute stroke | RBC exchange (manual or automated) during management of initial stroke was associated with a lower stroke recurrence (21% [8/38]) compared to simple transfusion (57% [8/14])39 Category 1 recommendation by ASFA35 ** |
| Severe acute chest syndrome (ACS) | aRCE shown to reverse hypoxia within 24 hours in 5 patients.40 Comparison of simple transfusion and aRCE in 81 children with ACS showed aRCE was given in more severe cases, yet similar length of stay/clinical course was achieved when compared to less severe cases treated with simple transfusion.41 Suggested by ASH 2020 guidelines for SCD: transfusion support34 and is a category 2 recommendation by ASFA35 ** |
| Multiorgan failure | No randomized trials, but small case series suggest improved outcomes with RBC exchange transfusion.42,43 Of note, recent case reports describe improvement with plasma (rather than RBC) exchange.44-46 |
| Prophylactic preoperative transfusion if hemoglobin >9 g/dL | Transfusion is indicated prior to surgery for patients with SCD due to high risk of perioperative complications in this population. A randomized trial demonstrated that a conservative regimen to achieve hemoglobin 10 g/dL was as effective as an aggressive regimen to decrease HbS <30%,47 therefore aRCE should be used only in patients with high baseline hemoglobin who cannot receive simple transfusion. Suggested by ASH 2020 guidelines for SCD: transfusion support34 |
| Long term chronic transfusion therapy | aRCE suggested by ASH 2020 guidelines for SCD: transfusion support34 and category 1 recommendation by ASFA.35 |
ASH, American Society of Hematology.
For all acute indications for aRCE, the hemoglobin upon acute presentation should be considered and if >2 g/dL below patient's baseline, a simple transfusion may be given first. In particular, this may be a temporizing measure to allow time for line placement and mobilization of apheresis service.
The American Society for Apheresis (ASFA) provides evidenced based recommendation for apheresis procedures: category 1 (first line therapy), 2 (second line therapy), 3 (role of apheresis not established; decision-making should be individualized), 4 (ineffective or harmful).