Oh Thank You Amelia for your kind introduction thank you the audience for being here and thank you to the committee for inviting me for this presentation so the title is very unspecific it’s about a phoresis it’s about the diseases that for which we do wafer resist and also what are the challenges that we have to obtain evidence to support these treatments so I have nothing to disclose and I think this is a very first nice light to represent what I’m going to talk about so parachutes reduce the risk of injury related to the rotational fall but their efficacy has not been proved by randomized control trials and when I say this actually I see apheresis so during the first 10 minutes of the presentation I will talk about the apheresis principles I’m not sure exactly how much I would like everybody to have a basic understanding of a phoresis I will go through the American Society for a phrases guidelines that provides recommendations about treatment I will go through to these examples one is going to behavior incompatible transplantation and the other one you consider Pharisees and even though they are not related I will show you how they are actually related and then challenges and opportunities looking into the future so first starting with definition so a phrase it means to remove so we can remove plasma and that is called plasmapheresis or Rican we can remove cells which is side apheresis which is different from forces which first it is transmissions such as in electrophoresis we don’t do that to the patient’s we don’t do any electrical transmission so sometimes we see plasmaphoresis in the chart and data misspelling or this big that’s not what we do to our dear patients so the first the concept of a phrase is it’s a very it’s a historical concept in terms of removing something that is but it’s actually pathologic and that started hundred years ago when with the with the bleeding or when the patients were treated actually by by bleeding’s but it wasn’t until 1956 when the first manual a phoresis procedure was performed on this patient that had water from hyper viscosity so for those of you who are not familiar with this disease there is a high concentration of IgM which is an algae valley and that contributes an increase viscosity on the blog and because of that the patient can have neurologic symptoms and don’t feel very well so the treatment for that is to remove to try to remove those in mineral glow billions so for these patients in 1956 what it was done they introduced a needle they collect one unit of blood they spin the blood remove the plasma with the pathogenic IgM and then returned the red blood cells into circulation and that was done throughout 15 days and the patient recovered so this is exactly what we do when we are doing a freezes procedures in our patients the only difference is that now we have automated mechanisms and we can use machines to perform that so so how it works so these are the two machines are currently in in use there are other machines that these are the two most frequently used this is a curved spectrum this is a curve up here so this is a machine that has been running since 70s or 80s it’s an excellent machine and it was time to replace her to replace it so about five years ago the Optio was introduced not many people is happy with the change because this machine is so very well known and everybody’s so used to it but this is what we are changing so this curve spectra has and this one too has a centrifuge inside so the blood is removed the patient is is connected to the machine such as in a dialysis instruments very similar procedure and then the blood is collected into this centrifuge by centrifugation it is possible to get separation by a specific gravity and we can separate the different components of the blood so we can separate red blood

cells from the perfect out from the plasma and then we can decide exactly what is that we want to collect depending on the disease of the patient so here you have the specific gravity of the different components of the plasma and this affects all of the blood and this is exactly how it looks in your in the interface in the centrifuge so the red blood cells will go to the button where polymorphonuclear cells are going to be very close to the red blood cells blast monocytes and lymphocytes are going to be close together platelets on the top and then plasma so you can specifically ask the machine to collect either plasma or platelets or different cells components so because we have this ability to separate blood components and to collect whatever we want we can do not only therapeutic procedures that also donor apheresis so we can connect to this machine healthy donors for transmission purposes so you can collect plasma and that would be called plasmapheresis and basically we would like to do these two donors that are AV type and the reason for that is that a B plasma doesn’t have any antibodies on it so that’s the universal donor we can also collect cells such as red blood cells platelets granulocytes and also hematopoietic progenitor cells so these cells are collected for transfusion purposes so we can the most common way to do at this time bone marrow transplant is by collecting peripheral stem cells through this machine so the focus of this talk of these targets about syrup Utica for aces so when we are thinking about therapeutic areas and we remove plasma we call it plasma exchange because when we remove the plasma we are going to replace whatever we are removing over the plasma that we are removing so the reason we want to we may want to remove plasma is because the plasma has pathologic substances such as for instance antibodies or para proteins or inflammatory mediators drug or toxins we may also want to remove cells which is going to be called city Pharisees to remove pathological cells such as we can well exchange for patients with sickle cell disease to remove cells with abnormal hemoglobin but being on malaria what patients have has very very severe disease we can also do look at the local depletion and this is important for patients with acute leukemias I’m very high white blood cell count that presents with symptoms of glucose phases and we can also remove platelets for patients with essential thrombocytosis are not responding to treatment so since I’m talking about apheresis I just wanted to give you an introduction of other types of a felices procedures we are I’m not going to expand on this but just to give you a brief overview so LDL apheresis I would like to ask the audience how many of you have have heard about LDL apheresis alright so this is excellent just five or few so this is a procedure that we perform here at the University actually and together with Harborview the machine is sitting at Harborview but covers patients at the University and Harvard Medical Center so this LDL apheresis procedure what it does is that it removes LDL actually and is the mechanism of separation is a little bit different so again we have a patient that we remove blood from the patients we don’t use a centrifuge to separate the different components of the blood but actually we’ll use a plasma filter or a filter that separates the plasma from the red blood cells and this would be is very similar to dialysis when the plasma is separated it goes through a plasma pump that then runs the plasma it gains some columns that can absorb the LDL and then the plasma and the rest of the components are returned to the patient so the other a phoresis procedure that I wanted to mention is photopheresis this is a very how many of you have heard about photopheresis all right so seven of you so that’s a little bit more than LDL apheresis so photopheresis is usually it’s a very I found it very fascinating and interesting what we do with these machines so what we do is also we collect blood which separates through centrifugation but we take the Buffy coat with the white blood cells we introduce psoralen that is a component that intercalates into the DNA and then just to the white blood cells and then the white blood cells are illuminated with UV light so the söderling becomes activated and damaged their DNA and in the Buffy coat is it reintroduce to the patient with these damaged white blood cells so these damaged white blood cells it is thought that they can produce an immune modulating response into the heart so these treatment is usually use for cutaneous t-cell lymphoma and

graft-versus-host disease but it’s been increasingly used in patients with cardiac and lung transplant rejection cellular rejection not and developmental rejection and the role of this mechanism for our immune diseases is still not known but it’s something that is under research at this time all right okay so going back to our a phrases after repeatedly various procedures so there isn’t what I’d like to call a physics prescription so when we are talking about or we’re considering a patient for a phoresis treatment we need to think that the patient needs a vascular access we are going to use an anticoagulant during the procedure that it could be either citrate or a combination of heparin at citrate we are going to choose what type what the amount of volume that we are going to process the replacement three that we are going to use and the treatment plan and all these various based bit based on the indication so a tree this is usually very well tolerated so sometimes we we think is can we benefit this patient from apheresis or not why why we consider to do an differences procedure in a patient so for the most part we use the macula criteria which is expressed here so if we understand a little bit of the pathogenesis of the disease is it antibody media rejection is there something that we can identify is the plasma we can remove or in the red blood cells that we can remove and if we remove it actually the patient is going to have an improvement or it’s going to be perkier as says here so we may consider to do a nefarious procedure on these patients so this is a Russian ad on the internet about promoting plasmapheresis on how well and how happy people get after apheresis I never saw one of our patients jumping like this I wish they were but what I can say is that sometimes I forget this can produce a significant improvement only with one treatment and as it says here unfortunately part long time this procedure was not a widespread occurrence due to its high cost equipment and the process complexity lack of cheap and effective disposable system so I’m very unfortunate so when once we make the decision that patient may benefit to get a treatment the other thing is that we the American Society for apheresis have place has developed these fact sheets which help us to with the disease understanding and also to decide whether we can do a thesis or not in these particular patients so these fact sheets has lots of information about specific diseases such as the frequency of the disease the procedure and what is the evidence to do the treatment the description of the disease what is the current management why we would do a Frazee some days and the technical note so for the most part every time we receive a request for a phrases there is already a fact sheet describing this if there is not a fact sheet we would use the McCleod criteria to say can we really benefit this patient by removing some particular component of the blood so one of the things that I like the most about a phrase is is that we get to interact with lots with lots of different clinical teams so all this 78 facts sheet or current indications for apheresis include hematological neurologic indications we work with surgery and Transplant neurology Rheumatology and internal medicine so they were the variety of the diseases we can treat is very broad so the asthma guidelines have developed different or have categorized to put the diseases from one to four being category type one a first-line therapy category type two second-line therapy three it means that the role of apheresis hasn’t been determined and four it means that it is ineffective or harmful and we shouldn’t attempt to do a felices there are a few of these diseases actually that it’s been shown that if raises is not effective so in addition to the category as fer has included the grail system to recommend based on the strength of the evidence so great one means a very strong evidence where i’m sorry a very strong recommendation and greater means a weak recommendations and the strength of the evidence is subdivided in a b and c based on the high quality moderate quality or low quality evidence so the lowest evidence that you can get is the to see as you see here let’s see it’s a to see and as you can as you can see most of the a phrases indications

have this type of evidence at this time so every time we do a phrase is an a patient for the most indications the evidence to support the indication what the evidence to support the treatment is actually very weak so i would like to talk about respect particular diseases that can represent this the difficulty difficulties to get evidence on a phrases so the number one is going to be able incompatible solid organ transplantation so what is the role of a phrase is and is transmitted in this type of transplant well number one we can do this sensitization which means remove antibodies before the organ is transplanted number two is rejection so after the organ has been transplanted if there is no development of antibodies we can remove those antibodies to protect the organ the anti values that we may consider to remove include HLA and retention receptor individual antibodies in the case of renal transplant and other antibodies that we don’t know but we know they may exist so just to give you an idea of what is the matching process for solid organ transplant so in the same way that we have antigens on the red blood cell surface we also have ABL antigens on the organ in the organs specifically on the endothelial so the endothelium of the organs express and that’s the reason the AVO it is important when considering a transplant so for instance if we have an O individual it’s an old owner these old owner doesn’t have any antigens on the kidney so on its organ so he can donate or she can donate his organ to any recipient in turns when this same all individual is a recipient and needs a northern the only type of organ that this patient can receive is an old donor so this creates some disparity in the organs available mainly for all recipients so when surgeons and transplant teams need to decide what what else the determinants for organ allocations for kidneys the waiting time is one of the main is one of the main determinant of how who should receive an organ and the second time is how compatible that organ is to the donor for kidneys for liver is a little bit different livers the medical urgency would determine what Hoover safety organ first and this is a current waiting list based on the type so for the most part all patients are the ones like 50 percent of the currently is mainly outpatients again they are not disadvantaged because the only organ that they can receive is a no follow by a B and a B and this is true for all organs and when we look at the kidneys and deeper organs as well so what are the options to increase the donor post to try to benefit these Oh recipients well number one we have the deceased donor that that’s the number one option and about and and then the living donors as well so the living donors only represent 50% of the kidneys at this time and I’m proud to say that last week we perform our first living liver donor here at the transplant here at the University of Washington so that’s something that may grow in the future and the surgeon is sitting here in the audience so the numbers the other thing that we can do is something is called per kidney donation and the per kidney donation is something that is very commonly used here at the University of Washington in which a donor is not compatible with a recipient and this donor is per with another donor is no compared to a recipient and then the organs are all swap so that’s another way we can increase donor availability for recipients that doesn’t don’t have a very good match there are also desensitization protocols again trying to remove antibodies from the from this patient and we can also combine the per kidney donation together with the desensitization to increase the donor pool there is another strategy that we do use here the University of Washington which is to use non a won organs and that means an a to organ for instance to be recipient and just to make it clear and it too is an organ that has any antigens but in very very low amount so they express so little a that may be the anti a antibodies are actually non significant so this a to could be potentially assumed to be very unlike to recipient so what are the risk as a city to incompatible transplant well these organs are incompatible because the the recipient have

antibodies that can reject their the organ so this antibody is combine the antigens on the allograph and can result in rejection so the rejection can be hyper acute when we have preformed antibodies and that’s minutes to hours and actually during the surgery the organ can turn black and just being destroyed by the antibody it could be acute antibody-mediated rejection or it can be acute similar rejections mainly by P cells or chronic rejections with chronic rejections could be through antibody mediated or similar or both so if a be incompatible organs has so the interest why we they’re performing contact incompatible transplant why we try to attempt this well the number one thing is that there is a high mortality rate in the waiting list so we need to increase the donor pool for this tour for these patients because we do have the ability to remove preformed antibodies with plasma exchange and that’s the desensitization protocol there are very strong immunosuppressive strategies that we can use for these patients and we also have the ability to remove newly form antibodies and also there is one mechanism and this is an immunologic mechanism mechanism that is called accommodation that mainly happens in the organs to try to survive this incompatible state so going to the evidence what is that we know about this incompatible transplants so the number one unless incompatible we will be this a to keep knee so eight to means that they have a very very low expression of the antigen that can be safely transplanted into the be patient so the B patients do have anti a so if we pick the patients that are B with very low anti a titers we would assume that this low anti a would not affect the ages and this is actually something that is being done so the units allocation system acknowledge this possibility and if the if a recipient has very low titers there is no need for this unseated the sensitization and there is no need for post transplant antibody follow-up and this patient have very similar outcomes to fully compatible organs so this is something good and we are not doing it reduces for this patient so what if we want to do one completely incompatible transplant if we want to if we want to do an incompatible transplant we need to look at the area very titles the titles can be done in different ways such as steel or gel method the most important thing is that one institution have a very robust and consistent way to perform this antivirus there is a lot of variability between institutions when doing titles the titles can be done or are usually done at room temperature that means our IgM or it can be done through the anti-human globulin phase which are mainly IgG so we do care about both IgG and IgM the therapeutic plasma exchange can be done before and after the transplant and I will show how followed by IVIG infusion and the goal is to decrease it the titer to a safe to a safe level that is not going to result into rejection usually the the safe titer is less than 16 for kidneys so this is a very common it’s one of the common or popular at least at Johns Hopkins desensitization for a VA incompatible transplant so what they do is between between 10 days and one week before the transplant they would start with immunosuppressive medication and plasma exchange combined with IV lg4 using the titles and the amount of plasma exchange and I really depends on the level of the titles then the transplants perform and at that time the patient receive either rituximab which is an anti C 20 antibody or splenectomy in the old days with rituximab splenectomy has been replaced and also receives tails and decreasing map and after the transplanted patient is follow with plasma exchange trying to control the titles again it is expected that the titles are going to increase after the transplant just because the antigen is being placed into this recipient so there is going to be an immune stimuli to increase the titers so plasma change need needs to be done after the transplant and if the titers are very elevated or is not responding very well there is a chance to repeat the rituximab or to perform a splenectomy many times rejection is treated with splenectomy so with this based on this on this treatment schedule what they’ve got it was that for the most part patients with very low titers only needed two

treatments so plasma exchange treatments before the transplant and after the transplant also about two treatments but as there was a good correlation between the titles a pre transplant titles together with the number of procedures they have to do so if the for instance if they’re if they’re a glutton Asian if the titers were between 64 and 128 the patient would need between four and six treatments before transplant and about four treatments after the transplant this is to keep the antibodies low the titers low and when they look at the outcomes the outcomes at one year three years and five years was 93 92 and 88 7% for grass survival I’m very similar for patient survival so the outcomes are very similar to the regular compatible transplant so I need to say that there are no randomized controlled trials looking at incompatible without plasma exchange for instance because we know we would fail this so well if this accommodation that I mentioned before so after the transplant what happened with the titles there you have an incompatible organ now the patient already has antibodies why there is no retraction well it is thought that there is a mechanism that undergoes in the graft not from the donor the donor is being immunosuppressed but it’s something some changes that happen on the graft so this is tolerance is different from I’m sorry accommodation is different from tolerance tolerance is a response from from the host so tolerance is developed when the host decreases the response to the graft accommodation is the graft changing its structure to decrease in new response or the damage induced by the dog by the recipient and we know this because if you take a recipient that has an organ and now the organ is accommodated and you give another organ from the same donor there is a very strong response so the the change has happened in the graph not in the donor the antibodies in the recipient retain antibody binding and complement the position and the hypothesis that there is a regulatory pathway that prevents injury so what are the postulated mechanisms well changes in the epitope spreading so changes in endothelium in terms of the antigen expression and also it is said that anti a and anti-b antibodies can bind the cognate antigen and we know that a and B antigens can bind Bombadil antigens and they can induce a dumb regulation of the immune response again these are basically postulates so it hasn’t been completely elucidated so the main question that I wanted to ask is so we know that in liver and kidneys this works very well can we do the same in livers that was my main question but we need to know is that is noticing that HLA so a B or a carbohydrate and HLA and polypeptides so we know that the immune response that they can elicit is completely different and this is critical to know because for kidneys the HLA typing is not as critical as the livers are not kidneys and the reason for this is that the kidneys are very sensitive to anti air and anti B but livers they may not be as as critical adults are not big children and for this is because we know that when we do incompatible livers in children they have a better outcome that when we do them in adults and then living is not the same as deceased and the reason for that is that we know that the pre conditioning treatment when we are using a living donor is is different from when we’re using a deceased donor so following the same model that I took with the kidneys what is our experience with the eight two livers into the old patients so we have so there was a report in 2012 about 300 patients that were who receive d8 so if you remember the a2 is the one that has very very low a and the old patients are the ones that have anti a so this is at twenty years worth of data and what they show is actually this a two organs it’s exactly the same as they are organs and these patients didn’t receive a freezes or didn’t receive any other different immunosuppressive medication that the than the compatible livers so this paper with 350 patients which is a very nice number so that may be the anti a titers for the a2 livers is not as critical as we think and then when they look at the in this cohort of patients they didn’t look I didn’t check the antibody so

there is no mention of the titles of these antibodies this in 2006 there is about 10 patients that were evaluated and we do have the titles for these patients and what they found is that again this is a very small cohort of patients on The Temptations the high anti air titers did not predict anti very major rejection so there were patients that have projections with very low titles in the 128 range and there were patients that have titles more than 6,000 and 8,000 with no rejection so maybe this rejection was not related to the titers so this is what it suggests what do you think you’d have experience well in the last 10 years we have done 1482 livers in tune on a patient so for the most part is were 13 outpatients and 1b patients so we haven’t done the titles on these patients because it seems a is not relevant only for the last two and in the last been only in two patients with look at the titles and the titles were kind of elevated in the 256 and 1000 for both patients and these patients all these pages all these 40 14 patients except one had a graph survival of at least one year so there was one patient that did have grass but it was not related to antibody material rejection so in terms of this that’s the a to experience what is the experience in incompatible liver transplant and this is a fully incompatible transplant well there are only clear series in case reports there is not a lot of literature out there we know that it is a high-risk procedure it increased anti very marry a rejection risk that is manifested as hepatic necrosis and intrahepatic biliary complications there are some desensitization protocols for living donors mainly from the Japanese experience and there is no standard protocol for deceased donors so again the University of Washington have performed only one living donor and for the most part we use deceased donors there is nothing published about this is donor desensitization so for the living donor the experience from Japan have shown that when they do this in cetacean protocol sister with rituximab and plasma exchange at some point they were using splenectomy but not anymore and then they continue with a very strong immunosuppressive medication and plasma exchange as needed they do something is called a local infusion which is to introduce prostaglandin e2 together with steroids into the hepatic circulation trying to prevent any enjoyment or rejection so the outcomes for this transplant they looked at the antibody marry until a mini rejection incident in patients with similar attacks man was only six percent at one year and only and 23 percent of patients not within a rituximab so they also looked at the antibody marry rejection was predicted by the i2g and i dream’d titles post transplant so the patients that have high titers after the transplant were the ones that develop antibody marry rejection so this is a critical point since we still don’t fully understand where is the role of this IgG and IgM antibodies after transplant and the overall one-year survival was eighty percent for the patient with no antibody major rejection and forty percent with patients with a action again this show how critical it would be to remove these antibodies when we try to attempt an incompatible labor so what is the u-dub experience well in the last five years we have to affirm to may be incompatible transplant both of them were forming and liver failure so these were patients with very high mel’s core that if they hadn’t receive an organ would have died within hours so that was how desperate the situation was so one of the patient is a 19 year old male he was group also has anti a and you receive a donor a before the transplant the titers were 64 128 so the patient received a freeze is before and after the transplant the IgG and IgM levels persisted elevated after the exit ran initially they decrease and then after the transplant after the first week the taters start increasing didn’t respond to plasma exchange and he was free transplanted with an compatible transplant two month later so the graft survival on this patient was 2 months but the patient is still alive 2 years later so this was also a successful story even if we consider that incompatible liver was breached to the compatible River the second patient is the 56 year old female that was also group O and received a donor a B so this was as incompatible as it can get so the IgG and IgM levels were not that high in a 64 range before the transplant we perform apheresis and after it

freezes before and after the transplant the titles remain low and then even one year after the transplant without references of course the titers continued to be low in the 2 & 8 range so the graft survival and the patient survival is greater than 1 year so this patient didn’t need a second transplant so this was a completely successful story for the user experience so what is the asthma guidelines says about the incompatible transplant well for kidneys as you can imagine the dissing situation as I mentioned how they correlate very well with the Oh compatible the dissing situation is a category type one that means that you can do it because it’s actually helpful and it helps to reduce the antibody for antibody mini rejection well it helps as well Group A two to eight to be or in to be deceased donor so when we do the grape grape and the group into we know that we don’t need to do a freezes on these patients when we transplant low titers be so it’s a category type for that means we shouldn’t desensitize this patient this patient don’t need a freezes now we look at the livers when we look at the liver disease dissing citation for living donor has based on the Japanese experience socket area type one that means it helps is it works so you should use it for deceased donor is a category 2 X 3 that means with an now and again there is not the strength of the evidence is to see that means there is a weak recommendation that means we don’t know exactly there is not a lot whole of data to show you what to tell you if you should do it or not the antibody major rejection again is very difficult to prove and there is not a lot of evidence for the group a to into a two-piece or in to be from this since donor that we have the 358 patients from the National Registry and the 14 patient for the a for the University of Washington hasn’t been addressed by the American Society for apheresis I’m not sure in the next guidelines which is going to be addressed but it would be good to have some comments on this one so what is next so after the the last a be incompatible liver here the University of Washington there was a multidisciplinary team that actually created a desensitization protocol to help these patients are informing on liver failure to get an ABN compatible transplant so we do have a protocol here but we have enrolling patients so far we don’t need better understanding of about the expression in the endothelium again we know that maybe the kidneys and the livers the expression is different based on the organ we do need to have brand s and you got a critical antibody titres before and after transplant so we know that for kidneys when we are doing an a2 into a B we do have to have very low titers for livers it’s in cell it doesn’t matter so again we do have to have better knowledge of that and also we don’t know if accomodation that has been also very well established in kidneys if something similar happens in two livers we just don’t know so to get evidence how can we get evidence from these patients to support better these patients so one way is to create a registry this is a rare occurrence so there is is there are no many opportunities to encounter this patient or to collaborate with other institutions and this is how I would like to start talking about the other project which is a successful project that collaborating with other institutions helped us to give some answers to a very rare disease so the other rare disease that I’m going to talk about is about hyper leukocytosis it’s not an entity itself but actually a manifestation of patients that may have actually methodological malignancies with very high white blood cell count so hyper leukocytosis usually happened when or can provoke something that is called luka stasis and Luco stasis represents signs and symptoms when the patient has white blood cell count greater than 100,000 so again these are patients with a new onset of a scheme ideological malignancies have a very high Y blood cell count and now because of this very high white blood cell count they may have neurologic symptoms some pulmonary symptoms and these patients are very sick so the number one goal on these patients is to reduce the amount of white blood cell count that they have in situation so the number one thing that we can do is to start chemotherapy and the other thing that we can do is we can do a freeze on these patients to remove the white blood cell count so when we do this treatment for the most part we modified this treatment a little bit to improve the collection of white blood cells and what we use is something else called hydroxy steel starch so hydroxyl

it’ll start it is a start that actually help sedimentation of red blood cells separating red blood cells from the white blood cells in the interface so the machine can actually collect a white blood cell count without taking the red blood cells so it improves the collection this is not widely used but many institutions use them so it’s been shown in the last 10 years 15 years that this hydroxyl still hydroxyl start has multiple address events this church has volume expanding properties so usually it has been used in the past to as a volume expander mainly for patients with sepsis or shock or hypotension so when we use them when we use the hydroxyl spirit start during sepsis or during cardiac surgery it’s been shown that these patients actually have high risk of renal disease and also death so that that’s not very good so the FDA use a black work black box warning saying you shouldn’t be using this unless it’s really really needed and in Europe had hydroxyl it’ll start is not longer approved for use for use so this happened about 2 or 3 years ago in 2012 and the ask the the apheresis community was very concerned about about this drug because again many hospital use Israel and say can we still use it should we stop using it we know we think we benefit our patient where we use it but we don’t know so for the most part the amount of procedures at one institution can come performs about between 5 and 10 procedures so acute leukemias with hyper leukocytosis are very rare it’s a rare entity so it was a challenge to try to answer this question so so what we did was there is a the Alpha the American Society for FAS is have research subcommittee so we came together and say how can we answer these questions all together so the proposal was to evaluate the renal toxicity in patients undergoing to consider phrases using this start we put together a research plan looking at outcome variables including the creating levels within the first 24 hours after the procedure and secondary outcomes looking at the news for window replacement therapy adverse event rate and the white blood cell count after the procedure we elected to do a retrospective chart review and we look at a five-year period and six institutions participated in this study so we used a redcap database to collect the data every institution look for IRB approval and data use equipment and with is a statistical analysis looking at something that is called difference-in-difference regression analysis so I need to disclose is that the redcap studies data were collected and managed using the redcap and the first cap is a secure web-based application designed to support data capture for research studies and these were the result so we were able between the six institutions to recruit 195 patients most of the patients did not receive start and just a minority receive start as expected most of their patient had acute leukemia and most of the acute leukemia or myeloid leukemia were m4 m5 and this is not this was expected because these patients usually have very very high white blood cell count and they do present with high with a local stasis with signs and centers for justices if when we compare at the baseline characteristic of the two groups they were very similar in terms of the white blood cell count and renal function so we look at the procedure characteristics and both there were no big difference between the two groups and when we look at the primary and secondary outcomes we look at the creatinine actually was not different when we compared before the track before the procedure and after the procedure within 24 hours and before the procedure and seven days after the procedure what we did find was that when we look at the web browser can’t read up from the zero today one is that the patients that receive start actually had a benefit because they have reviewed they were blood cell count by twenty five percent more than the patients that it does receive start again this is very consistent with the current data that we know that start can improve the white blood cell count there were no differences in the creatinine the glomerular filtration rate and the white blood cell count after seven days in the two groups and the other thing is that when we look at actually how the

patients recover clinically we use something that is called in your watney’s score which is a severity score used for patients with hematological malignancies and basically we look at the respiratory status and the neurologic score so then the score goes from zero to three zero mean asymptomatic and three means meaning severe symptoms so this is the grade and these are the patient’s so there were some differences in the baseline characteristic on these patients in the Health Group there were more asymptomatic patients than in no Health Group that there were not that many a symptomatic patients and then in the no Health Group there were many patients that have very severe symptoms so the conclusion from this study was that the use of the Hydra filters hydroxylated start did not result in increase in renal toxicity the use of hydroxide until start resulted in higher side of reduction and also the respiratory symptoms improvement was superior in this in the group the receive start of course there are several limitations and on this study which is the retrospective nature the variability between institutions and this group was a heterogeneous group of patients the advantage is that the use of a registry facilitated obtaining enough patients to develop a meaningful study so what are the challenges and opportunities well we I think with these two presentations like it’s very clear what are the challenges that we have when we are deciding whether a phrase is is useful or not for to treat our patients the number one is that the challenges for doing research is that there is lack of support for references research there is low incidence of some of these diseases this procedure has Co are costly there is a limited number of centers with for instance extracorporeal photopheresis or LDL apheresis there is limited animal model for references and there is lack of intra infrastructure for every this research so in 2012 there was a meeting at the NIH that is called the state of the science in possibly in therapeutic apheresis in which several professional from the apheresis community got together and and discussed what are the proposals or the recommendations to try to improve the apheresis data so the recommendations were to establish a constructor for apheresis medicine to facilitate networking information exchange and research collaboration to specifically charge in existing studies section there is not a specific study section at this time for a phrases research so the idea would be just to add a phrases in one existing study session or developed specific funding to include a phrases medicine and also to promote a free system anything as a variable feel for research for junior and established investigators so the American Society of apheresis what is doing is well they do have research subcommittee that includes multiple in situations and they are developing registries for rare diseases at this time they only have 40 cities including Wilson this is myasthenia gravis normally receptacle and Lukas it authorities there is a study I just presented but in the future they would like to include sickle cell disease TTP LDL apheresis incompatible liver transplant and I forgot to include FSGS as well so talking about registries there is not a national registry for apheresis in the United States there are registries in Canada France the International Society for alpha races that includes many European countries and the world a for this association so annually they present a report but they are very kind just that this actually is not representative for all the affiliates procedures they have so it still limited and why I am doing all these emphasis on the registries well there is this idea of doing this randomized registry trial which is the concept is using big data with small money so this this was a study doing perform in Scandinavia in 2012 I believe 2013 so what they did was with little money they created these very high quality of surveys not register II so they were including all these patient as in a regular registry and then as they were including patients they were able to identify patients that may qualify for a randomized trial and then they randomized these patients in real-time and it was very cost effective to the point that they enroll more than 10,000 patients in two years with 300 thousand dollars so fifty dollars per patient that’s quite impressive of course it’s Scandinavia and the system is a little bit different from our system but I think that’s something

that we may start considering when you have a when we have a low incidence disease as well so with this I go late to finish so Theodore Roosevelt which was present from United States in the beginning of 1900 said you do what you can with what you have where you are I remember my grandmother saying this as well in several opportunities I think the idea is just to try to be creative and and use the resources that we have and I think in a phoresis we can take a lot from this and I would like to acknowledge the as for research subcommittee and the participate in institution without them I will have been able to perform the study I also would like to thank the transplant service at the University of Washington Medical Center in particulars dr. Lena C Valesky who helped me to put the data together for the liver transplant here the transfusion support laboratory and of course the blood worker was a Forest Service physician and nurses who take care of all these patients and there a great group of people so yes the question is from a nephrologist if when we when they perform all these apheresis procedures and the concentration of antibody is higher in the beginning of the procedure because there is no delusion if we can use this as a repository if we can take these samples as a repository I think that’s an excellent idea I think that’s what we need to look at I think a phrase it needs more basic research no observational studies is the first thing that we we do to observe question and then try to answer so I think that’s the way to go it would be it would be a good idea yes so the question is when we are doing a or B organs into a patient that’s secreted matters that’s yes I’ve been thinking about it I think that’s another thing that we need to look at the only thing is that when we have an old recipient has anti a and anti B so there is no soluble a you’ll be at that point that could help us to decrease the antibodies so the a organ comes and I don’t know if the sukira status will help as much or not probably it does so just to translate to the non blood bank community what is the secret or status so as I mentioned before we do have a BL on our red blood cells and for the most part most of the patients would have also in our endothelial and places and secretions but if you are a non-secretor that means it’s on your genes that you are called non-secretor you are not going to have a bo expression in your secretions basically so those organs would be protected against the yes so the question is about accommodation and epitope spreading and if we can show whether it has happened or it definitely hasn’t happened the answer to that is I don’t know enough to tell you exactly how it happens or how we can demonstrate that so what we know is that when we do have biopsies of these patients you would have so a patient that has accumulated right so you take a biopsy from the kidney you would have in the endothelial the antibodies and complement and you will see that you will see that the position but you don’t see the damage that antibody and complement would produce when they get become activated so so that that’s the principle of accomodation like you do have complement binding you do have antibody antigen reaction but what you don’t have is the damage and some

patients that they have sepsis like symptoms and so you can have sepsis like symptoms and the absence of bacteria and so are these patients getting accept just like symptoms in the absence of a creme in if that’s the case is it possible that the leukocytes during the process are actually becoming activated and spilling into the material providing back to the patient and so plasmapheresis is something that needs to be done in addition to that and the basis for asking that question right is a number of genetic syndromes that lead to phagocytic cells that are susceptible to creating Auto inflammatory cells all right well that’s a very complex question because you touched on the hydroxyl it’ll start to be used to reduce the amount of white blood cells also on septic patients and if release it has been tried on sepsis regardless the the the white blood cell count and regardless the hydroxy lstart so so what is your question again I thought I understood that some of the patients that were where HGS was being used mm-hmm but they displayed such as likes it right so actually um patients with sepsis that were in multi organ failure and hypotensive and they needed volume expansion they were using has as a volume expander without a phrases without anything else right so they would use it as a volume expander I think there is all this controversy between giving crystalloids or color it’s right okay part of those colors would be the hair so how do we better expand these patients our volume depleted and so in that context is where head was was used and in that context is when they it was shown that the patient had renal toxicity an increase up there I was so concerned about your questions which as Emily as a statistician and so what if we do so the question is we did an observational study and we and what would happen if we use a randomized control trial for this population I think the main concern about doing the current randomized control trial is number one these patients can throw the emergency department very sick so I don’t know if would be possible to consent this patient saying hey do you want start or non start when actually they may die within the next twelve hours so it is a very accurate disease number two there are not enough patients so six institutions five years 200 patients that’s that’s not a very big number and if we take into account that many patients will not consent so probably we will get with 50% of consent let’s say 50% consent we would have to take two years or five years to get a hundred patients and I don’t know if we would have been able to see a difference I think that those were the challenges of our randomized control trial right so so the statistician the person that did the statistical analysis actually did this propensity score match so we were right so we were sure that actually the two were actually comparable so we can you you