Aphaeresis/ Apheresis (for removal of microclots)

A noteworthy excerpt: “Jaeger has bought a €200 000 microscope for her clinic and pays licence fees to Stellenbosch University for use of its method.”

Dr Jaeger is the doctor who runs the HELP apheresis clinic in Mulheim, Germany. Stellenbosch University is home to Dr Pretorius, whose research now focuses on detecting microclots in long Covid. Her microscope method is patented, hence why Dr Jaeger must pay fees for its use.

Dr Pretorius thus has a significant financial conflict of interest in promoting the microclot theory.

 

There is something spooky about this to me.
Here is a BMJ article written by the 'investigations editor' whoever that might be. It quotes charities and lawyers but I didn't catch any sign of a medical scientist opining?

When I have talked with medical colleagues I have been met with a genial but stony silence.

From what I can gather this apheresis setup looks as if it may be highly unethical. Yet it seems that my colleagues are no longer in the business of whistleblowing. Maybe they worry they might upset someone important in charge of pursestrings somewhere? Why isn't the BMJ getting a haematologist to say out loud that this looks totally unproven and unjustified?

 

ITV news report

https://www.youtube.com/watch?v=GtDWynfubFM

 

Surely a quick and dirty indication of whether this has any validity, ignoring any 'thoughts' on mechanisms/maksenssisness/etc., would be to see if anyone on dialysis has long covid, if they do then this cannot possibly be a solution/work around etc.

 

Well, OK, but Ariens is not a clinical haematologist, and his argument is pretty feeble. There is nothing wrong with trying to get rid of something that might be doing harm. The problem is the quality of evidence, not that.

Dr Banerjee would do, but again, he is arguing a technical theoretical point. The problem is the quality of the data. And he is a cardiologist, not a haematologist.

Why isn't the article written by a haematologist? There are plenty of them out there who know perfectly well whether or not the data mean anything at all.

 

Oh, yeah, totally. That's an issue, now? Literally standard practice for everything biopsychosocial. They literally depend on there being no follow-up at all.

I agree it's a concern. Can we all freaking agree that this should always be a concern? We can't agree to that? Only when convenient to push an agenda? NO? WHY THE F NOT?!!!

 

Isn't dialysis passing blood over a membrane and pulling things out by osmosis? Is there any filtration involved?

 

No idea, I though the point of dialysis was to remove things from the blood, presumably smaller things than cells, so regardless of how it's done I would expect, from a non medical point of view, that dialysis would remove microclots, which I am under the impression are 'quite small' - hence the micro.

I may be wrong of course.

 

The things dialysis removes are many orders of magnitude smaller than red blood cells, so simple filtration wouldn't work at all.

Also, they give heparin to prevent clotting in the dialysis machine, which wouldn't be necessary if it removed clots.

 

Dialysis which I've performed removes excess electrolytes like potassium and sodium and adds a bit of bicarb buffer to the acidic blood. Excess urea is removed (patients smell a bit bad when they come in for their treatments). Proteins, like albumin are large and do not cross the membrane of the fibers and so aren't lost. I forget the dalton limit.

As far as removing clots, those would probably gum up the very fibers used for the above functions. Heparin is used routinely prior to starting up the dialysis treatment; otherwise you'd have big time clotting of the fibers of the dialyzer.

I haven't done apheresis however, so I can only presume that some type of anti-coagulant is used for extra corporeal circulation of blood (as in dialysis).

 

(Off, but in Hungary there is a paleontologist whose name literally translates as Attila Ancient. There was also a drug programme coordinator whose name means Peter Powderbreaker.
These are really rare, unique surnames, I've never heard them anywhere else and that makes this even funnier.
Oh, and the number 1 celebrity hairdresser is called László Hairy.)

 

Overview opinion piece

My bolding

https://www.bmj.com/content/378/bmj.o1733

 

To add to @shak8 comment's on the difference with haemodialysis, HELP apheresis is —

1. Blood is separated into plasma and cellular components, by a capillary plasma filter. The cells are returned straight back to the patient in one limb of the circuit.
2. Sodium acetate buffer and heparin are added to plasma in the other limb of the circuit, which drops its pH and provides a substrate for the next step.
3. Soluble fibrinogen and lipoprotein complexes precipitate out at the lower pH in the presence of heparin. (I think larger fibrin polymers get captured too, though they will be insoluble anyway)
4. These undesirables* are then removed via a filter**
5. Heparin is then removed from the plasma.
6. The final bit returns the "nice and clear" plasma pH/osmolality etc to physiological normal using typical haemodialysis ultrafiltration and bicarb, and so back to the patient.

* As it is claimed. 40 years of Germany finding this useful for dyslipidaemias etc, but I don't know if removing fibrinogen was ever an expected or noted part of this process historically. It may have been a subclinical side-effect that was not of significance for people with normal fibrinogen, but I'm not sure.

** This is the filter that is full of junk in people's Twitter pictures, that can require multiple exchanges in a session.

 

LMAO. The same people harping about how hope is literally the main mechanism of treatment are actually using the argument that giving false hope is bad. You couldn't make this stuff up in a book or movie, it's so absurdly dishonest it's not believable that medicine could be this dysfunctional.

The BMJ literally published the SMILE study and has been harping LP for years, while the author of the first report is apparently buddy-buddy with Paul "Scuba-diving-while-'ill'" Garner. What a bunch of hacks. And this is a top journal. How can anyone trust anything out of medical research anymore?

I don't think this will be a valid treatment, although it could still provide clues to the cause so worth pursuing, but the fact that 100x-1,000x as much has been wasted already on useless and harmful BS treatments really says everything about how evidence is completely irrelevant in medicine unless it meets scientific standards. It's all about fashion, about what's popular and what people generally believe in. The fact that BPS BS is all there is, as a choice, says it all.

I assume that everyone warning about untested treatments will support this. I'm sorry, I meant absolutely none, of course:

https://twitter.com/user/status/1547532820557488128

 

Subsequent to the immediately above tweet. (Note this is regarding studying microclots and anti-coagulation, not HELP apheresis.)

https://twitter.com/user/status/1547647702451687425

 

Dr Asad Khan writes a rapid response to the BMJ.

He also notes that the article glossed over six patients who had positive results.

As far as apheresis is concerned, if not a cure, it may be that it will be shown to have a limited but useful role in select severe LC (+/- ME) presentations — perhaps it can reduce downstream symptoms relating to hypercoagulability, even if immunometabolic dysfunction & immunothrombosis continue to drive it, needing to be addressed via other means.