Aphaeresis/ Apheresis (for removal of microclots)

[cassava7]

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.

 

[Jonathan Edwards]

This seems to me to be an important and well balanced article. I think one of the important things it highlights is the different approaches to evidence and risk among clinicians - those providing the treatment, those urging caution until a clinical trial has been done, and those who are both clinicians and patients and want to get on with trying anything that might work, and arguing that clinicians shouldn't wait for clinical trials.

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?

 

[Trish]

It quotes charities and lawyers but I didn't catch any sign of a medical scientist opining?

But experts contacted by The BMJ said that more research is needed to understand how microclots form and whether they are causing long covid symptoms.

“They [microclots] may be a biomarker for disease, but how do we know they are causal?” said Robert Ariens, professor of vascular biology at the University of Leeds School of Medicine. He believes the clinics offering apheresis and anticoagulation therapy are prematurely providing treatment that is based on a hypothesis that needs more scientific research. “If we don’t know the mechanisms by which the microclots form and whether or not they are causative of disease, it seems premature to design a treatment to take the microclots away, as both apheresis and triple anticoagulation are not without risks, the obvious one being bleeding,” he continued.

There is as yet no published and peer reviewed evidence showing that apheresis and anticoagulation therapy reduce the microclots. “As we don’t know how they form, we cannot tell if this treatment will stop microclots from recurring,” Ariens said.

Some clinicians are concerned about the lack of follow-up care for patients when they leave clinics that offer apheresis. Anticoagulation should be given in a supervised way by clinicians who regularly follow up patients, because bleeding could present as bruising or nosebleeds but could also be a brain haemorrhage, said Amitava Banerjee, a cardiologist in London and chief investigator on the Stimulate-ICP trial into long covid. “I’m concerned that this has been pushed in a vulnerable group,” he continued. “We haven’t got solid evidence for single anticoagulation therapy, let alone triple.”

 

[Adam pwme]

ITV news report

 

[Wonko]

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.

 

[Jonathan Edwards]

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.

 

[rvallee]

Some clinicians are concerned about the lack of follow-up care for patients when they leave clinics that offer apheresis

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?!!!

 

[LarsSG]

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.

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

 

[Wonko]

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.

 

[LarsSG]

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.

 

[shak8]

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).

 

[Sean]

maksenssisness

 

[Hutan]

ITV news report

Did anyone else enjoy the name of the man who founded the Cyprus Long Covid centre offering aphaeresis for micro clots?
(screenshot)

 

[Wyva]

Did anyone else enjoy the name of the man who founded the Cyprus Long Covid centre offering aphaeresis for micro clots?
(screenshot)
View attachment 17668

(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.)

 

[John Mac]

Overview opinion piece

Editor's Choice
Long covid and apheresis: a miracle cure sold on a hypothesis of hope
In desperate times, even in good times, we all need hope. Hope is essential and helps us seek solutions. Yet hope can be a dangerous weapon.

[...]

Equally, it’s easier to argue against covid restrictions if you haven’t experienced long covid. Many people living with it are desperate for a return to “normal,” so much so that they are turning to unproved experimental therapies. A new BMJ investigation with ITN News finds that people are spending their life savings on apheresis, a treatment that claims to clear microthrombi from blood (doi:10.1136/bmj.o1671).20 There are no trials, only hypotheses. There is no research evidence of benefit, only anecdotal reports and the blind faith of vulnerable people seeking a miracle cure. We all need hope, but hope can sometimes be a dangerous thing.

My bolding

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

 

[SNT Gatchaman]

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.

 

[rvallee]

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.

only anecdotal reports and the blind faith of vulnerable people seeking a miracle cure

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:

**Calling adults with #longcovid**
If you are not on antiplatelets/anticoagulants and are willing to travel to Manchester to donate blood to help us develop microclot testing, please DM me and I will send you details.
#teamclots

 

[SNT Gatchaman]

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

 

[SNT Gatchaman]

Thousands seeking unproven long Covid blood treatments abroad [...] https://www.bmj.com/content/378/bmj.o1671

Dr Asad Khan writes a rapid response to the BMJ.

When I got called to Germany, I had developed myalgic encephalomyelitis (ME/CFS) with severe dysautonomia and gastroparesis. I could not tolerate sitting upright for more than a few minutes. I had extreme stimulus hypersensitivity - a sliver of light through the blinds would set off neuropathic pain and crippling nausea. Some fellow sufferers have committed suicide, including two UK doctors. I would have gone their way if it hadn't been for clinicians like Dr Jaeger who are prepared to push boundaries. I may not be cured, but I have been given a second chance at life.

Feedback about these [NHS Long Covid] clinics from fellow sufferers is overwhelmingly negative, with very few patches of good practice. They offer little more than pacing advice and psychological support for what is a serious multisystem organic condition. Patients even struggle to access drugs like antihistamines and beta blockers, which can greatly alleviate symptoms. Some clinics still advise Graded Exercise Therapy (GET) despite NICE clearly stating that it should not be offered in Long Covid or ME/CFS. It is insulting to suggest that patients should trust these clinics, when often they know more about the condition than the clinicians delivering the service. I would not be alive if I had left my care to the Long Covid clinics. I could not have waited any longer: 2.5 years into the pandemic, over 100 million worldwide are still waiting. This is inhuman and unacceptable.

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

There definitely need to be trials of treatment - however, where are they? Given the scale of the suffering (2 million in the UK alone) they need to be happening at lightning speed like they did with RECOVERY in acute COVID. Instead, studies of potentially harmful and unhelpful treatments such as exercise continue to be funded.

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.

 

[Hutan]

Thanks SNT Gatchaman. Dr Asad Khan makes some great points about the Long COVID-19 clinics.

-The occurrence of microclots in the blood of Long Covid patients is not a 'theory'. Professor Resia Pretorius has conclusively demonstrated their presence; her controls did not exhibit pathological micro-clotting. The techniques have been replicated in the UK, and the findings shall be published in due course.

Have you heard anything about this that you can share?