Diversion of prime to ameliorate citrate toxicity in pediatric extracorporeal apheresis

      Approximately 20–50 % of pediatric patients undergoing allogeneic hematopoietic stem cell transplantation may develop chronic Graft Versus Host Disease (GVHD) [
      • Baird K.
      • Cooke K.
      • Schultz K.R.
      Chronic graft versus host disease (GVHD) in children.
      ], which is an American Society for Apheresis (ASFA) Category II indication for Extracorporeal Photopheresis (ECP) [
      • Padmanabhan A.
      • Connelly-Smith L.
      • Aqui N.
      • Balogun R.A.
      • Klingel R.
      • Meyer E.
      • et al.
      Guidelines on the use of therapeutic apheresis in clinical practice – evidence-based approach from the Writing Committee of the American Society for Apheresis: the Eighth Special Issue.
      ]. We were recently referred a 30 kg patient with chronic GVHD primarily affecting the liver and integument – with prominent features being restriction in mouth opening (due to sclerosis) and hyperpigmentation of the skin. Treatments prior to referral included steroids, rituximab, sirolimus, and imatinib.
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