Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Plasmapheresis

  • Author: Elliot Stieglitz, MD; Chief Editor: Emmanuel C Besa, MD  more...
 
Updated: Dec 21, 2015
 

Background

Plasmapheresis is a term used to refer to a broad range of procedures in which extracorporeal separation of blood components results in a filtered plasma product.[1, 2] The filtering of plasma from whole blood can be accomplished via centrifugation or the use of semipermeable membranes.[3] Centrifugation takes advantage of the different specific gravities inherent to various blood products, such as red blood cells (RBCs), white blood cells (WBCs), platelets, and plasma.[4] Membrane plasma separation uses differences in particle size to filter plasma from the cellular components of blood.[3]

Traditionally, in the United States, most plasmapheresis is done with automated centrifuge-based technology.[5] In certain instances—in particular, in patients already undergoing hemodialysis—plasmapheresis can be carried out using semipermeable membranes to filter plasma.[4]

In therapeutic plasma exchange, using an automated centrifuge, filtered plasma is discarded and red blood cells along with replacement colloid such as donor plasma or albumin is returned to the patient. In membrane plasma filtration, secondary membrane plasma fractionation can selectively remove undesired macromolecules, which then allows return of the processed plasma to the patient instead of donor plasma or albumin. Examples of secondary membrane plasma fractionation include cascade filtration,[6] thermofiltration, cryofiltration,[7] and low-density lipoprotein pheresis.

Next

Indications

Plasmapheresis is currently used as a therapeutic modality in a wide array of conditions.[2, 8] Generally, it is used when a substance in the plasma, such as immunoglobulin, is acutely toxic and can be efficiently removed. Myriad conditions that fall into this category (including neurologic, hematologic, metabolic, dermatologic, rheumatologic, and renal diseases, as well as intoxications) can be treated with plasmapheresis.

The Apheresis Applications Committee of the American Society for Apheresis periodically evaluates potential indications for apheresis and categorizes them from I to IV in the basis of the available medical literature. The following are some of the indications, and their categorization, from the society’s 2010 guidelines.[2]

Category I (disorders for which apheresis is accepted as first-line therapy, either as a primary standalone treatment or in conjunction with other modes of treatment) are as follows:

  • Chronic inflammatory demyelinating polyneuropathy
  • Hyperviscosity in monoclonal gammopathies
  • Thrombotic thrombocytopenic purpura
  • Goodpasture syndrome (unless it is dialysis-dependent and there is no diffuse alveolar hemorrhage)
  • Hemolytic uremic syndrome (atypical, due to autoantibody to factor H)
  • Wilson disease, [9] fulminant

Category II (disorders for which apheresis is accepted as second-line therapy, either as a standalone treatment or in conjunction with other modes of treatment) are as follows:

  • Lambert-Eaton myasthenic syndrome
  • Multiple sclerosis (acute central nervous system demyelination disease unresponsive to steroids)
  • RBC alloimmunization in pregnancy
  • Mushroom poisoning
  • Acute disseminated encephalomyelitis
  • Hemolytic uremic syndrome (atypical, due to complement factor mutations)
  • Autoimmune hemolytic anemia (life-threatening cold agglutinin disease)
  • Systemic lupus erythematosus (severe)
  • Myeloma cast nephropathy

Category III (optimum role of apheresis therapy is not established; decision-making should be individualized) are as follows:

  • Posttransfusion purpura
  • Autoimmune hemolytic anemia (warm autoimmune hemolytic anemia)
  • Hypertriglyceridemic pancreatitis [10]
  • Thyroid storm

Category IV (disorders in which published evidence demonstrates or suggests apheresis to be ineffective or harmful; institutional review board [IRB] approval is desirable if apheresis treatment is undertaken in these circumstances) are as follows:

  • Stiff person syndrome
  • Hemolytic uremic syndrome (typical diarrhea-associated)
  • Systemic lupus erythematosus (nephritis)
  • Immune thrombocytopenia
Previous
Next

Contraindications

Plasmapheresis is contraindicated in the following patients:

  • Patients who cannot tolerate central line placement
  • Patients who are actively septic or are hemodynamically unstable
  • Patients who have allergies to fresh frozen plasma or albumin depending on the type of plasma exchange
  • Patients with heparin allergies should not receive heparin as an anticoagulant during plasmapheresis
  • Patients with hypocalcemia are at risk for worsening of their condition because citrate is commonly used to prevent clotting and can potentiate hypocalcemia
Previous
Next

Technical Considerations

Terminology

Although the term plasmapheresis technically refers only to the removal of plasma, it is also widely used to encompass therapeutic plasma exchange in which a replacement product is transfused after removal of the plasma.[11]

As distinct from plasmapheresis, cytapheresis is the selective removal of red blood cells (RBCs), white blood cells (WBCs), or platelets and can be accomplished by using identical centrifuge-based equipment. Applications include the following:

  • Erythrocytapheresis (selective removal of RBCs) is used in conditions such as sickle cell disease or malarial infection, in which RBCs are selectively removed and replaced with donor erythrocytes
  • Leukapheresis (selective removal of WBCs) is used in conditions such as hyperleukocytosis, in which pathologically high number of white cells are present (as, for example, in leukemia); it can also be used to collect peripherally circulating stem cells that can then be infused in an autologous or allogeneic stem cell transplant
  • Platelet apheresis (selective removal of platelets) can be used in conditions of thrombocytosis (eg, polycythemia vera)

Complication prevention

Having all the equipment and medications required for the procedure readily available at the start in order to minimize complications is important. Sterile technique is advised in order to reduce the likelihood of infection.

Premedication with acetaminophen, diphenhydramine, and hydrocortisone are often given if the patient is to receive any blood product, including priming the tubing with packed red blood cells, in particular if a history exists of prior reaction to blood products.[12]

Previous
 
 
Contributor Information and Disclosures
Author

Elliot Stieglitz, MD Pediatric Oncologist, University of California, San Francisco, School of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

James Huang, MD Clinical Professor of Pediatrics, Director of Pediatric Hematology, University of California, San Francisco, School of Medicine

James Huang, MD is a member of the following medical societies: American Society of Hematology, American Society of Pediatric Hematology/Oncology, Hemophilia and Thrombosis Research Society

Disclosure: Received grant/research funds from Baxter Healthcare Corporation for research; Received grant/research funds from BPL for research.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Emmanuel C Besa, MD Professor Emeritus, Department of Medicine, Division of Hematologic Malignancies and Hematopoietic Stem Cell Transplantation, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American Society of Clinical Oncology, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Hematology, New York Academy of Sciences

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors wish to thank Beth DuVardo, RN, and Lillian Larue, RN, of the Apheresis Unit at University of California, San Francisco, School of Medicine for their assistance with this article.

References
  1. [Guideline] Kaplan AA. Therapeutic plasma exchange: core curriculum 2008. Am J Kidney Dis. 2008 Dec. 52(6):1180-96. [Medline].

  2. Szczepiorkowski ZM, Winters JL, Bandarenko N, Kim HC, Linenberger ML, Marques MB, et al. Guidelines on the use of therapeutic apheresis in clinical practice--evidence-based approach from the Apheresis Applications Committee of the American Society for Apheresis. J Clin Apher. 2010. 25(3):83-177. [Medline].

  3. Siami GA, Siami FS. Membrane plasmapheresis in the United States: a review over the last 20 years. Ther Apher. 2001 Aug. 5(4):315-20. [Medline].

  4. Gerhardt RE, Ntoso KA, Koethe JD, Lodge S, Wolf CJ. Acute plasma separation with hemodialysis equipment. J Am Soc Nephrol. 1992 Mar. 2(9):1455-8. [Medline].

  5. Gurland HJ, Lysaght MJ, Samtleben W, Schmidt B. A comparison of centrifugal and membrane-based apheresis formats. Int J Artif Organs. 1984 Jan. 7(1):35-8. [Medline].

  6. Agishi T, Kaneko I, Hasuo Y, Hayasaka Y, Sanaka T, Ota K, et al. Double filtration plasmapheresis. 1980. Ther Apher. 2000 Feb. 4(1):29-33. [Medline].

  7. Siami GA, Siami FS. Current topics on cryofiltration technologies. Ther Apher. 2001 Aug. 5(4):283-6. [Medline].

  8. Malchesky PS. Therapeutic Apheresis: Why?. Ther Apher Dial. 2015 Oct. 19 (5):417-26. [Medline]. [Full Text].

  9. Pham HP, Schwartz J, Cooling L, Hofmann JC, Kim HC, Morgan S, et al. Report of the ASFA apheresis registry study on Wilson's disease. J Clin Apher. 2015 Aug 14. [Medline].

  10. Chang CT, Tsai TY, Liao HY, Chang CM, Jheng JS, Huang WH, et al. Double Filtration Plasma Apheresis Shortens Hospital Admission Duration of Patients With Severe Hypertriglyceridemia-Associated Acute Pancreatitis. Pancreas. 2015 Oct 21. [Medline].

  11. McLeod BC, Sniecinski I, Ciavarella D, Owen H, Price TH, Randels MJ, et al. Frequency of immediate adverse effects associated with therapeutic apheresis. Transfusion. 1999 Mar. 39(3):282-8. [Medline].

  12. Apter AJ, Kaplan AA. An approach to immunologic reactions associated with plasma exchange. J Allergy Clin Immunol. 1992 Jul. 90(1):119-24. [Medline].

  13. McLeod BC. Therapeutic apheresis: use of human serum albumin, fresh frozen plasma and cryosupernatant plasma in therapeutic plasma exchange. Best Pract Res Clin Haematol. 2006. 19(1):157-67. [Medline].

  14. Silberstein LE, Naryshkin S, Haddad JJ, Strauss JF 3rd. Calcium homeostasis during therapeutic plasma exchange. Transfusion. 1986 Mar-Apr. 26(2):151-5. [Medline].

  15. Krishnan RG, Coulthard MG. Minimising changes in plasma calcium and magnesium concentrations during plasmapheresis. Pediatr Nephrol. 2007 Oct. 22(10):1763-6. [Medline].

  16. Goldstein SL. Therapeutic Apheresis in Children: Special Considerations. Semin Dial. 2012 Jan 25. [Medline].

  17. Mokrzycki MH, Kaplan AA. Therapeutic plasma exchange: complications and management. Am J Kidney Dis. 1994 Jun. 23(6):817-27. [Medline].

  18. Galgiani JN, Catanzaro A, Cloud GA, Johnson RH, Williams PL, Mirels LF. Comparison of oral fluconazole and itraconazole for progressive, nonmeningeal coccidioidomycosis. A randomized, double-blind trial. Mycoses Study Group. Ann Intern Med. 2000 Nov 7. 133(9):676-86. [Medline].

  19. McLeod BC. Introduction to the third special issue: clinical applications of therapeutic apheresis. J Clin Apher. 2000. 15(1-2):1-5. [Medline].

  20. Sawada K, Malchesky PS, Nosé Y. Available removal systems: state of the art. Curr Stud Hematol Blood Transfus. 1990. 51-113. [Medline].

  21. Suzuki M, Yamane S, Matsugane T, Nobuto T, Azuma N, Nishide T. Evaluation of double filtration plasmapheresis, thermofiltration, and low-density lipoprotein adsorptive methods by crossover test in the treatment of familial hypercholesterolemia patients. Artif Organs. 1996 Apr. 20(4):296-302. [Medline].

 
Previous
Next
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.