Plasmapheresis


Plasmapheresis MachinePlasmapheresis is a medical procedure designed to remove some plasma from the blood. During a plasma exchange, unhealthy plasma is swapped for healthy plasma or a plasma substitute, before the blood is returned to the body.

The blood vessels contain plasma. It is a fluid made up of blood cells, platelets, and essential nutrients.

During plasmapheresis, blood is removed and separated into these parts by a machine.

Plasmapheresis can also refer to when plasma is removed from the body to be donated.

Plasmapheresis is a process that filters the blood and removes harmful antibodies. It is a procedure done similarly to dialysis; however, it specifically removes antibodies from the plasma portion of the blood. Antibodies are part of the body’s natural defence system which help destroy things that are not a natural part of our own bodies, like germs or bacteria.

What is Plasmapheresis?

Pheresis, or apheresis, describes any process that removes the blood, filters and retains elements of it, then returns the blood to the body. Platelets, red blood cells, white blood cells, or plasma may be separated.

The procedure is performed using a machine that removes small amounts of blood at a time.

Plasmapheresis

Plasmapheresis Machine

There are two ways to separate the components of blood:

  • Centrifugation. This process spins the blood, which divides it according to the density of the parts.
  • Filtration. This involves passing the blood through a filter to separate plasma.

During a plasma exchange, the machine will dispose of unhealthy plasma and replace it with healthy plasma from a donor. Unhealthy plasma can also be replaced with saline, albumin, or a combination of the two.

Indications of Plasmapheresis:

Plasmapheresis is currently used as a therapeutic modality in a wide array of conditions. 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 guidelines.

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:

  • Guillain-Barre syndrome.
  • Myasthenia gravis.
  • 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, fulminant.

Thrombotic Thrombocytopenic Purpura

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 (disorders for which the optimal role of apheresis therapy is not established; decision-making should be individualized) are as follows:

  • Post-transfusion purpura.
  • Autoimmune hemolytic anemia (warm autoimmune hemolytic anemia).
  • Hypertriglyceridemic pancreatitis.
  • 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.

Benefits of Plasmapheresis:

A plasma exchange can help to alleviate symptoms of the conditions above by removing harmful substances from the blood.

If a person has an autoimmune condition, a plasma exchange may also prevent the body from producing more harmful antibodies.

The procedure is usually one element of a treatment plan, which may include chemotherapy. Repeated plasma exchanges may be necessary.

Plasmapheresis Procedure:

A medical professional will perform plasmapheresis, usually in a hospital but sometimes in a private clinic.

Premedication with acetaminophen, diphenhydramine, and hydrocortisone are often given.

A local anaesthetic will numb the affected area, and the procedure should not cause pain.

The doctor will then insert a small tube into a vein in the arm or the groin. The tube will bring blood to the machine, which will collect it, treat it, and return it to the body.

Plasma exchange takes between 2 and 4 hours. A person will need to remain as still as possible to help the blood to flow smoothly. It may help to watch television or read as a distraction.

A medical professional will be present and check for side effects throughout the process.

After the plasma exchange is complete, the machine will be disconnected, and new blood tests will be performed.

Plasmapheresis

Contraindications of Plasmapheresis:

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.
  • Patients taking angiotensin-converting enzyme (ACE) inhibitors are advised to stop taking the medication for at least 24 hours before starting plasmapheresis.

References:

Elliot Stieglitz, MD; Emmanuel C Besa, MD. Plasmapheresis: Background, Indications, Contraindications https://emedicine.medscape.com/article/1895577-overview

Schwartz J, Padmanabhan A, Aqui N, Balogun RA, Connelly-Smith L, Delaney M, 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 Seventh Special Issue. J Clin Apher. 2016 Jun. 31 (3):149-62.

Claire Sissons. Plasmapheresis: Side effects and how it works – Last reviewed Tue 10 April 2018. https://www.medicalnewstoday.com/articles/321451.php

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.

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