Plasmapheresis
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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 RBCs along with replacement colloid (eg, donor plasma or albumin) are 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.
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 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:
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:
Category III (disorders for which the optimal role of apheresis therapy is not established; decision-making should be individualized) are as follows:
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:
Plasmapheresis is contraindicated in the following patients:
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 RBCs, WBCs, or platelets and can be accomplished by using identical centrifuge-based equipment. Applications include the following:
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]
[Guideline] Kaplan AA. Therapeutic plasma exchange: core curriculum 2008. Am J Kidney Dis. 2008 Dec. 52(6):1180-96. [Medline].
[Guideline] 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. [Medline].
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].
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].
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].
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].
Siami GA, Siami FS. Current topics on cryofiltration technologies. Ther Apher. 2001 Aug. 5(4):283-6. [Medline].
Malchesky PS. Therapeutic Apheresis: Why?. Ther Apher Dial. 2015 Oct. 19 (5):417-26. [Medline]. [Full Text].
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. 2016 Feb. 31 (1):11-5. [Medline].
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. 2016 Apr. 45 (4):606-12. [Medline].
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].
Apter AJ, Kaplan AA. An approach to immunologic reactions associated with plasma exchange. J Allergy Clin Immunol. 1992 Jul. 90(1):119-24. [Medline].
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].
Silberstein LE, Naryshkin S, Haddad JJ, Strauss JF 3rd. Calcium homeostasis during therapeutic plasma exchange. Transfusion. 1986 Mar-Apr. 26(2):151-5. [Medline].
Krishnan RG, Coulthard MG. Minimising changes in plasma calcium and magnesium concentrations during plasmapheresis. Pediatr Nephrol. 2007 Oct. 22(10):1763-6. [Medline].
Goldstein SL. Therapeutic apheresis in children: special considerations. Semin Dial. 2012 Mar-Apr. 25 (2):165-70. [Medline].
Mokrzycki MH, Kaplan AA. Therapeutic plasma exchange: complications and management. Am J Kidney Dis. 1994 Jun. 23(6):817-27. [Medline].
Owen HG, Brecher ME. Atypical reactions associated with use of angiotensin-converting enzyme inhibitors and apheresis. Transfusion. 1994 Oct. 34 (10):891-4. [Medline].
Elliot Stieglitz, MD Pediatric Oncologist, University of California, San Francisco, School of Medicine
Disclosure: Nothing to disclose.
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.
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.
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.
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.
Plasmapheresis
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