Transfusion medicine
Therapeutic apheresis
Therapeutic plasma exchange (TPE)


Minor changes: 16 February 2021

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PubMed Search: Therapeutic plasma exchange[TI] review[PT] transfusion

Elizabeth A. Godbey, M.D.
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Cite this page: Godbey EA. Therapeutic plasma exchange (TPE). PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/transfusionmedtherapeuticplasmaexchange.html. Accessed March 9th, 2021.
Definition / general
  • Automated instrument removes whole blood from patient, separates and removes plasma, returns remainder of blood along with replacement fluid
  • Instrument separation method: centrifugation (most common method in U.S.) or membrane filtration
  • Volume treated: most commonly 1 - 1.5 plasma volumes
Indications
  • In general, goal is to remove pathogenic substances present in plasma to mitigate disease processes
  • American Society for Apheresis (ASFA) guidelines were most recently published in 2019 (J Clin Apher 2019;34:171)
ASFA guidelines
  • Published every 3 years
  • For each indication, ASFA provides
    • Category: I - IV (description of the place of apheresis in treatment of the indication)
      • I: apheresis first line therapy
      • II: apheresis second line therapy
      • III: optimum role of apheresis therapy is not established
      • IV: apheresis ineffective or harmful
    • Grade: 1A - 2C (a reflection of the evidence used to assign the category)
    • Background information about disease
    • Practical guidance: replacement fluid, number of procedures, frequency of procedures, volume to treat
  • Reference: J Clin Apher 2019;34:171
Examples of TPE category I indications per 2019 ASFA guidelines
  • Catastrophic antiphospholipid syndrome
  • Chronic inflammatory demyelinating polyradiculoneuropathy
  • Focal segmental glomerulosclerosis recurrent in kidney transplant
  • Myasthenia gravis acute, short term treatment (long term treatment is category II)
  • Antibody mediated rejection following ABO compatible renal transplant (antibody mediated rejection following ABO incompatible renal transplant is category II)
  • Thrombotic thrombocytopenic purpura
  • Wilson disease, fulminant
  • Reference (includes all indications): J Clin Apher 2019;34:171
Vascular access
  • High flow rates
  • Peripheral veins, central venous catheter, ports, fistula, AV graft
Anticoagulation
  • Citrate or heparin
  • Use of supplemental calcium with citrate anticoagulation varies by institution (some administer calcium to every patient, some according to patient ionized calcium values or patient symptoms of hypocalcemia)
Replacement fluid
  • Typically, albumin or donor plasma (or a combination of these, for example, half albumin followed by half plasma)
  • See ASFA guidelines for indication specific recommendations (J Clin Apher 2019;34:171)
  • Plasma with coagulopathy, bleeding, peri-invasive procedure
  • Typically, 1 - 1.5 plasma volumes are exchanged per TPE procedure; the Optia instrument can calculate this volume based on patient specific data
  • One plasma volume = total blood volume x (1 - hematocrit)
TPE removes plasma
  • Includes not only potential pathogenic substances but also normal plasma contents such as coagulation factors
  • Can remove medications (especially those that are highly protein bound, small volume of distribution)
Potential adverse events
  • Associated with anticoagulant: e.g. symptoms of hypocalcemia secondary to citrate
  • Associated with concurrent ACE inhibitor use: hypotension
  • Associated with extracorporeal volume: e.g. hypotension
  • Associated with replacement fluid: e.g. allergic reaction to albumin or plasma
  • Associated with vascular access: e.g. infection
  • Very rare, death
Clinical documentation in the patient’s medical record
  • Documentation varies among apheresis physicians; basic information to consider including in notes:
    • Initial consult note: indication, ASFA category (if in ASFA guidelines), procedure type, number of planned procedures, anticipated schedule, replacement fluid to be used, volume to be exchanged, referring physician, access, vitals / brief physical, pertinent laboratory values, allergies, medications, past medical history
    • Daily procedure notes: indication, procedure type, vitals / brief physical, pertinent laboratory values, interventions and outcome if procedure related side effects occurred, replacement fluid
Board review style question #1
Which of the following entities is considered a category I indication for therapeutic plasma exchange?

  1. Amyloidosis, systemic
  2. Autoimmune hemolytic anemia, severe
  3. Catastrophic antiphospholipid syndrome (CAPS)
  4. Thyroid storm
Board review style answer #1
C. Catastrophic antiphospholipid syndrome (CAPS)

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