Transfusion medicine

Therapeutic apheresis

Therapeutic plasma exchange (TPE)


Editorial Board Member: Kyle Annen, D.O.
Deputy Editor-in-Chief: Patricia Tsang, M.D., M.B.A.
Elizabeth A. Godbey, M.D.

Topic Completed: 30 June 2021

Minor changes: 30 June 2021

Copyright: 2021, PathologyOutlines.com, Inc.

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

Elizabeth A. Godbey, M.D.
Page views in 2020: 1
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Cite this page: Godbey EA. Therapeutic plasma exchange (TPE). PathologyOutlines.com website. https://www.pathologyoutlines.com/topic/transfusionmedtherapeuticplasmaexchange.html. Accessed December 8th, 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 updated 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 role of apheresis in treatment of the indication)
      • 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.”
      • II: “Disorders for which apheresis is accepted as second-line therapy, either as a standalone treatment or in conjunction with other modes of treatment”
      • III: “Optimum role of apheresis therapy is not established. Decision making should be individualized.”
      • IV: “Disorders in which published evidence demonstrates or suggests apheresis to be ineffective or harmful. IRB approval is desirable if apheresis treatment is undertaken in these circumstances.”
    • 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 (not comprehensive)
  • 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
  • Access must accommodate high flow rates
  • Peripheral veins, central venous catheter, ports, fistula, AV graft are options; choice will depend on urgency and frequency of plasma exchange needed
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; always use plasma for TTP
  • 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
  • For a 1 plasma volume exchange using albumin as replacement fluid, coagulation factors may decrease by 25 - 50% and are expected to recover 80 - 100% by 48 hours; fibrinogen is expected to decrease by 63% and recover 65% by 48 hours; fibrinogen may need to be supplemented in some patients
  • Can remove medications (especially those that are highly protein bound, small volume of distribution); for example, IVIG and monoclonal antibody medications will be extensively removed by plasma exchange; administration should be postponed until after the procedure
  • For an extensive discussion of plasma content changes resulting from TPE, please see Winters: Apheresis: Principles and Practice, Volume 1: Therapeutic Apheresis, 4th Edition, 2020
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
  • Note styles and content vary among institutions and among providers, but an example of a brief daily progress note follows:
    • Ms. X underwent plasma exchange today for myasthenia gravis (MG) exacerbation. She tolerated the procedure without procedure related side effects. Ms. X reports that her MG symptoms continue to improve.
      • Vital signs: temperature 37 C, pulse 74 bpm, BP 137/64 mmHg, RR 20 br/min
      • General: appeared comfortable, no acute distress
      • Laboratory values: hemoglobin: 11.5 g/dL, PLT: 268x10e9/L, fibrinogen: 194 mg/dL
    • Ms. X is a 50 year old female who presented for plasma exchange for myasthenia gravis exacerbation. This was plasma exchange number X out of Y requested. The next procedure is planned for [date]. Further management per neurology.
  • 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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Reference: Therapeutic plasma exchange
Board review style question #2
Which of the following entities is considered a category I indication for therapeutic plasma exchange?

  1. IgA nephropathy (Berger disease)
  2. Myasthenia gravis (acute, short term treatment)
  3. Myasthenia gravis (long term treatment)
  4. PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections) exacerbation
Board review style answer #2
B. Myasthenia gravis (acute, short term treatment)

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Reference: Therapeutic plasma exchange
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