Therapeutic apheresis (plasma exchange or cytapheresis): Complications
- Andre A Kaplan, MD
Andre A Kaplan, MD
- Professor of Medicine
- University of Connecticut Health Center
- Joy L Fridey, MD
Joy L Fridey, MD
- Regional Medical Director
- American Red Cross Blood Services, Southern California
Therapeutic apheresis is an extracorporeal treatment that separates blood components (plasma and/or cellular components) from the patient's blood for the treatment of conditions in which a pathogenic substance in the blood is causing morbidity. Therapeutic plasma exchange (TPE) denotes the selective removal of a patient’s plasma and replacement with another fluid; cytapheresis refers to selective removal of abnormal or excessive numbers of blood cells.
This topic review will discuss the complications of therapeutic apheresis. An overview of the terminology used to describe apheresis procedures; the types of indications for which therapeutic apheresis is effective, including American Society for Apheresis (ASFA) therapeutic categories; and practical issues in apheresis techniques are discussed separately. (See "Therapeutic apheresis (plasma exchange or cytapheresis): Indications and technology".)
An overview to the patient with a suspected acute transfusion reaction is also presented separately. (See "Approach to the patient with a suspected acute transfusion reaction".)
OVERVIEW OF COMPLICATIONS
The basic premise of therapeutic apheresis is that removal of certain pathologic substances (or cells, in cytapheresis) will reduce organ or tissue damage and may permit reversal of a pathologic process. In order to prevent volume depletion during therapeutic plasmapheresis, the volume of plasma removed must be replaced by plasma, colloid, or crystalloid. In some cases, use of allogeneic (donor) plasma is preferred because it provides needed proteins or other factors; however, donor plasma should be avoided if possible, other than when it is indicated as replacement fluid, such as for thrombotic thrombocytopenic purpura, in which it provides needed proteins or other factors. (See "Therapeutic apheresis (plasma exchange or cytapheresis): Indications and technology", section on 'Replacement fluids'.)
The frequency and types of complications from therapeutic apheresis depends upon the overall condition of the patient, the number of procedures, the replacement fluid, and the venous access device. A review of the reported complications from over 15,000 therapeutic plasma exchange (TPE) treatments found that adverse reactions were substantially more common with plasma than with albumin replacement (20 versus 1.4 percent) .
- Mokrzycki MH, Kaplan AA. Therapeutic plasma exchange: complications and management. Am J Kidney Dis 1994; 23:817.
- Huestis DW. Mortality in therapeutic haemapheresis. Lancet 1983; 1:1043.
- Apheresis Principles and Practice, 2nd ed, McLeod BC (Ed), AABB, Bethesda 2003.
- Kaplan AA, Halley SE. Plasma exchange with a rotating filter. Kidney Int 1990; 38:160.
- Weinstein R. Prevention of citrate reactions during therapeutic plasma exchange by constant infusion of calcium gluconate with the return fluid. J Clin Apher 1996; 11:204.
- Pearl RG, Rosenthal MH. Metabolic alkalosis due to plasmapheresis. Am J Med 1985; 79:391.
- Stigelman WH Jr, Henry DH, Talbert RL, Townsend RJ. Removal of prednisone and prednisolone by plasma exchange. Clin Pharm 1984; 3:402.
- Standards for Cellular Therapy Product Services, 6th ed, AABB, Bethesda 2013.
- Orlin JB, Berkman EM. Partial plasma exchange using albumin replacement: removal and recovery of normal plasma constituents. Blood 1980; 56:1055.
- Goss GA, Weinstein R. Pentastarch as partial replacement fluid for therapeutic plasma exchange: effect on plasma proteins, adverse events during treatment, and serum ionized calcium. J Clin Apher 1999; 14:114.
- Chirnside A, Urbaniak SJ, Prowse CV, Keller AJ. Coagulation abnormalities following intensive plasma exchange on the cell separator. II. Effects on factors I, II, V, VII, VIII, IX, X and antithrombin III. Br J Haematol 1981; 48:627.
- Gelabert A, Puig L, Maragall S, et al. Coagulation alterations during massive plasmapheresis. In: Plasma Exchange, Sieberth HG (Ed), Schattauer Verlag, Stuttgart 1980. p.71.
- Wing EJ, Bruns FJ, Fraley DS, et al. Infectious complications with plasmapheresis in rapidly progressive glomerulonephritis. JAMA 1980; 244:2423.
- Pohl MA, Lan SP, Berl T. Plasmapheresis does not increase the risk for infection in immunosuppressed patients with severe lupus nephritis. The Lupus Nephritis Collaborative Study Group. Ann Intern Med 1991; 114:924.
- Kaplan AA. Towards a rational prescription of plasma exchange: The kinetics of immunoglobulin removal. Semin Dial 1992; 5:227.
- Keller AJ, Urbaniak SJ. Intensive plasma exchange on the cell separator: effects on serum immunoglobulins and complement components. Br J Haematol 1978; 38:531.
- Owen HG, Brecher ME. Atypical reactions associated with use of angiotensin-converting enzyme inhibitors and apheresis. Transfusion 1994; 34:891.
- Brecher ME, Owen HG, Collins ML. Apheresis and ACE inhibitors. Transfusion 1993; 33:963.
- Sutton DM, Nair RC, Rock G. Complications of plasma exchange. Transfusion 1989; 29:124.
- Ring J, Messmer K. Incidence and severity of anaphylactoid reactions to colloid volume substitutes. Lancet 1977; 1:466.
- Bambauer R, Jutzler GA, Albrecht D, et al. Indications of plasmapheresis and selection of different substitution solutions. Biomater Artif Cells Artif Organs 1989; 17:9.
- Apter AJ, Kaplan AA. An approach to immunologic reactions associated with plasma exchange. J Allergy Clin Immunol 1992; 90:119.
- Technical Manual, 17th ed, Roback JD (Ed), American Association of Blood Banks, Bethesda 2011.
- Jørstad S. Biocompatibility of different hemodialysis and plasmapheresis membranes. Blood Purif 1987; 5:123.
- Nicholls AJ, Platts MM. Anaphylactoid reactions due to haemodialysis, haemofiltration, or membrane plasma separation. Br Med J (Clin Res Ed) 1982; 285:1607.
- OVERVIEW OF COMPLICATIONS
- ANY REPLACEMENT FLUID
- Citrate-induced hypocalcemia
- Citrate-induced metabolic alkalosis
- Inadvertent removal of a medication
- Vascular catheter complications
- NON-PLASMA REPLACEMENT FLUIDS
- Coagulation factor depletion
- Immunoglobulin depletion
- Angiotensin converting enzyme (ACE) inhibitor-related complications
- DONOR PLASMA OR RED BLOOD CELL EXPOSURE
- Anaphylactic reactions
- Transfusion-related acute lung injury (TRALI)
- Infectious risks of plasma or RBC
- EVALUATION FOR SUSPECTED COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS