Complications of Plasmapheresis
Plasmapheresis carries several potential complications that require careful monitoring and preventive measures, with the most common being hypocalcemia, hypotension, and allergic reactions. 1, 2
Common Complications
Cardiovascular Complications
- Hypotension occurs in approximately 8.4% of procedures, ranging from mild to severe cases requiring vasopressors 3
- Cardiac arrhythmias may develop in about 3.5% of procedures 3
- Blood pressure instability can occur due to rapid fluid shifts during the procedure 1, 4
Electrolyte Disturbances
- Hypocalcemia is one of the most frequent complications, often related to citrate in replacement fluids 5, 2
- Symptoms of hypocalcemia (paresthesias, muscle cramps) can be significantly reduced with prophylactic calcium administration (from 9.1% to 1% incidence) 2
- Hypokalemia may also occur and requires monitoring 5
Coagulation Abnormalities
- Removal of clotting factors can lead to coagulation defects 4
- Bleeding risk is increased, though serious hemorrhagic complications are rare (0.02%) 2
- Thrombosis can occur due to changes in coagulation factors and platelet activation 4
Infection Risk
- Increased infection risk due to removal of immunoglobulins 6, 4
- Catheter-related infections may develop with prolonged central venous access 5, 7
- The overall risk of serious infections is approximately 0.02% per procedure 2
Severe Complications
Life-Threatening Events
- Severe adverse events occur in approximately 2.16% of procedures 3
- Anaphylactoid reactions occur in about 0.25% of cases, more commonly with fresh frozen plasma than albumin replacement 2
- Mortality associated with plasmapheresis is estimated at 0.05% based on systematic reviews 1, 2
Respiratory Complications
- Respiratory events including bronchospasm occur in approximately 0.2% of procedures 2
- Transfusion-related acute lung injury (TRALI) can occur, particularly when using fresh frozen plasma 8
- Pulmonary embolism is a rare but serious potential complication 1
Replacement Fluid-Related Complications
Fresh Frozen Plasma (FFP) vs. Albumin
- FFP replacement is associated with significantly higher adverse reaction rates (20%) compared to albumin (1.4%) 2
- FFP carries risks of ABO incompatibility, transmission of infectious diseases, and allergic reactions 8
- Albumin replacement generally has fewer complications but may not replace specific clotting factors 8, 2
Technical and Procedural Complications
Vascular Access Issues
- Complications related to central venous catheter placement (pneumothorax, arterial puncture) 5, 7
- Catheter-related thrombosis and occlusion 7
- Mechanical issues with the plasmapheresis circuit 9
Prevention Strategies
Monitoring and Prophylaxis
- Continuous monitoring of vital signs, especially blood pressure and heart rate during the procedure 3
- Prophylactic calcium administration significantly reduces hypocalcemic symptoms 2
- Careful selection of replacement fluids based on the patient's condition and specific disease being treated 4
Procedural Considerations
- Proper training of medical personnel is essential for procedure safety 3
- Appropriate anticoagulation management to prevent circuit clotting while minimizing bleeding risk 9
- Timing coordination when used with other therapies (e.g., rituximab should be administered after plasmapheresis since the procedure removes the drug) 4
Special Populations
Critically Ill Patients
- Higher risk of hemodynamic instability in ICU patients 3
- May require more intensive monitoring and supportive care 3
- Benefit-risk assessment should be carefully considered in hemodynamically unstable patients 10
By understanding these potential complications and implementing appropriate preventive measures, the safety profile of plasmapheresis can be significantly improved, making it a relatively safe procedure when performed by qualified personnel with proper monitoring 3, 2.