From the Guidelines
Plasma exchange is indicated for several medical conditions, including antibody-mediated rejection in cardiac transplantation, thrombotic thrombocytopenic purpura (TTP), Guillain-Barré syndrome, myasthenia gravis crisis, chronic inflammatory demyelinating polyneuropathy (CIDP), hyperviscosity syndrome in paraproteinemias, and severe cases of ANCA-associated vasculitis, as supported by recent guidelines and studies 1.
Indications for Plasma Exchange
The primary indications for plasma exchange include:
- Antibody-mediated rejection in cardiac transplantation, where plasma exchange has been used to reduce alloantibody levels and prevent allograft rejection 1
- Thrombotic thrombocytopenic purpura (TTP), where plasma exchange should be initiated immediately upon diagnosis with daily exchanges of 1-1.5 plasma volumes until platelet count normalizes
- Guillain-Barré syndrome, where 5 exchanges over 1-2 weeks are typically performed early in the disease course
- Myasthenia gravis crisis, which may require 5-6 exchanges over 10-14 days
- Chronic inflammatory demyelinating polyneuropathy (CIDP), which often needs 2 exchanges weekly for 3-6 weeks
- Hyperviscosity syndrome in paraproteinemias, which usually requires daily exchanges until symptoms resolve
- Severe cases of ANCA-associated vasculitis, where plasma exchange may be considered for patients at higher risk of progression to end-stage renal disease (ESRD) 1
Procedure and Monitoring
The procedure works by removing pathogenic antibodies, immune complexes, or replacing missing plasma components. Potential complications include bleeding, hypotension, allergic reactions, and electrolyte disturbances, so patients should be monitored closely during treatment. Vascular access is typically established via a central venous catheter, and each session generally lasts 2-4 hours with replacement fluids consisting of albumin or fresh frozen plasma depending on the condition being treated.
Recent Guidelines and Studies
Recent guidelines and studies support the use of plasma exchange in these conditions, with the most recent study published in 2021 providing evidence for the use of plasma exchange in ANCA-associated vasculitis 1. The study found that plasma exchange decreased the risk of ESRD in patients with glomerulonephritis, but did not decrease mortality. The benefit was most pronounced in patients with the highest risk of ESRD.
From the Research
Indications for Plasma Exchange (Plasmapheresis)
The indications for plasma exchange, also known as plasmapheresis, include:
- Neurological disorders such as myasthenia gravis (MG) and Guillain-Barré syndrome (GBS) 2, 3, 4
- Thrombotic thrombocytopenic purpura (TTP) and hemolytic-uremic syndrome (HUS) 5, 6
- Chronic inflammatory demyelinating polyneuropathy (CIDP) 3
- Multiple sclerosis (MS) 3, 4
- Voltage gated potassium channel (VGKC) complex antibody associated disorders 3
- Limbic encephalitis, including those with antibodies against VGKC complex and N-methyl-D-aspartate (NMDA) receptor antibodies 3
- Rapidly progressive glomerulonephritis 4
Key Findings
- Plasma exchange is a well-tolerated treatment with a low complication rate, mainly hypotensive/vasovagal reactions 2
- Patients with GBS seem more prone to complications than those with MG 2
- The treatment is effective in achieving complete remission in patients with TTP/HUS, with high-dose plasma infusion being a possible alternative to plasma exchange in some cases 6
- The indications for plasma exchange have evolved over time, with a shift from hematologic disorders to neurologic disorders 4