When is prophylactic plasma exchange (PPE) recommended?

Prophylactic Plasma Exchange: Indications and Recommendations

Prophylactic plasma exchange (PPE) is generally not recommended for most clinical scenarios and should be reserved for specific high-risk patient populations with certain conditions, particularly those at high risk of end-stage kidney disease (ESKD) in ANCA-associated vasculitis. 1

ANCA-Associated Vasculitis (AAV)

Glomerulonephritis in AAV

• For patients with AAV and low or low-moderate risk of developing ESKD, immunosuppression alone is recommended rather than adding plasma exchange, regardless of pulmonary hemorrhage status 1
• For patients with AAV and moderate-high or high risk of developing ESKD, plasma exchange may be considered as it can reduce progression to ESKD, though with increased risk of serious infections 1
• The benefit of plasma exchange is most pronounced in patients with the highest risk of ESKD (118 fewer cases of ESRD per 1,000 cases of active glomerulonephritis) 1
• Plasma exchange does not reduce mortality in AAV patients with glomerulonephritis (risk ratio 1.15) 1

Pulmonary Hemorrhage in AAV

• For patients with active, severe AAV with alveolar hemorrhage, plasma exchange is conditionally not recommended in addition to standard remission induction therapies 1
• No differences in mortality or remission rates have been observed in trials evaluating plasma exchange for alveolar hemorrhage 1
• Plasma exchange may be considered as "salvage" or "rescue" therapy for critically ill patients not responding to recommended remission induction therapies 1

Other Conditions

COVID-19

• The AABB suggests against prophylactic COVID-19 convalescent plasma transfusion for uninfected persons with close contact exposure to COVID-19 (weak recommendation, low-certainty evidence) 1

Thrombotic Thrombocytopenic Purpura (TTP) and Hemolytic Uremic Syndrome (HUS)

• Therapeutic plasma exchange is the recommended treatment for idiopathic familial and nonfamilial TTP as well as HUS not associated with diarrhea 2
• High-dose plasma infusion may be an alternative first-line therapy when therapeutic plasma exchange is not immediately available 3

Risks and Complications of Plasma Exchange

• Plasma exchange is associated with several complications, including:
  • Mild to moderate adverse reactions occur in approximately 25% of procedures 4
  • Severe, life-threatening adverse events occur in approximately 0.7% of procedures 4
  • Common complications include hypocalcemia, hypovolemia, and anaphylactoid reactions 5
  • Serious complications include cardiovascular events (0.2%), respiratory events (0.2%), and anaphylactoid reactions (0.25%) 5
  • Increased risk of serious infections (risk ratio 1.19) in AAV patients 1

Practical Considerations

• Plasma exchange requires intravenous lines or central venous catheters that may cause discomfort or increase the risk of infection, clotting, or bleeding 1
• Potential need for blood products with plasma exchange 1
• Plasma exchange may affect the pharmacokinetics of some drugs 1
• Prophylactic calcium administration lowers the incidence of hypocalcemic symptoms during plasma exchange 5
• Treatments using albumin as volume replacement are associated with fewer adverse reactions compared to those using fresh-frozen plasma (1.4% vs 20%) 5

Key Takeaways

• Prophylactic plasma exchange is not routinely recommended for most conditions 1
• The strongest indication for considering plasma exchange is in AAV patients with high risk of progression to ESKD 1
• The decision to use plasma exchange should balance potential benefits against risks, particularly the increased risk of serious infections 1
• Plasma exchange is relatively safe when performed properly, but serious complications can occur 4, 5