High Volume Plasmapheresis Volume Recommendations
For high volume plasmapheresis, use 60 mL/kg volume replacement, which represents approximately 1.3 times the standard plasma volume calculation of 45 mL/kg. 1, 2
Standard vs. High Volume Protocols
Standard Volume Plasmapheresis
- Standard exchanges use 1-2 plasma volumes per session, calculated as body weight (kg) × 0.045 L (or 45 mL/kg) 2
- This typically results in 3-4 liters in average adults 2
- Achieves approximately 55% reduction in intravascular protein levels with one plasma volume exchange 3
High Volume Plasmapheresis Definition
- High volume plasmapheresis is defined as exchange of 8-12 liters or 15% of ideal body weight 4
- The most commonly cited protocol uses 60 mL/kg volume replacement 1, 2
- This represents approximately 1.3-1.5 times standard plasma volume 5
Clinical Application by Indication
ANCA-Associated Vasculitis with Severe Renal Disease
- Use 60 mL/kg volume replacement 1, 2
- Perform 7-10 treatments total 1, 2
- For diffuse pulmonary hemorrhage: initiate daily until bleeding stops, then every other day 1, 2
Cardiac Transplant Antibody-Mediated Rejection
- Exchange 1-2 plasma volumes (standard calculation) 1
- Perform 4-5 sessions over 10-14 days 1
- Some centers use daily or every other day for minimum of 5 sessions 1
Hyperviscosity Syndrome
- Replace approximately two-thirds of patient's plasma volume (typically 3-4 liters in adults) 2
- This is lower than high volume protocols due to specific pathophysiology 2
Replacement Fluid Considerations
Volume-Based Albumin Dosing
- For exchanges >5 liters, use 8g albumin per liter of plasma removed 6
- 5% albumin solution is the most common replacement fluid for most indications 2
- Fresh frozen plasma is reserved for thrombotic microangiopathies or bleeding risk due to cost and allergenicity 5
Practical Calculation Example
For a 70 kg patient requiring high volume plasmapheresis:
- High volume protocol: 70 kg × 60 mL/kg = 4,200 mL (4.2 L) 1, 2
- Standard protocol: 70 kg × 45 mL/kg = 3,150 mL (3.15 L) 2
- Albumin replacement: 4.2 L × 8g/L = 33.6g albumin 6
Critical Technical Requirements
Session Completion
- Complete the entire high volume exchange in a single session (typically 1-4 hours) rather than extending over multiple days 6
- Change the filter/dialyzer after each treatment session to maintain optimal efficiency 6
Safety Monitoring
- Use proper blood warming equipment, especially for high volume procedures, to prevent hypothermia 6
- Monitor for hemodynamic changes, coagulation abnormalities, and electrolyte imbalances 2
- Citrate anticoagulation is preferred over heparin 5
Common Pitfalls to Avoid
- Never use fixed volumes without weight-based calculation—plasma volume varies significantly with body size 2
- Never use plasma exchange as monotherapy—always combine with immunosuppression or definitive treatment 2, 5
- Do not administer rituximab before plasmapheresis—the procedure removes the drug from circulation; give rituximab after the session 2
- Avoid ultrafiltration rates that cause hemolysis in membrane-based systems 3