What are the indications for plasma exchange (plasmapheresis)?

From the Guidelines

Plasma exchange (plasmapheresis) is indicated for patients with severe kidney impairment, rapidly progressive renal disease, and certain autoimmune conditions.

Indications for Plasma Exchange

• Severe kidney impairment (serum creatinine ≥500 μmol/L) 1
• Rapidly progressive renal disease, particularly in patients with ANCA-associated vasculitis 1
• Diffuse pulmonary hemorrhage, especially in patients requiring mechanical ventilation 1
• Overlap syndrome of ANCA vasculitis and anti-GBM GN 1
• Neurologic conditions such as myasthenia gravis and Guillain-Barré syndrome, where plasmapheresis is a first-line therapy 1
• Certain autoimmune conditions, such as severe and rapidly progressive neurologic irAEs, where plasmapheresis is often indicated as a second-line therapy 1

Important Considerations

• The use of plasmapheresis should be weighed against potential risks, including hemodynamic shifts, infection, and thrombosis 1
• The timing of rituximab infusion in relation to plasmapheresis needs to be considered, as plasmapheresis removes rituximab 1
• The evidence for plasmapheresis in certain conditions, such as pulmonary hemorrhage, is based on retrospective studies and may not be as strong as for other indications 1

From the Research

Indications for Plasma Exchange (Plasmapheresis)

The indications for plasma exchange, also known as plasmapheresis, are diverse and span several medical specialties, including:

• Hematology: supportive treatment of multiple myeloma, Waldenström's macroglobulinemia, idiopathic thrombocytopenic purpura (ITP), pure red cell aplasia (PRCA), polyneuropathies connected with hematological disorders, and hemophagocytic syndrome (HLH) 2
• Nephrology: antineutrophil cytoplasmic antibody-associated vasculitis, desensitization protocols for transplantation, and certain renal diseases such as thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome, cryoglobulinemia, focal segmental glomerulosclerosis, and Goodpasture syndrome 3, 4
• Neurology: various neurological diseases, although specific indications are not detailed in the provided studies 2, 5
• Critical care: therapeutic plasma exchange may be useful in a wide spectrum of illnesses characterized by microvascular thrombosis, autoantibodies, immune activation, and certain infections 6

Specific Conditions Treated with Plasmapheresis

Some specific conditions where plasmapheresis is used or considered include:

• Thrombotic thrombocytopenic purpura (TTP) 2, 4
• Hemolytic uremic syndrome (HUS) 4
• Anti-neutrophil cytoplasmic antibody-associated vasculitis 3, 4
• Cryoglobulinemia 4
• Focal segmental glomerulosclerosis 4
• Goodpasture syndrome 4
• Waldenström's macroglobulinemia 2
• Idiopathic thrombocytopenic purpura (ITP) 2
• Pure red cell aplasia (PRCA) 2
• Polyneuropathies connected with hematological disorders 2
• Hemophagocytic syndrome (HLH) 2

Use of Plasmapheresis in Different Medical Specialties

Plasmapheresis is utilized across various medical specialties due to its ability to remove pathogenic macromolecules from the plasma, making it a valuable treatment option for a wide range of diseases 2, 3, 6, 4, 5.