What are the potential side effects and electrolyte derangements of plasmapheresis in patients with autoimmune diseases?

Side Effects and Electrolyte Derangements of Plasmapheresis

Plasmapheresis causes fluid and electrolyte imbalance as its primary electrolyte-related complication, with hypocalcemia and hypokalemia being the most common disturbances, while serious complications remain rare at 0.05% mortality when performed by trained staff. 1, 2

Primary Electrolyte Derangements

Calcium and Potassium Abnormalities

• Hypocalcemia occurs frequently due to citrate anticoagulation binding ionized calcium during the procedure 3
• Hypokalemia represents one of the most common mild complications, typically caused by electrolyte shifts during plasma removal and replacement 3
• These electrolyte disturbances are usually mild and can be anticipated with proper monitoring and replacement protocols 2

Acid-Base Disturbances

• Acid-base equilibrium disruptions can occur during the procedure, though these are generally preventable with modern protocols 4

Common Side Effects (Mild to Moderate)

Hemodynamic Changes

• Hypotension is the most frequent adverse effect, occurring in 8.4% of procedures in ICU patients 5
• Blood pressure instability during the procedure is common but typically self-limited 1
• Symptoms of hypovolemia can develop during the procedure, particularly with extracorporeal photopheresis 1

Cardiovascular Effects

• Cardiac arrhythmias occur in approximately 3.5% of procedures 5
• Bradycardia may develop during treatment, occasionally requiring procedure discontinuation 4
• Tachycardia can occur as part of the infusion-related symptom complex 1

Other Common Symptoms

• Sensations of cold with temporarily elevated temperature (1.1% of procedures) 5
• Paresthesias (1.1% of procedures) 5
• Nausea and headache are common but self-limited 1
• Muscle pains and pyrexia may occur during the procedure 1

Serious Complications (Rare)

Life-Threatening Events

• Severe complications including shock, persistent arrhythmias, and hemolysis occur in only 2.16% of procedures 5
• Overall mortality is estimated at 0.05% based on systematic reviews of over 15,500 patients 2, 6
• Anaphylaxis is rare but represents a serious risk, particularly in patients with IgA deficiency 1

Infection-Related Risks

• Septicemia is a recognized complication, particularly related to central venous catheter access required for the procedure 1
• Central venous access increases infection, clotting, and bleeding risks 6
• Theoretical risk of blood-borne virus infections exists, though modern screening has minimized this 1

Coagulation Abnormalities

• Removal of clotting factors can result in coagulation defects since plasmapheresis nonselectively removes plasma proteins 6, 7
• This risk is particularly relevant when albumin rather than fresh frozen plasma is used for replacement 2

Critical Practice Points to Minimize Complications

Monitoring Requirements

• Monitor for hemodynamic changes, coagulation abnormalities, and electrolyte imbalances throughout the procedure 2
• Continuous observation by highly trained medical personnel is essential for safety 5
• Proper monitoring can prevent most complications that are nowadays avoidable 4

Replacement Fluid Considerations

• Using fresh frozen plasma (FFP) as replacement fluid carries additional risks of transfusion-related complications compared to albumin 3
• The choice of replacement fluid should balance coagulation factor replacement needs against transfusion risks 2

Access-Related Precautions

• Central venous access is typically necessary but increases risk of infection, thrombosis, and bleeding 1, 6
• Large-bore peripheral catheters may be used when feasible to reduce central line complications 6

Evidence Quality Note

The Cochrane meta-analysis of 556 Guillain-Barré patients demonstrated that plasmapheresis did not increase risk of infection, blood pressure instability, cardiac arrhythmias, or pulmonary embolism, providing high-quality evidence for the overall safety profile when performed appropriately 2. However, the British Association of Dermatologists guidelines consistently emphasize that plasmapheresis requires specialist equipment, trained staff, and is labor-intensive, underscoring that safety depends heavily on proper execution 1.