Why is fresh‑frozen plasma preferred over 5 % albumin for therapeutic plasma exchange in patients with coagulopathy, bleeding, anticoagulation, or severe hypogammaglobulinemia?

FFP vs Albumin in Therapeutic Plasma Exchange

Fresh frozen plasma (FFP) should be used instead of 5% albumin in therapeutic plasma exchange when patients have pre-existing coagulopathy, active bleeding, are on anticoagulation therapy, or have severe hypogammaglobulinemia, because FFP replaces all plasma constituents including coagulation factors and immunoglobulins that albumin lacks. 1

Primary Replacement Fluid Selection

Albumin is the standard replacement fluid for most therapeutic plasma exchange procedures because it is:

• Pasteurized to inactivate viruses 1
• Associated with very low risk of febrile and allergic reactions 1
• Convenient to store and administer without requiring blood typing or thawing 1

However, albumin causes transient mild deficiencies of most plasma proteins, which is acceptable in patients without bleeding or coagulation disorders. 1

When FFP Becomes Necessary

Coagulopathy and Bleeding

FFP must be used when patients have documented coagulopathy with bleeding (PT >1.5 times normal or INR >2.0) because it contains all coagulation factors needed for hemostasis. 2, 3 The standard therapeutic dose is 15 ml/kg to achieve minimum 30% concentration of plasma factors. 2, 3

Specific High-Risk Conditions

FFP is specifically indicated for therapeutic plasma exchange in:

• Thrombotic thrombocytopenic purpura (TTP) - a definite indication where FFP replaces deficient ADAMTS13 enzyme 4, 1
• Patients on anticoagulation therapy requiring urgent reversal, particularly warfarin 2, 3
• Severe hypogammaglobulinemia where immunoglobulin replacement is needed alongside plasma exchange 1

Pre-existing Coagulopathy

Any patient with baseline coagulation abnormalities undergoing plasma exchange requires FFP to prevent worsening of their coagulation status, as albumin would further dilute remaining clotting factors. 1

Critical Safety Considerations

FFP Risks vs Benefits

While FFP provides complete plasma protein replacement, it carries higher risks than albumin:

• Must be ABO-compatible and type-specific 2, 1
• Requires advance ordering and thawing before use 1
• Higher incidence of febrile and allergic reactions 1, 5
• Risk of transfusion-related acute lung injury (TRALI) 2
• Risk of circulatory overload 2
• Potential infectious disease transmission 2

In Guillain-Barré syndrome, albumin is actually preferred over FFP because a large multicenter trial showed no superiority of FFP while demonstrating more frequent complications with FFP use. 5 This illustrates that FFP should only be used when its specific components (coagulation factors, immunoglobulins) are clinically necessary.

Practical Algorithm

Use 5% albumin when:

• No bleeding disorder present
• Normal coagulation parameters
• No anticoagulation therapy
• Normal immunoglobulin levels
• Conditions like Guillain-Barré syndrome, myasthenia gravis, or other neurologic disorders 5

Switch to FFP when:

• INR >1.5 or PT >1.5 times normal with bleeding 2, 3
• TTP diagnosis 4, 1
• Active anticoagulation requiring reversal 2, 3
• Severe hypogammaglobulinemia 1
• Acute disseminated intravascular coagulation (DIC) 4

The decision is not about routine preference but about matching the replacement fluid to the patient's specific deficiencies - albumin for volume and oncotic pressure alone, FFP when coagulation factors or other plasma proteins are critically needed. 1, 6