Plasmapheresis By Yousaf khan Renal dialysis lecturer IPMS KMU

1. Plasmapheresis
Yousaf khan
Renal Dialysis Lecturer
IPMS -KMU

2. Plasmapheresis:
• Therapeutic apheresis refers to an extracorporeal procedure in which
blood separator technology is used to remove abnormal blood cells and
plasma constituents.
• The terms plasmapheresis, leukapheresis, erythrocytapheresis and
thrombocytapheresis describe the specific blood element that is removed.
• In plasmapheresis or therapeutic plasma exchange large quantities of
plasma are removed from a patient and replaced with fresh frozen
plasma, albumin solution and saline.

3. Plasmapheresis

4. Techniques of Plasmapheresis:
• During plasmapheresis, blood (which consists of blood cells and a
clear liquid called plasma) is initially taken out of the body through a
needle or previously implanted catheter.
• Plasma is then removed from the blood by a cell separator.
• Two procedures are commonly used to separate the plasma from
the blood cells, with each method having its own advantages and
disadvantages:

5. Technicalconsiderations
Membrane apheresis:
Advantage:
• Fast and efficient plasmapheresis
• No citrate requirement
• Can be adapted for cascade filtration
Disadvantage:
• Removal of substance limited by sieving coefficient of membrane
• Unable to perform cytapheresis
• Requires high blood flows, central venous access
• Requires heparin anticoagulation limiting use in bleeding disorders

6. Technicalconsiderations
Centrifugal devices
Advantage:
• Capable of performing cytapheresis
• No heparin requirement
• More efficient removal of all plasma components
Disadvantage:
• Expensive
• Requires citrate anticoagulation
• Loss of platelets

7. Procedure
• After plasma separation, the blood cells are returned, while the
plasma, which contains the antibodies, is first treated and then
returned to the patient in traditional plasmapheresis.
• In plasma exchange, the removed plasma is discarded and the
patient receives replacement donor plasma, albumin, or a
combination of albumin and saline (usually 70% albumin and 30%
saline).
• Medication to keep the blood from clotting (an anticoagulant) is
given to the patient during the procedure.
• Plasmapheresis is used as a therapy in particular diseases.

8. • An important use of plasmapheresis is in the therapy of autoimmune
disorders, where the rapid removal of disease-causing autoantibodies from
the circulation is required in addition to other medical therapy.
• It is important to note that plasma exchange therapy in and of itself is
useful to temper the disease process, while simultaneous medical and
immunosuppressive therapy is required for long-term management.
• Plasma exchange offers the quickest short-term answer to removing
harmful autoantibodies; however, the production of autoantibodies by the
immune system must also be suppressed, usually by the use of
medications such as prednisone, cyclophosphamide, cyclosporine,
mycophenolate or a mixture of these.
• Other uses are the removal of blood proteins where these are overly
abundant and cause hyperviscosity syndrome.

10. ConditionforwhichPEhas an establishedrole
Removal of abnormal circulation factor
• Antibody ( anti –GBM disease, myasthenia gravis )
• Monoclonal protein ( myeloma protein )
• Circulating immune complexes ( cryoglobulinemia, SLE)
• Alloantibody ( Rh alloimmunization in pregnancy )
• Toxic factor
Replenishment of specific plasma factor
• TTP (Thrombotic Thrombocytopenic Purpura)
Other effects on immune system:
• Improvement in function of reticuloendothelial system
• Removal of inflammatory mediators ( cytokines, complement)
• Stimulation of lymphocyte clones to enhance cytotoxic therapy

11. Renalindication
Primary renal disease
• Goodpasture's syndrome
• Recurrent focal and segmental glomerulosclerosis in the transplanted
kidney
• IgG nephropathy
• Transplantation
Seconday renal disease:
• Rhabdomyolysis
• Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic syndrome
• Multiple myeloma in kidney

12. Vascular access:
• Centrifuge device systems blood flow in the range of 40 -50 ml/mint.
• Best approach is the use of a large bore, dual lumen catheter
• Intravascular devices available for nondialysis use such as swan Ganz
catheter and triple lumen catheter

13. Techniquesofplasmapheresisancillarymeasures
Anticoagulation:
• Either heparin or citrate can be used
• Heparin requirements are double that for HD due to loss in plasma.
• Loading dose is 30-60 u/kg, followed by 1000 u/h infusion.
• For citrate anticoagulation citrate is infused continuously as acid citrate
dextrose.
• Patients should receive calcium IV or orally.
• Problems include hypocalcemia and alkalosis.
• Citrate metabolism impaired in liver disease.
• FFP contain citrate.

14. Techniquesof plasmapheresisancillary
measures
• Ancillary immunosuppression:
• Used to suppress further antibody synthesis during and after PE (e.g.
cyclophosphamide or azathioprine).
• Replacement fluids:
• Replacement by colloidal agent is essential to maintain hemodynamic
stability.
• Albumin generally in the form of an isonatric 5% solution or to plasma
in the form of FFP

15. Choiceof Replacementsolution
• Albumin
• Advantage:
• No risk of hepatitis
• Stored at room temperature
• Allergic reaction are rare
• No concern about ABO blood
group
• Depletes inflammation
mediators
• Disadvantage:
• Expensive
• No coagulation factors
• No immunoglobulin's
• Fresh Frozen Plasma
• Advantage:
• Coagulation factors
• Immunoglobulin's ‘’ beneficial’’
factors complement
• Disadvantage:
• Risk of hepatitis, HIV transmission
• Allergic reaction
• Hemolytic reaction
• Must be thawed
• Must be ABO compatible
• Citrate load

16. Complicationofplasmapeheresis
Related to vascular access:
• Hematoma
• Pneumothorax
• Retroperitoneal bleed
Related to the procedure
• Hypotension form externalization of blood in the extracorporeal
circuit.
• Hypotension due to decrease intravascular oncotic pressure.
• Bleeding from reduction in plasma levels of coagulation factors
• Edema formation due to decrease intravascular oncotic pressure
• Loss of cellular elements ( platelets )
• Hypersensitivity reactions

17. Complicationofplasmapeheresis
Related to anticoagulation:
• Bleeding, especially with heparin
• Hypocalcemic symptoms ( with citrate)
• Arrhythmias
• Hypotension
• Numbness and tingling of extremities
• Metabolic alkalosis from citrate

18. Hemodialysis and hemoperfusion in the
treatment of poisoning
• Hemodialysis and hemoperfusion common
• Treatment should be applied selectively in the context of
comprehensive management strategy
• Cardiorespiratory support, early gastric lavage and
administration of multiple dose activated charcoal or specific
antidots

19. Dialysisand Hemoperfusion
Criteria for consideration of dialysis or hemoperfusion in poisoning
1. Progressive deterioration despite intensive supportive therapy
2. Severe intoxication with depression of midbrain function leading
to hypoventilation hypothermia and hypotension.
3. Development of complication of coma, such as pneumonia or
septicemia etc
4. Impairment of normal drug excretory function in the presence of
hepatic, cardiac or renal insufficiency
5. Intoxication with agents with metabolic and or delayed effects
6. Intoxication with and extractable drug or poison, which can be
removed at a rate exceeding endogenous elimination by liver or
kidney

20. CHOICEOF THERAPY
DRUG SERUM CONCETRATION METHOD OF CHOICE
Phenobarbital 100 mg/L HP, HD
Glutethimide 40 HP
Methaqualone 40 HP
Salicylated 800 HD
Theophylline 40 HD
Paraquat 0.1 HP> HD
Methanol 500 HD

21. Technicalpoints
1. Vascular access for hemodialysis or hemoprfusion in poisoning –
with out AVF – Percutaneous cannulation of large central vein
using dx catheter.
2. Choice of hemodialyzer: high flux, high efficiency dialyzer with
high urea clearance and biocompatible membranes used.
3. Choice of a hemoperfusion cartridge
4. The hemoperfusion circuit: same circuit like dx
5. Priming the hmoperfusion circuit setup and priming procedure
differ depending on the brand of cartridge used.
6. Heparinization during hemoperfusion (2000-3000 units bolus in
arterial line)
7. Duration of hemoperfusion: 3hours

22. Some available hemoperfusiondevice
Manufacturer device Sorbent type Polymer coating
Asahi Hemosorba Bead charcoal Poly-HEMA
Clark Biocompatible
system
charcoal Heparinized
polymer
Gambro Adsorba Norit Cellulose acetate
Braun Haemoresin XAD-4 none
Smith and
Nephew
Hemocol or
Haemocol
Sucliffe speakman
charcoal
Acrylic hydrogel

23. Complication
1: Hemodialysis
a. Hypophosphatemia ( P is not present in dx solution)
b. Alkalemia ( standerd dx solution have high HCO3)
c. Disequilibrium syndrome ( pt have high urea and poison dialyzed
with high flux dialyzer lead to disequilibrium syndrome.
2: Hemoperfusion:
a. Mild transient thrombocytopenia and leukopenia can occur but
levels usually return to normal with in 24 to 48 hr.
b. Adsorption or activation of coagulation factors has also been
observed rarely.
3: Continuous therapy:
a. Fluid and electrolyte imbalances may be potential problem and
require frequent monitoring.
b. Prolonged anticoagulation may predispose to bleeding.