Plasmapheresis: Principles, Uses, and Patient Care

Plasmapheresis is a medical procedure that removes harmful substances, such as autoantibodies, immune complexes, or toxins, from the blood by separating plasma from blood cells.
This presentation explains the mechanism, indications, steps of plasmapheresis, types of equipment used, patient monitoring, possible complications, and clinical applications in diseases like autoimmune disorders, kidney diseases, neurological disorders, and more.
Learn how plasmapheresis supports patient care and improves treatment outcomes in critical conditions.

1. Plasmapheresis
The term “Apheresis,” comes from the Latin word “aphaeresis” is commonly used in medicine with the
meaning of “separation.
Plasmapheresis or Therapeutic plasmapheresis is an extracorporeal therapeutic procedure that involves removal,
return, or exchange of blood plasma. When plasma is removed from the blood, it is replaced it with a substitute
solution such as fresh frozen plasma, albumin, or saline.
Indications:
The disorders where therapeutic plasmapheresis can be done are grouped into four categories by the Apheresis
Applications Committee of the American Society for Apheresis (ASFA).
Category 1 includes disorders where plasmapheresis can be done as a first-line treatment,
Category 2 includes disorders where plasmapheresis can be done as a second-line treatment in addition
to the existing standard of care
Category 3 includes disorders in which the evidence of the benefit of plasmapheresis is minimal, and
therapy must be individualized
Category 4 includes disorders in which the evidence suggests that plasmapheresis is either ineffective or
harmful, however, may be considered after approval from the institute ethics committee.
The alphabetical list of various indications for plasmapheresis, along with their ASFA category, is as follows.
Category 1
Acute inflammatory demyelinating polyradiculoneuropathy/Guillain-Barre syndrome

2. ANCA-associated rapidly progressive glomerulonephritis (dialysis-dependent or associated with diffuse
alveolar hemorrhage)
Anti-glomerular basement membrane disease-Goodpasture syndrome (dialysis independent or associated
with diffuse alveolar hemorrhage)
Chronic inflammatory demyelinating polyradiculoneuropathy
Focal segmental glomerulosclerosis (recurrent in the transplanted kidney)
Hyperviscosity in monoclonal gammopathies
Liver transplantation: Desensitization
Myasthenia gravis
N-methyl D-aspartate receptor antibody encephalitis
Paraproteinemic demyelinating neuropathies/chronic acquired demyelinating polyneuropathies
(IgA/IgG/IgM mediated)
Progressive multifocal leukoencephalopathy associated with natalizumab
Renal transplantation: Desensitization and antibody-mediated rejection
Thrombotic microangiopathy (Factor H autoantibodies and ticlopidine)
Thrombotic thrombocytopenic purpura
Wilson disease (fulminant)
Category 2
Acute disseminated encephalomyelitis
Cardiac transplantation: Desensitization
Catastrophic antiphospholipid syndrome
Cryoglobulinemia; symptomatic/severe
Dilated cardiomyopathy, idiopathic (NYHA 2-4)
Hashimoto encephalopathy: Corticosteroid responsive encephalopathy associated with autoimmune
thyroiditis
Hematopoietic stem cell transplantation, ABO-incompatible
Lambert-Eaton myasthenic syndrome
Multiple sclerosis
Myeloma cast nephropathy
Neuromyelitis Optica spectrum disorders
Overdose, envenomation, and poisoning, such as mushroom
Pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections (PANDAS)
Phytanic acid storage disease (Refsum disease)
Systemic lupus erythematosus (severe)
Category 3
Acute liver failure
ANCA-associated rapidly progressive glomerulonephritis (dialysis independent)
Anti-glomerular basement membrane disease, Goodpasture syndrome (dialysis-dependent, no DAH)
Aplastic anemia, pure red cell aplasia
Autoimmune hemolytic anemia
Burn shock resuscitation
Cardiac neonatal lupus
Cardiac transplantation: Antibody-mediated rejection
Chronic focal encephalitis (Rasmussen encephalitis)
Complex regional pain syndrome; chronic
Erythropoietic porphyria, liver disease

3. Hemolysis liver enzymes low platelet (HELLP) syndrome (postpartum)
Hematopoietic stem cell transplantation, HLA desensitization
Hemophagocytic lymphohistiocytosis; hemophagocytic syndrome; macrophage activating syndrome
Henoch-Schonlein purpura
Heparin-induced thrombocytopenia and thrombosis
Hypertriglyceridemic pancreatitis
Immune thrombocytopenia; refractory
IgA nephropathy; crescentic
Lung transplantation: Desensitization and antibody-mediated rejection
Paraneoplastic neurological syndromes
Pemphigus Vulgaris; severe
Pruritus due to hepatobiliary diseases
Scleroderma (systemic sclerosis)
Sepsis with multiorgan failure
Stiff-person syndrome
Thrombotic microangiopathy (complement factor gene mutations, MCP mutations, clopidogrel, and
calcineurin inhibitors)
Thyroid storm
Toxic epidermal necrolysis (refractory)
Vasculitis
Voltage-gated potassium channel antibodies
Category 4
Amyloidosis, systemic
Dermatomyositis/polymyositis
HELLP syndrome (antepartum)
Lupus nephritis
Thrombotic microangiopathy (gemcitabine and quinine)
Contraindications
The contraindications for therapeutic plasmapheresis are as follows:
Non-availability of central line access or large bore peripheral lines
Hemodynamic instability or septicemia
Known allergy to fresh frozen plasma or replacement colloid/albumin
Known allergy to heparin
Hypocalcemia (restricts the use of citrate as an anticoagulant during the procedure); relative
contraindication
Angiotensin-converting enzyme (ACE) inhibitor used in last 24 hours; relative contraindication (can
cause acute, severe hypotension)
Venous Access: For this procedure high blood flow rates are required (100–150 mL/min) and venous access
is either by a central venous catheter (Internal Jugular Vein, Femoral Vein, Subclavian Vein) or large bore
peripheral lines. Arteriovenous (AV) Access is used for Plasmapheresis in patients who are on MHD.

4. Types of Plasmapheresis
֎Centrifuge-Based Plasmapheresis Utilizes a centrifuge to
separate plasma from blood components based on their
density. Filtered Plasma is then discarded or replaced with
fluids such as donor plasma, albumin, or colloids. Cellular
Components (RBCs, WBCs, and Platelets) returned to the
patient with replacement fluids.
The steps for performing plasmapheresis using centrifuge-
based equipment are as follows:
1.Automated centrifuge-based plasmapheresis machines are
used. Which requires Large-bore venous access (e.g.,
central venous catheters or peripheral veins).
2.Initially, a waste of around 3-5 mL blood from the
central venous catheter is discarded.
3.After drawing baseline samples for complete hemogram,
calcium, and fibrinogen, it is flushed with 5-10 mL of
heparinized saline.
4.The double lumen catheter is now connected to the machine tubing to start the priming procedure.
5.The machine calculates total body volume (TBV), and the effective plasma volume (which equals TBV
× (1 – hematocrit)) of the patient based on the operator entered height and weight.
6.The replacement product to be used and its desired volume (40 - 60 mL/kg) is decided by the clinician,
(Albumin 5% or 25% for non-bleeding patients, Fresh Frozen Plasma (FFP) for patients with clotting
disorders or bleeding risk) and entered into the machine, based on which it calculates the centrifuge
speed. The separated plasma is discarded by the machine, and the RBCs are returned back to the patient
along with the replacement fluid.
7.Finally, post-procedure, tubings are connected to heparinized saline, and reinfusion is initiated.
8.Post-plasmapheresis blood for fibrinogen and calcium is sent again, and lumens of central venous
catheters are flushed.
Advantages
Efficient for high-volume plasma removal.
Superior for removing circulating immune complexes, autoantibodies, and cryoglobulins.
Widely available and preferred in most centers worldwide.
Disadvantages
Replacement fluids (donor plasma, albumin) are mandatory, increasing cost and risk of reactions (e.g.,
allergic or infectious).
Not selective for macromolecules—it removes all plasma proteins non-specifically.
֎Membrane-Based Plasmapheresis
Blood passes through a semipermeable membrane of Hollow Fiber Dialyzers that allows plasma
(containing proteins and macromolecules) to pass through while retaining blood cells (RBCs, WBCs,

5. platelets). Plasma is filtered to remove harmful macromolecules like autoantibodies, immune complexes, or
cryoglobulins. The membrane allows selective removal of these substances while retaining smaller, essential
components such as electrolytes, albumin, and clotting factors. The "cleaned" plasma, free of harmful
substances, is returned to the patient along with the cellular components. Unlike centrifuge-based methods
where plasma is discarded, the filtered plasma can be processed and returned to the patient, eliminating
the need for replacement fluids. A standard hemodialysis machine is modified to accommodate
semipermeable membrane filters. Central venous access is necessary to achieve the high blood flow
rates required (100–150 mL/min). Anticoagulants such as heparin or citrate are used to prevent clotting
within the extracorporeal circuit.
Advantages
No Need for Replacement Fluids
Plasma is filtered and processed to remove harmful substances but is returned to the patient. This
eliminates the need for:
oDonor plasma (reducing the risk of allergic or infectious complications).
oAlbumin or other colloids, reducing costs.
Selective Filtration: Membranes can target and remove specific macromolecules (e.g., immune
complexes, autoantibodies, cryoglobulins) while retaining other essential components.
Disadvantages
Need for High Blood Flow: Membrane-based plasmapheresis requires central venous access to achieve
the high blood flow rates needed, which may not be feasible in all patients.
Limited Efficiency for High-Volume Plasma Exchange: This method may be less efficient than
centrifuge-based plasmapheresis for procedures requiring the removal of large plasma volumes.
Filter Lifespan: Membranes have a finite lifespan and may need replacement during the procedure if
they clog or become less effective.
Specialized Equipment: Not all centers may have the required membrane filters or the expertise to
modify hemodialysis machines for this purpose
Complications:
The common complications that can occur during or post-plasma exchange procedure:
Hypocalcemia or hypomagnesemia as a result of the use of citrate anticoagulation. This is managed with
the intravenous replacement of calcium and magnesium.
Hypothermia
Transfusion reactions. They are managed symptomatically with pheniramine,
hydrocortisone/dexamethasone, and/or epinephrine.
Fluid and electrolyte imbalance.
Bleeding diatheses due to hypofibrinogenemia and thrombocytopenia.
Hypotension
Flushing
Gastrointestinal symptoms like nausea and vomiting