Plasmapheresis Treatment in Delhi, India

Therapeutic Plasmapheresis – it is performed with the objective of removing some particular constituents from a patient's plasma. (The term plasma exchange rather than plasmapheresis is normally used for this procedure.)

Plasmapheresis of normal donors for preparation of plasma fraction, e.g. in donor hyperimmunized to Rh, plasma is used for the production of Anti-Rh immunoglobulin.

Plasmapheresis is a therapeutic intervention that involves extracorporeal removal, return, or exchange of blood plasma or its components. The mechanism of this procedure is accomplished by either centrifugation or filtration using semipermeable membranes.

The two ways to separate the elements of blood using machines are:

• Centrifugation: In this process, the blood spins in a machine for several minutes, which results in separated components based on the density of the elements.
• Filtration: The blood is filtered to separate the plasma.

During plasma exchange, the machine eliminates unhealthy plasma. Then, it replaces it with healthy plasma received from a donor, saline, albumin, or a combination of the two.

The different techniques commonly used in plasmapheresis.

• Centrifugation technique
• Continuous flow technique
• Intermittent flow technique
• Membrane filtration technique

Plasma exchange treats a wide range of medical conditions, such as:

• Brain and nervous system conditions - acute Guillain–Barré syndrome.
• Blood disorders - Thrombotic Thrombocytopenic Purpura
• Some kidney conditions – Good pasture syndrome
• Hyperviscosity syndromes - Myeloma. These conditions cause the blood to thicken, leading to organ damage or a stroke.

A Transfusion Medicine specialist doctor, along with the blood bank Technician, performs plasma exchange in a hospital ICU setting. The entire process of plasma exchange takes about three to five hours.

The machines are highly sophisticated, in which at no point in time the patient's blood is exposed outside; it remains within a sterile kit which is used for the procedure. This kit is a single-use kit & is discarded after use in the patient.

Plasmapheresis is a therapeutic modality for many conditions. It is advocated when a substance in the plasma, for example, immunoglobulin, is acutely toxic and can be efficiently removed. Various conditions fall into this category, including neurologic, hematologic, metabolic, dermatologic, rheumatologic, renal diseases, and intoxications.

The AFSA, Apheresis Applications Committee of the American Society for Apheresis, regularly evaluates potential indications for apheresis.

It categorizes them from I to IV based on the available medical literature. The following are some indications and their categorization from society's guidelines.

Category I indications - disorders for which plasmapheresis is the first-line therapy, include the following:

• Guillain-Barre syndrome
• Myasthenia gravis (acute short-term treatment)
• Hyperviscosity in hyper-gamma-globulinemia
• Thrombotic thrombocytopenic purpura
• Chronic inflammatory demyelinating polyneuropathy
• Good pastures syndrome
• Thrombotic micro-angiopathy, complement-mediated (autoantibody to factor H)
• Wilson disease

Category II indications - disorders for which plasmapheresis is the second-line therapy include the following:

• Lambert-Eaton myasthenia syndrome
• Thyroid storm
• Mushroom poisoning
• Autoimmune haemolytic anaemia (severe cold agglutinin disease)
• Systemic lupus erythematosus (severe)
• Multiple sclerosis
• Acute disseminated encephalomyelitis
• Myeloma cast nephropathy

Category III indications - disorders for which the role of apheresis is not established include the following:

• Post transfusion purpura
• RBC alloimmunization in pregnancy
• Autoimmune haemolytic anaemia (severe warm)
• Hyper-triglyceridemic pancreatitis
• Drug overdose/poisoning
• Immune thrombocytopenia
• Thrombotic microangiopathy, complement-mediated (complement factor mutations)
• Stiff person syndrome

Category IV indications - disorders in which published evidence suggests that apheresis may be ineffective or harmful include the following:

• HELLP syndrome (antepartum)
• Multifocal motor neuropathy
• Haemolytic uremic syndrome (typical diarrhoea-associated)
• Idiopathic polyarteritis nodosa

Some evidence suggests that plasmapheresis can be successfully employed in patients to alleviate infection-related symptoms associated with antibody-dependent enhancement (ADE) of bacterial disease.

Plasmapheresis is contraindicated in the following patients:

• Patient intolerant to central line placement.
• Patients with sepsis or those who are hemodynamically unstable. Even though plasmapheresis removes different mediators from the blood, it appears to be helpful in treating sepsis. But it is risky in patients who are in a septic state since they are coagulopathic and hemodynamically unstable.
• Patients allergic to fresh frozen plasma (FFP) or albumin
• Patients allergic to heparin should not be given heparin as an anticoagulant during the procedure.
• Hypo-calcaemic patients are at risk of worsening their condition because citrate is commonly used to prevent clotting and can potentiate hypo-calcaemia.
• Avoid taking ACE inhibitors for at least 24 hours before starting plasmapheresis.

The main is proper vascular access. In most cases, central venous catheters are used in PEX, especially in acute conditions. They can be placed in the internal jugular, femoral and subclavian veins. However, if life-long treatment is needed (e.g. LDL apheresis), arteriovenous fistula creation may be required.

Considerations in the selection of replacement fluid include the type of procedure, the indication, and the patient's coagulation status.

Depending on the underlying disease.

Some combination of albumin + NS +FFP

• Where FFP not indicated: 2/3 albumin +1/3 NS
• Where FFP is indicated: % replaced as FFP varies
• Hyper viscosity: 100% replace with NS

Plasmapheresis is a procedure that is very safe. However, complications do occur & adverse events occur in about 4% of procedures. The great majority of adverse events are mild. Reported adverse events are

• Paraesthesia
• Hypotension
• Urticaria
• Nausea
• Shivering
• Flushing
• Dyspnea
• Vertigo
• Arrhythmias
• Abdominal pain
• Anaphylaxis

• Notify the doctor if you have symptoms like seizures, irregular heartbeat, abdominal pain, wheezing, chest pain, shortness of breath, nausea/vomiting, fever, chills, fainting, joint pain with fatigue, and excessive itching or rashes.
• Take enough rest and drink plenty of fluids.
• Take a well-balanced diet as suggested by the physician.

Thus, plasmapheresis is a valuable treatment in patients with autoimmune diseases in which all other treatment modalities have failed. Hence, it can be employed as a treatment of choice in certain autoimmune diseases involving the oral cavity in which the adverse effects of other treatment modalities outweigh the therapeutic effects. This area holds scope for further studies and trials, thereby providing patients with untreatable diseases with a new treatment modality with fewer side effects and faster recoveries.

Reviewed by Dr. Sangeeta Pathak, Associate Director & Head - Transfusion Medicine, Transfusion Medicine on 27-Apr-2023.