Plasma Exchange Issues

Carol L. Koski, M.D., Principal Author

Plasma exchange may not be appropriate for children. The procedure is usually well tolerated but complications can include cardiac arrhythmia from an electrolyte imbalance, citrate-induced hypocalcemia, hemolytic anemia, and infection and thrombosis or other vascular injury at the site of venous access.

In addition, the patient, rarely, may experience allergic reactions to the plasma replacement solutions, leading to an activation of coagulation, complement and fibrinolytic cascades, as well as platelet aggravation.

The most common problem with PE therapy is hypotension, which can be manifested as feeling faint, dizziness, blurred vision, feeling cold, sweating or abdominal cramps. Hypotension can be remedied by lowering the patient's head, raising the legs, and administering intravenous fluid. Hypotension during plasma exchange is aggravated by the concomitant administration of ACE inhibitors.

During the course of PE therapy, patients experience a lowered anticoagulation rate due to the loss of platelets and clotting factors removed with plasma. In the absence of liver dysfunction, clotting factors in the circulation return to normal within 24 hours. Bleeding can occasionally occur. Some anticoagulation medications can cause other adverse reactions, which begin with tingling around the mouth or in the limbs, muscle cramps or a metallic taste in the mouth. If allowed to progress, these reactions can lead to an irregular heartbeat or seizures.

An allergic reaction to the solutions used to replace the plasma or to the sterilizing agents used for the tubing can be a true emergency. This type of reaction usually begins with itching, wheezing or a rash. The plasma exchange must be stopped immediately and the person treated with intravenous medications to limit the extent of the reaction.

Excessive suppression of the immune system can temporarily occur with PE, since the procedure is not selective about which antibodies it removes. In time, the body can replenish its supply of needed antibodies, but some physicians give these intravenously after each plasma exchange treatment. Outpatients may have to take special precautions against infection.

Medication dosages need careful observation and adjustment in people being treated because some drugs can be removed from the blood or modified by the procedure.

PE therapy has several other limitations. In addition to being invasive, it:

• is a time-consuming procedure,
• is expensive, and
• can be performed only at specialized centers, located mostly in major population areas.

The procedure requires large bore intravenous catheters and venous access can be problematic. Many patients require a surgically placed central catheter which may eventually become infected or develop clots. (Ropper, 2003)

Because of adverse events related to difficulty with venous access, the use of citrate, and the hemodynamic changes that occur with PE therapy, the EFNS/PNS joint task force recommends that either IVIG or corticosteroid therapy be considered prior to plasma exchange. (Joint Task Force, 2005)

As a consequence of all these issues, even if PE therapy is used in the initial management of patients to establish immunoresponsiveness, or in the short term during institution of another regimen, most patients ultimately require other measures for long-term maintenance.