Ministry of Health

Dakahlia Medical diroctorate

New Mansoura General Hospital
Nephrology Department

Plasmapharesis Protocol

Dr. NevienNabih Dr. Osama El Sayad

Assistant Specialist of nephrology Egyptian Fellowshipof nephrology
New Mansoura General Hospital New Mansoura General Hospital

Dr. Osama El Shahat

Consultant of Nephrology
Head of nephrology department
New Mansoura General Hospital
Def:
Plasmapheresis is the removal, treatment, and return of (components of)
blood plasma from blood circulation. In plasmapheresis or therapeutic
plasma exchange <TPE> large quantities of plasma are removed and
replaced with fresh frozen plasma, albumin and / or saline

Indication: Examples of diseases that can be treated with plasmapheresis:

Idiopathic pulmonary fibrosis

Guillain-Barre syndrome
Miller Fisher syndrome[7]
Chronic inflammatory demyelinating polyneuropathy
Good pasture's syndrome
Hyper viscosity syndromes:
o Cryoglobulinemia
o Paraproteinemia
o Waldenstrm macroglobulinemia
Myasthenia gravis
Thrombotic thrombocytopenic purpura (TTP)/hemolytic uremic
syndrome
Wegener's granulomatosis
Lambert-Eaton Syndrome
Antiphospholipid Antibody Syndrome (APS or APLS)
Microscopic polyangiitis
Recurrent focal and segmental glomerulosclerosis in the transplanted
kidney
HELLP syndrome
 PANDAS syndrome
Refsum disease
Behcet syndrome
HIV-related neuropathy[8]
Graves' disease in infants and neonates
Pemphigus vulgaris
Neuromyelitis optica
Multiple sclerosis
Rhabdomyolysis
Toxic Epidermal Necrolysis (TEN)

Procedure of plasmapheresis:

A: Centrifugal plasma separation : blood cells are separated during

centrifugation , there are two centrifugation methods Intermittent flow
device and continuous flow device

B: membrane plasma separation : plasma separators use membranes with a

molecular weight 3 million

Estimation of plasma volume:

There are several equations

1-The plasma volume is estimated 35- 40 ml\ kg. 35ml is applicable to the
patient with normal Hct value and 40 ml\ kg is applicable to the patient with
low Hct

2- there is a simplified method for predicting the estimated plasma volume is

{0.065 xweight( kg) x {1-Hct}

Choice of replacement solution:

A: albumin : its advantage there is no risk of hepatitis , stored at room

temperature , allergic reaction are rare, depletes inflammation mediators
, but its disadvantage as its very expensive and no coagulation factor
and no immunoglobulin

B: fresh frozen plasma: advantage : has coagulation factors and

immunoglobulin , its disadvantage : risk of hepatitis, HIV .
Allergicreaction.Hemolytic reaction
Complication of plasmapheresis:

Related to the vascular access

1-Hematoma
2-Pneumothorax
3-Retroperitoneal bleed

Related to the procedure

1-Hypotension: can be avoided by adjust volume balance and should measure

the blood pressure every half hour

2-Bleeding: can be treated by two unite of fresh frozen plasma at the end of
session

3-Edema

4-Loss of cellular element

5-Hypersensitivity reaction: can be avoided by premedication for the

sensitized individual
a: prednisone 50 mg orally 13 hours , 7hours , 1 hour before treatment
b. diphenhydramine 50 mg orally 1 hour before treatmen
c: ephedrine 25 mg orally 1 hour before treatment

Related to anticoagulation

1-Bleeding
2- Hypocalcemic symptom: can be treated by prophylactic 10% CaCl
during treatment
3-Arrhythmia: due to hypokalemia which can be avoided by ensure
serum potassium concentration of 4 mm in the replacement solution
4-Hypotension
5-Numbness and tingling
6-Metabolic alkalosis from citrate

Post procedure:

We should do serum calcium, serum k& CBC to the patient

The plasmapheresis technique is consider as immunosuppressive therapy so

the patient should be isolated.