plasmapheresis


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Plasmapheresis

 

Definition

Plasmapheresis is a blood purification procedure used to treat several autoimmune diseases. It is also known as therapeutic plasma exchange.

Purpose

In an autoimmune disease, the immune system attacks the body's own tissues. In many autoimmune diseases, the chief weapons of attack are antibodies, proteins that circulate in the bloodstream until they meet and bind with the target tissue. Once bound, they impair the functions of the target, and signal other immune components to respond as well.
Plasmapheresis is used to remove antibodies from the bloodstream, thereby preventing them from attacking their targets. It does not directly affect the immune system's ability to make more antibodies, and therefore may only offer temporary benefit. This procedure is most useful in acute, self-limited disorders such as Guillain-Barré syndrome, or when chronic disorders, such as myasthenia gravis, become more severe in symptoms. In these instances, a rapid improvement could save the patient's life. Neurologic diseases comprise 90% of the diseases that could profit from plasmapheresis.

Precautions

Patients with clotting disorders may not be suitable candidates for plasmapheresis.

Description

The basic procedure consists of removal of blood, separation of blood cells from plasma, and return of these blood cells to the body's circulation, diluted with fresh plasma or a substitute. Because of concerns over viral infection and allergic reaction, fresh plasma is not routinely used. Instead, the most common substitute is saline solution with sterilized human albumin protein. During the course of a single session, two to three liters of plasma is removed and replaced.
Plasmapheresis requires insertion of a venous catheter, either in a limb or central vein. Central veins allow higher flow rates and are more convenient for repeat procedures, but are more often the site of complications, especially bacterial infection.
When blood is outside the body, it must be treated to prevent it from clotting. While most of the anticlotting agent is removed from the blood during treatment, some is returned to the patient.
Three procedures are available:
  • "Discontinuous flow centrifugation." Only one venous catheter line is required. Approximately 300 ml of blood is removed at a time and centrifuged to separate plasma from blood cells.
  • "Continuous flow centrifugation." Two venous lines are used. This method requires slightly less blood volume to be out of the body at any one time.
  • "Plasma filtration." Two venous lines are used. The pasma is filtered using standard hemodialysis equipment. It requires less than 100 ml of blood to be outside the body at one time.
A single plasmapheresis session may be effective, although it is more common to have several sessions per week over the course of two weeks or more.

Preparation

Good nutrition and plenty of rest make the procedure less stressful. The treating physician determines which of the patient's medications should be discontinued before the plasmapheresis session.

Aftercare

The patient may experience dizziness, nausea, numbness, tingling, or lightheadedness during or after the procedure. These effects usually pass quickly, allowing the patient to return to normal activities the same day.

Risks

Reinfusion (replacement) with human plasma may cause anaphylaxis, a life threatening allergic reaction. All procedures may cause a mild allergic reaction, leading to fever, chills, and rash. Bacterial infection is a risk, especially when a central venous catheter is used. Reaction to the citrate anticoagulant used may cause cramps and numbness, though these usually resolve on their own. Patients with impaired kidney function may require drug treatment for the effects of citrate metabolism.
Plasma contains clotting agents, chemicals that allow the blood to coagulate into a solid clot. Plasma exchange removes these. Bleeding complications are rare following plasmapheresis, but may require replacement of clotting factors.

Normal results

Plasmapheresis is an effective temporary treatment for:
  • Guillain-Barré syndrome (an acute neurological disorder following a viral infection that produces progressive muscle weakness and paralysis)
  • Myasthenia gravis (an autoimmune disease that causes muscle weakness)
  • chronic inflammatory demyelinating polyneuropathy (a chronic neurological disorder caused by destruction of the myelin sheath of peripheral nerves, which produces symptoms similar to Guillain-Barré syndrome)
  • thrombotic thrombocytopenic purpura (a rare blood disorder)
  • Paraproteinemic peripheral neuropathies (a neurological disorder affecting the peripheral nerves)
  • blood that is too thick (hyperviscosity)
Other conditions may respond to plasmapheresis as well. Beneficial effects are usually seen within several days. Effects commonly last up to several months, although longer-lasting changes are possible, presumably by inducing shifts in immune response.

Resources

Books

Samuels, Martin, and Steven Feske, editors. Office Practice of Neurology. New York: Churchill Livingstone, 1996.

Key terms

Anaphylaxis — Also called anaphylactic shock, it is a severe allergic reaction to a foreign substance that the patient has had contact with. Penicillin is an example of a substance that causes severe allergic reactions for some people.
Antibody — Chemicals produced by the body to defend it against bacteria, viruses, or other cells foreign to the body (antigens). Each specific antibody reacts against a specific foreign body. Antibodies are also termed immunoglobulins.
Autoimmune — Autoimmune refers to the body's development of intolerance of the antigens on its own cells.
Hemodialysis — A method to take out unwanted parts of the blood. The patient's blood is run through a catheter and tubing into a machine called a dialyzer, which filters out the unwanted blood component.
Plasma — Plasma makes up 50% of human blood. It is a watery fluid that carries red cells, white cells, and platelets throughout the body.

plasmapheresis

 [plaz″mah-fĕ-re´sis]
the removal of plasma from withdrawn blood, with retransfusion of the formed elements into the donor; generally, type-specific fresh frozen plasma or albumin is used to replace the withdrawn plasma. The procedure may be done for purposes of collecting plasma components or for therapeutic purposes.

plas·ma·phe·re·sis

(plaz'măf-ĕ-rē'sis),
Removal of whole blood from the body, separation of its cellular elements by centrifugation, and reinfusion of them suspended in saline or some other plasma substitute, thus depleting the body's own plasma without depleting its cells.
[plasma + G. aphairesis, a withdrawal]

plasmapheresis

/plas·ma·phe·re·sis/ (plaz″mah-fĕ-re´sis) the removal of plasma from withdrawn blood, with retransfusion of the formed elements into the donor; generally, type-specific fresh frozen plasma or albumin is used to replace the withdrawn plasma. The procedure may be done for purposes of collecting plasma components or for therapeutic purposes.

plasmapheresis

(plăz′mə-fĕr′ĭ-sĭs, -fə-rē′-)
n.
A process in which plasma is taken from donated blood and the remaining components, mostly red blood cells, are returned to the donor.

plasmapheresis

[plaz′məfərē′sis]
the removal of plasma from previously withdrawn blood by centrifugation, reconstitution of the cellular elements in an isotonic solution, and reinfusion of this solution into the donor or another client who needs red blood cells rather than whole blood. Compare leukapheresis, plateletpheresis. See also apheresis.

plasmapheresis

Plasma exchange  Therapeutics External shunting of plasma from the peripheral circulation, to remove an undesired substance–eg, toxins, medications–overdose, antibodies, or other 'noxins' or, less commonly, to obtain plasma for donation; pheresed fluid is resuspended in an appropriate fluid–eg, albumin or albumin in saline, then readministered to the Pt; the removal of one plasma volume–± 2500 ml effects a 65% ↓ in toxin or autoantibody in the circulation–2 volume exchanges ↓ toxin by another 20% Indications Hyperviscosity syndrome, myasthenia gravis, Eaton-Lambert syndrome, Goodpasture syndrome, post-transfusion purpura, acute Guillain-Barré syndrome, and to ↓ circulating toxins–eg, paraquat, methylparathion, mushrooms–Amanita phylloides. See Hemapheresis.

plas·ma·phe·re·sis

(plaz'mă-fĕr-ē'sis)
Removal of whole blood from the body, separation of its cellular elements by centrifugation, and reinfusion of these elements in a suspension of saline or some other plasma substitute, thus depleting the body's own plasma without depleting its cells.
[plasma + G. aphairesis, a withdrawal]

plasmapheresis

A method of reducing the concentration of unwanted substances, especially destructive ANTIBODIES and IMMUNE COMPLEXES in the blood. Blood is withdrawn and the cells are removed and suspended in a PLASMA substitute. It is then retransfused. The method is used mainly in such conditions as MYASTHENIA GRAVIS, GOODPASTURE'S SYNDROME and severe complicated cases of SYSTEMIC LUPUS ERYTHEMATOSUS.

plasmapheresis

the removal of plasma from withdrawn blood, with retransfusion of the formed elements into the donor; generally, type-specific fresh frozen plasma or albumin is used to replace the withdrawn plasma. The procedure may be done for purposes of collecting plasma components or for therapeutic purposes. See also plasma exchange.
References in periodicals archive ?
In summary, our cases of CABG-induced TTP and those reported in the literature are characterized by A) a florid presentation with most or all of the components of the classic TTP pentad; B) a frequent delay in the diagnosis; C) a good response to plasmapheresis and dialysis/CRRT in most cases; and D) a tendency not to relapse in those who have survived and obtained complete remission.
Despite all clinical observations, further prospective research are necessary to establish the role of plasmapheresis in mild AIDP/GBS, long-term management of CIDP, treatment of neuropathy associated with IgM gammopathy, MCs and the prethymectomy period of MG, and in fulminant central nervous system demyelinating diseases.
Adults with acute episodes of TTP require daily plasmapheresis in which the patient's plasma is exchanged with fresh frozen plasma.
Lester Sauvage of the Hope Heart Institute in Seattle, Washington, uses IAT and plasmapheresis (withdrawal of blood and return of selected components) routinely for cardiothoracic surgery.
In the study, 34 high immunological risk patients were given plasmapheresis or immunoadsorption before and after the transplantation of a donor kidney from a brain dead (28) or live donor (6).
Plasmapheresis treatment in Guillain-Barre syndrome: potential benefit over IVIg in patients with axonal involvement.
In this process, a patient undergoes plasmapheresis to remove cholesterol from existing HDL particles using an organic solvent.
Nonspecific immunoglobulin and plasmapheresis should be considered for patients with Guillain-Barre syndrome but are not indicated for patients with paralysis due to damage of anterior horn cells (30).
Therapeutic plasmapheresis is a process by which components in plasma, believed to cause or exacerbate disease, are selectively removed.
Disparities between total and ionized calcium secondary to calcium citrate complexing have been reported in patients receiving citrated blood or other blood products and during donor plasmapheresis [5,61.