The most widely performed apheresis procedure — removes large-molecular-weight pathogenic substances from plasma while preserving cellular blood components. Indicated across more than 80 disease conditions in the ASFA 9th Edition guidelines.
Patients taking ACE inhibitors (e.g., lisinopril, enalapril, ramipril) must have these medications held for a minimum of 24 hours before TPE. ACE inhibitors block the breakdown of bradykinin; when blood contacts negatively charged surfaces in the apheresis circuit, bradykinin is generated and can accumulate to levels that cause severe anaphylactoid reactions including flushing, hypotension, and bronchospasm. This interaction is particularly pronounced with negatively charged membrane filters and certain albumin preparations. Confirm medication hold status before initiating any procedure.
During TPE, whole blood is continuously withdrawn from the patient and directed into a centrifugal or membrane-based separation device. The device separates plasma from the cellular components — red blood cells, white blood cells, and platelets. The plasma fraction, which contains the pathogenic substances driving disease, is discarded. The cellular components are then combined with a replacement fluid and returned to the patient.
The primary therapeutic targets of TPE are large-molecular-weight substances that cannot be effectively removed by dialysis or pharmacological means alone. These include autoantibodies (IgG, IgM, IgA), immune complexes, cryoglobulins, paraproteins, lipoproteins, endotoxins, and inflammatory cytokines. A single session exchanging 1.0 plasma volume removes approximately 63% of an intravascular substance; exchanging 1.5 plasma volumes removes approximately 78%.
Because TPE removes the entire plasma compartment indiscriminately, it also removes beneficial proteins including albumin, coagulation factors, immunoglobulins, and medications. This necessitates replacement fluid administration and careful consideration of timing relative to other therapies.
Centrifugal Separation: Blood components are separated by density using centrifugal force. The Spectra Optia® and similar platforms use this method. Plasma is skimmed from the buffy coat layer and collected for removal.
Membrane Filtration: Plasma passes through hollow-fiber membranes with defined pore sizes (typically 0.2–0.6 µm), separating plasma from cells based on size. Used in membrane plasmapheresis systems.
Medication Removal: TPE removes significant quantities of medications, especially those that are highly protein-bound. Intravenous immunoglobulin (IVIg), rituximab, and other biologics administered before TPE may be substantially cleared. Coordinate timing of all medications with the apheresis team.
The standard replacement fluid for the majority of TPE procedures. Albumin is an oncotically active protein that maintains intravascular volume effectively. It carries no risk of viral transmission and has a very low rate of allergic reactions compared to plasma products.
Provides all coagulation factors, von Willebrand factor, and ADAMTS13. Required as the replacement fluid for Thrombotic Thrombocytopenic Purpura (TTP) and other conditions where coagulation factor replacement is clinically necessary.
A hybrid approach using albumin for the majority of the exchange volume with a final wash of FFP to partially replenish coagulation factors. Reduces the total FFP volume used while providing some factor replacement at the end of the procedure.
Used as a supplemental flush or for small-volume replacements. Not appropriate as a primary replacement fluid for standard TPE due to lack of oncotic activity — will not maintain intravascular volume adequately for full plasma volume exchanges.
| Condition | ASFA Category | Grade | Clinical Context |
|---|---|---|---|
| Guillain-Barré Syndrome | I | 1A | Acute inflammatory demyelinating polyneuropathy; TPE equivalent to IVIg |
| Thrombotic Thrombocytopenic Purpura (TTP) | I | 1A | Acquired ADAMTS13 deficiency; FFP replacement mandatory |
| Myasthenia Gravis (Crisis / Pre-op) | I | 1B | Removes AChR and MuSK antibodies; rapid clinical improvement |
| CIDP | I | 1B | Short-term benefit; maintenance therapy often required |
| Acute Liver Failure (Non-Acetaminophen) | I | 1A | High-volume TPE with FFP; bridge to transplant or recovery |
| NMDA Receptor Encephalitis | I | 1C | Second-line therapy alongside immunosuppression |
| ANCA-Associated Vasculitis (Dialysis-Dependent) | II | 2B | Adjunct to immunosuppression in severe renal involvement |
| Hyperviscosity Syndrome | I | 1B | Symptomatic hyperviscosity from paraprotein; rapid reduction |
Source: ASFA 9th Edition Guidelines (J Clin Apher. 2023;38(2):77–278). See Disease Library for all 80+ indications.
Tingling in lips, fingertips, and around the mouth; muscle cramps; lightheadedness. Caused by citrate anticoagulant binding ionized calcium. Managed with oral or IV calcium supplementation. Patients should report symptoms promptly.
Lightheadedness, dizziness, or fainting from fluid shifts. More common in patients who are dehydrated, elderly, or hemodynamically borderline. Managed with IV fluid boluses and rate adjustment.
Generalized fatigue and feeling cold are common during and after the procedure, particularly with albumin replacement. Warm blankets and slow procedure pace can help.
Mild nausea occurs in a subset of patients, often related to citrate accumulation or vasovagal response. Usually resolves with rate reduction.
Severe flushing, hypotension, bronchospasm. Caused by bradykinin accumulation when ACE inhibitors are not held. Requires immediate procedure termination and emergency management.
Urticaria, angioedema, or anaphylaxis from FFP proteins. More common with FFP replacement than albumin. Pre-medication with antihistamines may reduce risk.
Rare; associated with severe hypocalcemia or electrolyte disturbances. Continuous cardiac monitoring is recommended for high-risk patients.
Depletion of coagulation factors with albumin replacement. Clinically significant bleeding is rare but possible, particularly in patients with pre-existing coagulopathy or when invasive procedures are planned shortly after TPE.