this type of proceures can treat many immunological diseases

1. Prof. Ahmed Hassan MD
ASS. Prof. Of Nephrology NIUN
Consultan of Nephrology 6 October Insurance Hospital

2. National Institute of Nephrology
And Urology ( NIUN)

3.  Define & identify the indication of plasmaphoresis in
renal disease
 Outline appropriate therapy
 Detailed instruction for the equipment involved in
plasmaphoresis
 Highlight potential complication of plasmaphresis

4.  It is the removal of large volumes of plasma to be
replaced by fresh frozen plasma or albumin solutions.
 It is an extracorporeal therapy and as such is
dependent on adequate vascular access.
 The terms "plasma exchange" and
"plasmapheresis" are often used inter-changeably
Definition

5. Plasmapheresis Functions
 Removes Immune Complexes
 Removes Antibodies
 Removes Plasma (for high lipids)
 Removes/activates Complement
 Removes inflammatory mediators
 Infuses FFP or IVIG (blocking antibodies which
attach to Fc portion of antibody)
 Can be thought of as another immunosuppressant.

6. Common Indication Of
Plasmaphoresis In Nephrology
 Good pasture's syndrome
 Hyperviscosity syndromes
 Cryoglobulinemia
 Paraproteinemia
 Waldenström macroglobulinemia
 Thrombotic thrombocytopenic purpura(TTP)/ HUS
 Wegener's granulomatosis
 Microscopic polyangiitis
 Antiphospholipid Antibody Syndrome(APS or APLS)
 SLE (Lupus cerebritis).
 Recurrent FSGS & ABS mediated in kidney Tx.

7.  Myasthenia gravis
 Guillian barre” syndtome
 Chronic inflammatory demyelinating
polyneuropathy
 Multiple sclerosis
 Dermatomyositis
 Myeloma
 Waldenstorm’s macroglobulinemia
 Hypertriglyceridemia

8.  Like that of CRRT
◦ Central lines may be percutaneus or tunnelled (permicath).
◦ The tunnelled one is preferred as plasmaphoresis result in
profound immunosuppression.

11. 1. Centrifugal cell separators
 Centrifugation takes advantage of the different
specific gravities inherent to various blood products,
such as red blood cells (RBCs), white blood cells
(WBCs), platelets, and plasma
2. Membrane Plasmafiltration:
 Uses highly permeable membranes
 Plasma passes through the membrane pores, whilst
the cells are simultaneously returned to the patient
Techniques of Plasmapheresis

14. Dialysis & Transplantation 2009 February: 1-4

16. Techniques of Plasmapheresis
 Membrane apheresis  Centrifugal devices
 Advantage:
• Fast and efficient plasmapheresis
• No citrate requirement
• Adapted for cascade filtration
 Disadvantage:
• Removal of substance limited by
sieving coefficient of membrane
• Unable to perform cytapheresis
• Requires high blood flows, central
venous access
• Requires heparin anticoagulation
limiting use in bleeding disorders
 Advantage:
• Capable of performing
cytapheresis
• No heparin requirement
• More efficient removal of all
plasma components
 Disadvantage:
• Expensive
• Requires citrate anticoagulation
• Loss of platelets

17.  Gambro PF 1000 N/ 2000 N
 Blood flow
◦ Optimum 100-150 ml/m
 Prime:
◦ Pf 1000N need 2000ml of N.saline with the last 1000 cc
contain 5000 iu heparin.
◦ Pf 2000 N need 3000ml of N.saline with the last 1000 cc
contain 5000 iu heparin.
Min. Bl. flow
Max. Bl.flow
Max. TMP
Priming vol.
Surface area
50ml/m
200ml/m
200
23 ml
0.15 m2
PF 1000 N
100ml/m
250ml/m
120
41ml
0.35 m2
PF 2000 N

18. QUF (ml/m)
PF 1000 N
QUF (ml/m)
PF 2000 N
Blood flow
(ml/m)
15-19
50
29-36
39-48
100
43-53
57-69
150
54-67
74-91
200

19.  Volume:
◦ 1- 1.5 plasma volume/ session that can be calculated by:
◦ Plasma volum in L= (0.0625 XWt (kg) )X (1- haematocrit)
◦ Plasma volume= 40 X Wt/kg
 Rate:
◦ It is determined by blood flow (100-150 ml/m) that equal to
Uf rate of 30-35/m & 45-55 ml/m respectively).
◦ The plasma filtration rate vary indirectly with haematocrit
 Duration:
◦ Duration /m= (plasma volume X exchange volume) / plasma
filtration rate

20.  Check clotting /CBC before and after therapy
 Continuous ECG & Bl. pressure monitoring to detect
hypotension & dysrrythmias.
 Monitor body temperature and maintain it > 36

21.  Heparin
◦ Initial dose 50 iu/kg
◦ Maintenance dose 15-20 iu/kg/hr

22.  Fresh frozen plasma:
◦ Indicated in hemolytic uremic syndrome &
thrombotic thrombocytopenic purpura.
 Initially Albumin 5% followed by
FFP/Albumin 5% 1:1
◦ For other pathologies

23. Albumin Fresh frozen plasma
 Advantage:
-No risk of hepatitis
-Stored at room temperature
-Allergic reaction are rare
-No concern about ABO bl. group
- Depletes inflammatory mediators
 Disadvantage:
-Expensive
-No coagulation factors
-No immunoglobulin's
• Advantage:
-Coagulation factors
-Immunoglobulin's ‘’ beneficial’’ -
factors complement
• Disadvantage:
-Risk of hepatitis, HIV
transmission
-Allergic reaction
-Hemolytic reaction
-Must be ABO compatible
-Citrate load

24.  Electrolyte
◦ Obtain serum calcium
◦ Keep calcium level > 8 mg/dl
◦ IV calcium in fusion at a rate of 0.25ml/kg
◦ Monitor s. K & Hco3
 Fluid balance:
◦ Usually a volume is given back equal to that removed
unless the patient already severely overloaded.

25.  Hydrocortisone
◦ < 12yrs 2-4mg/kg maximum 100mg
◦ > 12 yrs 100-200mg
 Chlorpheniramine:
5-10mg
6-12 yrs
10-20mg
> 12 yrs

27.  Hypocalcemia
 Hemorrhage
 Thrombocytopenia
 Hypotension
 Hypokalemia
 Infection
 Membrane incompatibility
 Hypothermia
 Sensitivity to replacement fluid

28.  Plasma exchange is accomplished with a medical
device called a blood cell separator.
 It uses a centrifuge or membrane plasma filtration to
separate plasma from cellular blood components.
 A replacement fluid prescribed is added to replace the
volume of plasma which is removed.
 The mix of cellular components and replacement
fluid is returned to the patient.
 The blood cell separators accomplish all the above
steps in an automated, continuous, and safe manner.