ICU · Pharmacology
Therapeutic plasma exchange (plasmapheresis) in ICU
Also known as Plasma exchange (PLEX) · Plasmapheresis · Therapeutic plasma exchange (TPE)
Therapeutic plasma exchange in the ICU — what it removes, centrifugal versus membrane separation, the ASFA evidence framework, replacement fluid (albumin versus plasma), access and citrate anticoagulation complications, and the disease trials: TTP, Guillain-Barré syndrome, myasthenia gravis, anti-GBM disease, ANCA vasculitis (Jayne 2007, PEXIVAS) and hyperviscosity.
Checked against its sources on 8 Oct 2026
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Red flags
- Citrate anticoagulation: hypomagnesaemia 45.6% and hypocalcaemia 17.9% of sessions in pooled data — monitor ionised calcium
- In GBS, FFP replacement caused more complications than albumin without better efficacy
- TTP: plasma exchange was superior to plasma infusion
- Dialysis-dependent anti-GBM disease had 8% renal survival at one year
- PEXIVAS: plasma exchange did not reduce death or ESKD in severe ANCA vasculitis
Meet the patient
A 26-year-old woman reaches ICU after four days of ascending weakness following a diarrhoeal illness. Two doors open: plasma exchange or IVIg, which were equivalent in the international trial, and behind both sits the circuit question every TPE patient shares — what replaces the plasma, and what does the anticoagulant cost?[6][5][14]
References18ShowHide
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- [2]Padmanabhan A, Connelly-Smith L, Aqui N, et al. Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. Journal of clinical apheresis, 2019.PMID 31180581
- [3]Kaplan AA Therapeutic plasma exchange: a technical and operational review. Journal of clinical apheresis, 2013.PMID 23420589
- [4]Sanchez AP, Balogun RA Therapeutic Plasma Exchange in the Critically Ill Patient: Technology and Indications. Advances in chronic kidney disease, 2021.PMID 34389138
- [5]Efficiency of plasma exchange in Guillain-Barré syndrome: role of replacement fluids. French Cooperative Group on Plasma Exchange in Guillain-Barré syndrome. Annals of neurology, 1987.PMID 2893583
- [6]Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barré syndrome. Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group. Lancet (London, England), 1997.PMID 9014908
- [7]Raphaël JC, Chevret S, Hughes RA, et al. Plasma exchange for Guillain-Barré syndrome. The Cochrane database of systematic reviews, 2012.PMID 22786475
- [8]Gajdos P, Chevret S, Toyka KV Intravenous immunoglobulin for myasthenia gravis. The Cochrane database of systematic reviews, 2012.PMID 23235588
- [9]Rock GA, Shumak KH, Buskard NA, et al. Comparison of plasma exchange with plasma infusion in the treatment of thrombotic thrombocytopenic purpura. Canadian Apheresis Study Group. The New England journal of medicine, 1991.PMID 2062330
- [10]Scully M, Cataland SR, Peyvandi F, et al. Caplacizumab Treatment for Acquired Thrombotic Thrombocytopenic Purpura. The New England journal of medicine, 2019.PMID 30625070
- [11]Levy JB, Turner AN, Rees AJ, et al. Long-term outcome of anti-glomerular basement membrane antibody disease treated with plasma exchange and immunosuppression. Annals of internal medicine, 2001.PMID 11388816
- [12]Jayne DR, Gaskin G, Rasmussen N, et al. Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. Journal of the American Society of Nephrology : JASN, 2007.PMID 17582159
- [13]Walsh M, Merkel PA, Peh CA, et al. Plasma Exchange and Glucocorticoids in Severe ANCA-Associated Vasculitis. The New England journal of medicine, 2020.PMID 32053298
- [14]Liu T, Zhang Z, Wang Y, et al. The Safety and Efficacy of Regional Citrate Anticoagulation in Therapeutic Plasma Exchange: A Systematic Review and Meta-Analysis. Therapeutic apheresis and dialysis : official peer-reviewed journal of the International Society for Apheresis, the Japanese Society for Apheresis, the Japanese Society for Dialysis Therapy, 2026.PMID 41420369
- [15]Zhou YY, Maitta RW Ionized calcium changes in adult patients undergoing therapeutic plasma exchanges. Transfusion and apheresis science : official journal of the World Apheresis Association : official journal of the European Society for Haemapheresis, 2026.PMID 41308285
- [16]Tombak A, Uçar MA, Akdeniz A, et al. Therapeutic Plasma Exchange in Patients with Neurologic Disorders: Review of 63 Cases. Indian journal of hematology & blood transfusion : an official journal of Indian Society of Hematology and Blood Transfusion, 2017.PMID 28194064
- [17]Ansell SM, Kyle RA, Reeder CB, et al. Diagnosis and management of Waldenström macroglobulinemia: Mayo stratification of macroglobulinemia and risk-adapted therapy (mSMART) guidelines. Mayo Clinic proceedings, 2010.PMID 20702770
- [18]Gertz MA, Anagnostopoulos A, Anderson K, et al. Treatment recommendations in Waldenstrom's macroglobulinemia: consensus panel recommendations from the Second International Workshop on Waldenstrom's Macroglobulinemia. Seminars in oncology, 2003.PMID 12720120