Makindo Medical Notes | Plasmapheresis

Plasmapheresis (Plasma Exchange, PLEX) is a therapeutic extracorporeal procedure that removes and replaces plasma to clear pathogenic substances (autoantibodies, immune complexes, toxins).
Blood is separated into cellular components and plasma; the plasma is discarded and replaced with albumin, saline, or fresh frozen plasma.
Typical course: 4–6 exchanges over 7–14 days, depending on disease and response.
Goal: reduce disease activity by lowering the burden of circulating autoantibodies/complexes until other therapies (e.g. immunosuppressants) take effect.

🎯 Indications

Neurological:
- Guillain–Barré Syndrome (GBS): Hastens recovery if started early; alternative to IVIG.
- Myasthenia Gravis: Used in crisis or peri-operatively before thymectomy.
- Multiple Sclerosis: For severe steroid-refractory relapses.
Haematological:
- Thrombotic Thrombocytopenic Purpura (TTP): Life-saving; removes autoantibodies to ADAMTS13 and replaces deficient enzyme.
- Atypical HUS, cryoglobulinaemia, hyperviscosity in Waldenström’s macroglobulinaemia.
Other: Goodpasture’s syndrome (anti-GBM disease), ANCA vasculitis with severe renal/pulmonary involvement.

⚠️ Side Effects / Risks

Haemodynamic: Dizziness, hypotension, headache, nausea due to fluid shifts.
Electrolyte disturbance: Citrate anticoagulant → hypocalcaemia (tingling, cramps, tetany).
Bleeding risk: Due to anticoagulation or depletion of clotting factors.
Infections: Removal of immunoglobulins can transiently increase susceptibility.
Vascular access issues: Infection, thrombosis, bleeding at line site.
Rare: Allergic reactions to replacement fluids.

💡 Teaching Pearl: - TTP = plasma exchange saves lives. - In GBS or MG crisis, plasmapheresis is often used as an alternative to IVIG — both are equally effective. - Always consider electrolyte monitoring and calcium replacement during/after procedures.

📊 Plasmapheresis vs Intravenous Immunoglobulin (IVIG)

Feature	Plasmapheresis (PLEX)	Intravenous Immunoglobulin (IVIG)
Mechanism	Physically removes pathogenic substances (autoantibodies, immune complexes, complement) from plasma and replaces with albumin/FFP.	Supplies pooled donor IgG → modulates immune system by blocking Fc receptors, neutralising autoantibodies, and downregulating inflammation.
Onset of Action	Rapid (hours–days).	Rapid (days).
Administration	Requires central venous access, specialised machine, and trained staff.	Given as IV infusion (typically over 2–5 days); easier to deliver in most hospitals.
Duration	Usually 5 exchanges over 7–14 days.	Typically 2 g/kg total dose, divided over 2–5 days.
Indications (neurology)	GBS, Myasthenia Gravis crisis, severe MS relapse, anti-GBM disease, TTP (life-saving).	GBS, Myasthenia Gravis crisis, CIDP, Kawasaki disease, ITP, some autoimmune encephalitides.
Advantages	Removes autoantibodies directly; useful in hyperviscosity, cryoglobulinaemia, TTP (curative role).	More widely available, easier to administer, no need for vascular access.
Disadvantages	Invasive, risk of line infection/thrombosis, fluid shifts, hypocalcaemia (from citrate), bleeding risk.	Expensive; risk of volume overload, aseptic meningitis, renal impairment (rarely thromboembolic events).
Contraindications	Severe coagulopathy, poor vascular access, haemodynamic instability.	IgA deficiency with anti-IgA antibodies (risk of anaphylaxis), severe renal impairment, volume overload.
Availability	Specialist centres only (ICU/renal/neurology units).	More widely available in secondary care settings.
Relative Effectiveness	In GBS and Myasthenia crisis → equally effective. Choice depends on logistics, availability, comorbidities.

💡 Teaching Pearl: - Both PLEX and IVIG are first-line in GBS and myasthenic crisis — never use together (no added benefit). - PLEX is life-saving in TTP (unique). - IVIG has broader autoimmune indications (Kawasaki, ITP, CIDP).

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Plasmapheresis

📖 About

🎯 Indications

⚠️ Side Effects / Risks

📊 Plasmapheresis vs Intravenous Immunoglobulin (IVIG)

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