Iranian Journal of Pathology (2014) 9 (3), 167 - 180167 Review Article Plasmapheresis- Review Article Alireza Abdollahi 1,2 1. Dept. of Pathology, Tehran University of Medical Sciences, Tehran, Iran 2. Thrombosis Hemostasis Research Center, Tehran University of Medical Sciences, Tehran, Iran ABSTRACT Plasmapheresis, which is defined as the removal of plasma, can be either “adjusted plasma” or “exchange of plasma”. The former is defined as selective withdrawal of certain (un)-pathological plasma components in different ways such as perfusion and then returning the remained donor plasma to him, the latter is non-selective removal of all components of plasma to provide blood products for injection into patients or to be used as the input of blood transfusion refinery or to remove the pathogen contained plasma before compensating for the volume losses with an equal volume of plasma or more commonly, replacing plasma with a substitute fluid (colloid or crystalloid) such as albumin. Plasmapheresis was divided generally into two groups: 1- Plasma products by donor plasmapheresis 2- Therapeutic plasmapheresis Therapeutic plasma exchange or TPE are often attributed to plasma that exit from the body of patient then compensated by any kind of replacement fluid volumes to support neurmolemic situation of patients. Plasmapheresis is currently used as a therapeutic modality in a wide array of conditions. Generally, plasmapheresis is used when a substance in the plasma, such as immunoglobulin, is acutely toxic and can be efficiently removed. Myriad conditions fall under this category, including neurologic, hematologic, metabolic, dermatologic, rheumatologic, and renal diseases, as well as intoxications, that can be treated with plasmapheresis. Keywords: Plasmapheresis, Exchange the Plasma Address communications to: Dr Alireza Abdollahi, Department of Pathology, Tehran University of Medical Sciences, Tehran, Iran. Email: [email protected] Vol.9 No.3, Summer 2014 IRANIAN JOURNAL OF PATHOLOGY 168 Plasmapheresis- Review Article Introduction rectly did plasmaphresis while preventing blood phaeresis is derived from a Greek word losses (3, 4). and it means removing or separating At the end of 1940s and early 1950s, simultane- (1). ously the appearance of plastic advanced blood A bag and advanced refrigerated centrifuge, he- Hemaphaeresis means bleeding from a donor and removing certain components and returning the maphresis was used more broadly as a treatment remaining components to him (2-3). method. In 1952, Carifols -Lucas used the man- There are two kinds of Hemaphaeresis (4): ual plasmapheresis procedure for the preparation 1- Cytapheresis is withdrawal of the whole blood of blood products. Thus, whole blood has been cells that have different titles by the type of cell. transfused from a donor, and then the plasma was If it is separated from leukocytes, it is known as separated from red blood cells by using centri- “Leukopheresis”, if separated from red blood fuge, and red blood cells after a week bleeding cells, it is “Erythropheresis” and if separated was returned to the donor (1, 8-10). He also re- from platelets it is as “Plateletpheresis” or ported the usefulness of pheresis in the patients` “Plasmapheresis”. therapy with hypertension disease. In 1950s, Dr. 2- Plasmapheresis, which is defined as the re- Edwin Cohn had established the using a continu- moval of plasma, can be either “adjusted plasma” ous flow centrifuge with more than 60 years since or “exchange of plasma”. The former is defined it was invented by De Laval for use in the dairy as selective withdrawal of certain (un)-patholog- industry to prepare blood products and improve ical plasma components in different ways such the effectiveness of a therapeutic plasmapheresis as perfusion and then returning the remained during the Second World War. These devices can donor plasma to him, the latter is non-selective be separated an on-line blood component in a removal of all components of plasma to provide closed system and in this system, the obtained blood products for injection into patients or to products were sterile (1, 11-13). be used as the input of blood transfusion refin- In 1962, Judson provided a device for separation ery or to remove the pathogen contained plasma of leukocytes from the whole blood by supporting before compensating for the volume losses with IBM and NCI and managed to produce 2,990 an equal volume of plasma or more commonly, units of IBM successfully. This device consists replacing plasma with a substitute fluid (colloid of disposable plastic tubes that were sterile or crystalloid) such as albumin (5-7). previously, and worked with a steady stream of closed system and it was the first device that History enables functionality to provide the processing Hendon (1902s) was the first to conduct research of large volumes of blood. This device is capable on the therapy method of Hemaphairesis by with- of exchanging plasma, collecting platelets, drawing blood from animals to be washed and granulocytes, lymphocytes and erythrocytes (1, reinjected. Fleig (1909) after Hendon used this 14-17). method for the treatment of human uremia (2). CS3000 were accessible commercially in Abel et al. (1914) have explained the removal of the early 1980s, produced by Fenwall. It is plasma technique through the treatment of poi- a continuous -flow device consisting of two soned dogs whose kidneys had been removed. To rotating chamber with a special form. In 1988, that effect, in a bid to get more anti-serum from Cobe Company began selling a new device as immunized horses for serum therapy, they cor- SPECTRA. This type of devices is automatically IRANIAN JOURNAL OF PATHOLOGY Vol.9 No.3, Summer 2014 Alireza Abdollahi, et al. 169 equipped with computer systems that can platelet donors during donor plasmapheresis and or the aphaeresis with minimal contamination of white loss volume will be compensated if it needed blood cell. Moreover, SPECTRA have been alternative and replacement fluids. Second, when moving for medical procedures affairs that are plasmapheresis has been done, simultaneously easily transferred to the patient’s room (18). donors have a long relaxation time that it was Subsequent development of the basic principles compared with the whole blood donors and established by the people, eventually leading to allows to refill the intervascular to the interstitial the construction of several kinds of semi-auto- capillaries with blood (24, 25-27). matic separation devices for clinical applications There are plasma hematoma and pain of needle in blood that the wider use of plasmaphresis was in the injection space of the body that is the most followed as a method of treatment. Continuation common complication in the donor plasma but of this trend depends on the development of con- the incidence of hematoma was not more than sumer devices and software whatever needs to be whole blood donors. more selective separation of blood components, There are rarely allergic reactions when it was and other ingredients can be returned to the do- prepared to rub the iodine fluid to skin. It was nor or patient (18, 19). an important adverse effect associated with Plasma pheresis was divided generally into two anticoagulant citrate when used as anticoagulant groups (1, 20): in vitro system and it was part of the remaining Plasma products by donor plasmapheresis blood components back to the donor’s Therapeutic plasma pheresis bloodstream. If donors have a low weight, maybe they have many symptoms of citrate (28-30). Plasma Products by Donor Plasmapheresis Sometimes there are rare mild reactions to citrate Description The donor plasmapheresis interpreted the donated (anesthesia around the mouth, tremor or tingling plasma by volunteers to be used in transfusion or sensation, tingling, or feeling cold or stuffy conversion to some specific products in plasma nose) and If the patients are faced with these processing center (21). reactions it is not alarming but demonstrated that doctors should control this process to reduce Complications of Donor Plasma and prevent serious symptoms of citrate toxicity. The donor plasma is far less than the whole donor Sometimes reactions have acute forms due to blood cell with the rate of adverse reactions in citrate toxicity (muscle cramps, whole body donors’ blood components (22-23). vibration, nausea, vomiting and tetanus) that are AFFP: apheresis fresh frozen plasma; 0.5% to rare in plasmapheresis but potentially have been 2.5%; a serious problem and disorder (31-33). Rare: < 0.5%; very rare: < 0.10%; Frequent: 5% to 20% Therapeutic PlasmaPheresis or Therapeutic Adverse reactions are more in first time donors Plasma Exchange (TPE) and it has less vasovagal responses (24). Description In contrary the whole blood donors, there Therapeutic plasma exchange or TPE are are two reasons to reduce the blood volume often attributed to plasma that exits from the (hypovolemia) that it has less reduction of body of patient then compensated by any blood volume than other donors in donors` kind of replacement fluid volumes to support plasmapheresis. First, an ejecting of the whole neurmolemic situation of patients (34). Table 1 blood volume is often less than whole blood shows Indications for Therapeutic Apheresis. Vol.9 No.3, Summer 2014 IRANIAN JOURNAL OF PATHOLOGY 170 Plasmapheresis- Review Article Table 1- Indications for therapeutic apheresis purified by a cheaper techniques such as hemofil- generally accepted for reimbursement by third- teration or unrecoverable high flux hem-dialysis. party payers (8,9) 2- Relatively removed material has a long half- life so that in vitro removal of such substances Plasma exchange into the body is passed much faster than the Ig*G clearing way of the body called as metabolism. Myasthenia gravis For example, the IgG with an approximately Eaton-Lambert syndrome Goodpasture syndrome 21 day’s half-life even if it has a treatment with Myeloma with renal failure immune-suppressors and stops producing new Guillain-Barre syndrome antibodies after 21 days, its decrease was at 50%.