What Is Therapeutic Plasma Exchange (Plasma Exchange Therapy)?

Therapeutic plasma exchange (TPE), or plasma exchange therapy, is a procedure in which the plasma in your blood is removed and replaced with another fluid, similar to what happens in kidney dialysis. Therapeutic plasma exchange is also called plasmapheresis and apheresis.

Plasma exchange therapy is used to treat several neurological diseases, including multiple sclerosis (MS). Therapeutic plasma exchange is a fairly painless procedure and serious side effects are rare.

This article covers exactly what therapeutic plasma exchange entails. You will also learn which conditions plasma exchange therapy can be used for, as well as what to expect if you have this treatment done.

Purpose of Plasma Exchange Therapy

During therapeutic plasma exchange, a machine removes blood from your body and then separates the plasma—the liquid portion—from your red and white blood cells. The plasma is then discarded and replaced with a different type of fluid, usually donor plasma and/or albumin solution, before being returned along with the cells back to your body.

In the case of MS, these are thought to be antibodies against the protein that makes up myelin.

Scientists believe that removing these antibodies during an MS relapse could limit the duration of the relapse and the damage caused by inflammation. However, once these antibodies are sequestered or deposited in the lesions that occur with MS, plasma exchange can no longer remove them and it will probably not have any treatment benefit. This is why early treatment results in better outcomes.

Uses for Therapeutic Plasma Exchange

Therapeutic plasma exchange is recommended by the American Society for Apheresis (ASFA) as a second-line treatment for MS when you're having an acute relapse that's not responding to the go-to therapy of corticosteroids (like Solu-Medrol).

It's also sometimes used for people who are unable to receive high doses of corticosteroids.

TPE is not currently recommended by the ASFA to treat primary or secondary progressive multiple sclerosis, as there isn't enough evidence that it's effective for this purpose. However, the organization's guidelines do acknowledge that more research may show that plasma exchange therapy is a beneficial long-term therapy for chronic progressive MS.

While MS treatment is the most common use, plasma exchange therapy is also used in cases of solid organ transplant rejection and for a variety of other, rarer diseases and conditions. Some examples include:

• Myasthenia gravis
• Guillain-Barré syndrome
• Chronic inflammatory demyelinating polyradiculonueropathy
• Thrombotic thrombocytopenic purpura

Plasma Exchange in COVID-19

On March 24, the FDA announced an investigational treatment for COVID-19 using therapeutic plasma exchange. Working under the assumption that people who have recovered from COVID-19 now have antibodies to the SARS-Cov-2 virus in their blood, researchers are interested in using those antibodies as a treatment for those who are sick. 

In clinical trials, antibody-rich plasma will be collected from blood samples of recovered COVID-19 patients and transferred to critically ill COVID-19 patients. Mount Sinai Health System in New York City will be the first in the U.S. to experiment with therapeutic plasma exchange for this purpose. It is one of the hospitals that are part of the National COVID-19 Convalescent Plasma Project.

The FDA is allowing any healthcare provider treating serious cases of COVID-19 to use single-patient emergency Investigational New Drug Applications (eINDs) to request plasma for their patients.

Who Should Not Have This Treatment

Plasma exchange therapy may not be appropriate for some people with certain conditions or allergies, including:

• People who are unable to have a central line placed
• People with an allergy to albumin or fresh frozen plasma
• People who have active sepsis or are otherwise hemodynamically unstable
• People with hypocalcemia, a low level of calcium in the blood

The Plasma Exchange Therapy Procedure

Here's an overview of what happens during therapeutic plasma exchange:

1. Needles are placed in both of your arms, or sometimes into another location, like your neck, if the veins in your arm can't be accessed.
2. Blood is then drawn out of your body through the needle in one arm, where it goes through a tube into a blood cell separator, a centrifuge that isolates the plasma from the red and white blood cells.
3. The cellular components are combined with the donor plasma and/or albumin solution and a short-acting anticoagulant, usually citrate, is added to prevent clotting.
4. The replacement fluid is then delivered to you through the needle in your other arm.

All of these steps happen automatically and continuously through IV-type needles/catheters. In some cases, this is done through one needle and the separation and remixing are done in small batches.

The whole procedure takes between two and four hours to complete.

How Effective Is Plasma Exchange Therapy?

The treatment guidelines from the ASFA, which include extensive literature reviews, report that five to seven plasma exchange therapy treatments benefit approximately 50% of patients with an MS relapse that doesn't respond to steroid treatment. The researchers also found that the earlier patients were treated with therapeutic plasma exchange, ideally within 14 to 20 days of their symptoms first appearing, the better their outcome was.

One 2017 study looked at 37 patients who were treated with therapeutic plasma exchange because their MS relapses had been unresponsive to corticosteroids. The researchers wanted to see if the plasma exchange therapy helped these patients again become responsive to corticosteroids, so during the first relapse the patients had post-plasma exchange therapy, they were all treated with steroids once again.

With the steroid treatment, 10 of the patients showed marked improvement, 24 showed moderate improvement, and there was no effect in three. The researchers concluded that corticosteroids might still be the first-line therapy in subsequent relapses after therapeutic plasma exchange.

Another 2016 study looked at therapeutic plasma exchange for 36 patients with either secondary progressive or active primary progressive MS that hadn't responded well or at all to steroid treatment for relapse. They were all treated with five courses of plasma exchange therapy within a span of two weeks, followed by one plasma exchange therapy treatment per month for the next year.

Half of the patients (18) had a significant improvement in their Expanded Disability Status Scale (EDSS) a year after therapeutic plasma exchange, while 16 remained stable, and two deteriorated further. Prior to plasma exchange therapy, 16 patients with active primary progressive MS had reported a total of 16 relapses the year before. A year after therapeutic plasma exchange, the total number of relapses decreased to two.

The study also found that the improvement rate was greater in patients with active primary progressive MS (71%) than in those with secondary progressive MS (43%). These results indicate that therapeutic plasma exchange may indeed be a beneficial second-line option for some patients with progressive MS who don't respond to steroids.

Side Effects and Risks of Plasma Exchange Therapy

The possible side effects of therapeutic plasma exchange include:

• A drop in blood pressure that may cause faintness, dizziness, blurred vision, feeling cold, and cramps
• Mild allergic reactions
• Muscle cramping
• Bruising or swelling
• Fatigue

These depend on a number of factors such as your general health, the number of therapeutic plasma exchange procedures you have, and the type of replacement fluid that's used.

Complications

Serious complications from therapeutic plasma exchange are not very common. The most dramatic of these is anaphylaxis, which is a severe, whole-body allergic reaction usually caused by the plasma replacement fluid. This is one of the reasons why plasma exchange therapy is done within a monitored setting.

Infections from therapeutic plasma exchange are a potential risk, but also rare, thanks to new technology and sterile replacement fluid.

Blood clots are another rare serious complication of therapeutic plasma exchange. Your healthcare provider may prescribe a blood thinner called an anticoagulant before your procedure to reduce this risk. Examples include Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (apixaban), and Savaysa (edoxaban).

Other potential risks of therapeutic plasma exchange include:

• Bleeding
• Irregular heart rhythm
• Shortness of breath
• Abdominal cramps
• Tingling in the limbs
• Seizures

Very rarely, plasma exchange therapy can lead to death, but this occurs in only 0.03% to 0.05% of cases. The majority of deaths result from respiratory or cardiac complications.

Cost of Plasma Exchange Therapy

Prices for therapeutic plasma exchange vary depending on where you live, where you have the procedure done, and whether or not your insurance covers the procedure. Plasma exchange therapy treatment is usually somewhere in the ballpark of $1200 per procedure when albumin is the replacement fluid that's used.

If your healthcare provider deems it necessary for you to have plasma exchange therapy, your insurance will likely cover it, though you may need pre-approval or a letter from your healthcare provider. Contact your insurance provider for more information.

Summary

Therapeutic plasma exchange is generally a safe and well-tolerated procedure. Still, it is not without potential side effects and risks that are worth knowing about.

Be sure to talk to your healthcare provider about any concerns or questions you may have regarding all of your treatment options and whether therapeutic plasma exchange might be an appropriate choice for you. You can use our Doctor Discussion Guide below to help you start that conversation.

Multiple Sclerosis Doctor Discussion Guide

Get our printable guide for your next doctor's appointment to help you ask the right questions.

Download PDF

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