1228 Plasmapheresis in Renal Disease

  • Guidelines for Plasmapheresis in Renal Disease


    Apheresis is of Greek origin and means to "take away". Plasmapheresis therefore means removal of plasma.

    Plasma constitutes 55% of circulating blood volume. The other 45% is formed elements, such as RBC's, WC's and platelets. The components of plasma include:

    • Water 
    • Plasma proteins-albumin, fibrinogen, globulin
    • Antibodies
    • Hormones 
    • Minerals  
    • Gases Nutrients  
    • Enzymes 
    • Organic waste products 
    • Drugs

    Therapeutic Plasma Exchange (TPE) occurs when the removed plasma is replaced or exchanged with a replacement fluid, usually 4% albumin, FFP, or a combination of both. The removal of autoantibodies, immune complexes, inflammatory mediators and cytokines is the intended benefit of the procedure in the renal unit.

    Indicators for Plasma exchange in Renal Disease

    • Goodpasture's syndrome 
    • Systemic vasculitis with crescentic nephritis
    • Haemolytic Uraemic Syndrome/ TTP 
    • Lupus Nephritis 
    • Allograft rejection

    TPE may be used for a variety of other non renal diseases with Haematological and Neurological involvement.

    Methods of Plasma Exchange

    Separation of plasma and whole blood may be performed by filtration or by centrifugation.

    The Fresenius 4008 haemodialysis machine is used here at the Royal children's Hospital, Melbourne, with adaptation and filters specific to plasma exchange. The filters have pore sizes up to 0.5 micrometers allowing the passage of immune complexes.

    Exchange Volume Calculation

    A single plasma volume is approximately 50ml/kg. Therefore a double exchange, which is most common, is 100 ml/kg. The volume can also be calculated as follows:

                         TBV x (I-haematocrit (Hct)).  (TBV=80ml/kg)


    As in Haemodialysis, the extracorporeal blood circuit volume should not exceed 8% of the total blood volume, calculated at 80 ml/kg. Blood prime will be required in some circumstances, especially in small children (<20kg).

    Blood line volumes for the Fresenius machine are

    Adult: 170mls

    Paediatric: Arterial 59ml Venous 46ml

    Filter Sizes and priming volumes are:

    • PSu 1s-0.3m2 SA, 36ml priming volume.
    • PSu 2s-0.6m2 SA, 70ml priming volume.
    • LF-030-00 0.3m2 SA, 30ml priming vol
    • LF-050-00 0.45m2 SA, 50ml priming vol
    • PF 1000 N 0.15m2 SA, 23 ml priming vol
    • PF 2000 N 0.35m2 SA, 41 ml priming vol                                              


    • Ionised Calcium level should be >1mmol/L pre exchange. If not, a calcium gluconate infusion should commence and run during treatment. An ionized calcium test should be taken 30-40 min into procedure as well to ensure level doesn't fall below 1 mmol/L. At risk groups for hypocalcaemia include those receiving FFP replacement  (high citrate content) and those with liver disease (impaired capacity to metabolise citrate).
    • Coagulation profile
    •  FBE
    • U&E
    • Others according to disease process eg LDH, anti-GBM Ab, ANCA, dsDNA.
    • Urine for microscopy and Pr:Cr monthly


    Initial Dose

    Patient Weight

    Units of Heparin /Kg

    Total initial dose
















    Maintenance Dose

    • 15-20 units/kg/hr

    The above dosage guidelines may need to be exceeded in patients with a low haematocrit or when the plasmafiltration rate is high.

    Rate of Exchange

    Filtration rate should commence slowly- .2 ml/kg/min grading up to no more than .5 ml/kg/min when using FFP.

    When using 4% albumin, a faster rate of isovolaemic exchange can be undertaken (eg 3 litre exchange over 2 hours).

    The limitation to rate of exchange when using FFP is due to the presence of 17% ACD, which is only around 4% in albumin replacement.

    Replacement Fluid

    4% Albumin is the most commonly used replacement fluid, with FFP x1 or 2 units at the end of therapy to minimize the risk of bleeding.

    PICU uses an electrolyte balanced replacement solution produced by RCH pharmacy - this is generally not necessary for plasma exchange in the ambulatory care unit, but may be prescribed in special circumstances at the discretion of the renal consultant.  

    IVIG may be ordered for administration at the end of the exchange procedure.

    Some disease such as HUS and TTP are more effectively treated by using FFP as the replacement fluid.

    Reactions to Albumin and FFP are not uncommon, and it is recommended that patients known to react receive Hydrocortisone and/or Promethazine or cetirizine hydrochloride at the beginning of treatment.

    All patients should have a PRN dose written up at the bedside in case of a reaction.

    Refer to Pharmacopeia for dosage.  

    Apheresis using Spectra Optia®


    This procedure describes the process for Therapeutic Plasma Exchange (TPE) using the Spectra Optia® Apheresis System.


    • Circuit volume is fixed at 185mls. Patients <25kg will require BLOOD PRIME.
    • Consider using Filtration TPE for transplant patients; those not suitable to receive whole blood products[BC1] .



    This procedure applies to all trained Apheresis Nurses who perform TPE to patients under the care of The Department of Nephrology at The Royal Children’s Hospital (RCH). Trained Apheresis Nurse refers to Div 1 Nurses who have been trained and assessed to be competent in TPE using the Spectra Optia® Apheresis System. Nurses who are undergoing apheresis tuition may also perform this procedure under direct supervision of a trainer in accordance with unit policies and procedures.



    It is the responsibility of the Parent Unit making the referral to;

    • Facilitate consent, insertion and management of appropriate central venous catheter in consultation with the Nephrology Department.

    • Provide Overall ongoing care.


    It is the responsibility of the Covering Nephrologist or delegate to;

    • Describe the procedure and obtain informed consent / assent from the parent (guardian) and patient.

    • Informed consent; inclusive of discussion of the risks associated with vascular access, Hypocalcaemia, Anaphylaxis, Blood products and Coagulopathy.

    • Review and assess patients suitable for Therapeutic Plasma Exchange treatment.
    • Authorise commencement of initial exchange procedure.
    • Ensure that ALL Pathology requests, medication orders and blood bank requests are completed.
    • Oversee the care of the child during the exchange procedure.
    • Be available during the procedure within RCH.
    • Assess the efficacy of the procedure with target endpoints.


    It is the responsibility of the Apheresis Nurse to;

    • Liaise with the Covering Nephrologist and, or delegate, and the Haemodialysis Nurse Coordinator, for the scheduling, planning and duration of the procedure.
    • Liaise and where applicable arrange attendance during the procedure with Multidisciplinary Staff i.e. comfort first procedural pain staff, music therapist, play therapist.
    • Perform Plasma Exchange  as described, ensuring patient care, safety and comfort.
    • Report and notify the Nephrologist or delegate of all adverse events.
    • Ensure the patient is stable during and at the completion of the procedure. Medical review is initiated as applicable.
    • Handover care of patient at the end of the exchange procedure to the parent (primary) unit.


    It is the responsibility of the Quality Manager (QM) or equivalent to ensure implementation, maintenance and compliance with this procedure.


    BB- Blood Bank, RCH Laboratory Services


    CVC – Central venous catheter.


    TPE- Therapeutic Plasma Exchange


    TBV- Total Blood Volume, (<9.1kg-100mls/kg, 9.2-22.7kg-80mls/kg, 22.8-24.9kg-70mls/kg)


    Equipment and supplies

    • Spectra Optia® Apheresis System
    • Heat Sealer
    • Cardiac Monitoring Unit             *

    • Spectra Optia® Exchange Kit. Cat No: 10220
    • ACD-A™ 500ml. Baxter. Cat No: AHB 7898
    • 0.9% NaCl 1000ml. Baxter. Cat No: AHB 1324
    • 0.9% NaCl 10ml. (x2) Pfizer. Cat No: 61045033
    • Blood Warmer Unit       
    • Parker Healthcare Blood Warmer Line (25ml) 
    • Sterile Caps. Braun Cat No: 4495101
    • Sterile dressing pack. Multigate Medical Cat No: 06-888Q
    • Chlorhexidine in alcohol 70%. David Craig. Galenicals. Cat No: 72138/1
    • Syringes 10ml (x5). Terumo Cat No:SS+10ES
    • Blood Gas Syringe.
    • 3way tap (as required for calcium infusion)
    • FBE [K2 EDTA] tube.
    • Alcohol wipes.
    • Sterile Gloves.
    • Heparin for Vascath / Permcath care. (note as approved by RCH Drug Usage Committee)



    • Completed order to perform Plasma exchange procedure, inclusive of target volume for exchange, i.e-1.5-2 times TPV.
    • Completed Hospital Consent for performing TPE [one consent for course of treatment is adequate]
    • Completed Hospital Consent for receiving Blood Products.

    • Completed Pathology Requests as applicable.
    • Completed Blood Bank Release Order. [Normal Serum Albumin or Fresh Frozen plasma, as applicable]
    • Completed Orders for Medication.
    • Apheresis Record.




    The aim of the procedure is to separate out plasma from other components of blood, removing the plasma (and with it disease mediators) and replacing it with a replacement solution such as Normal Serum Albumin or Fresh Frozen Plasma.


    Indications for Plasma exchange include;

    • Removal or Alloantibodies-Antibody Mediated Rejection
    • Removal of Autoimmune Antibodies-SLE, Anti GBM disease
    • Removal of Antigen/Antibody complexes-
    • Removal of plasma bound poisons or drugs-Mushroom poisoning
    • Removal of excessively high cholesterol-Familial Hypercholestrolaemia
    • Removal of antibodies or antibody complexes and replacement with exchange solution loaded with beneficial factors-Atypical haemolytic uraemic syndrome, Thrombotic thrombocytopenic purpura.


    Pre Procedure Checks

    • Exchange Solution (4% Albumin or FFP):

    • Target exchange of 1.5-2 TPV. Note-4 litres Max Exchange volume for single procedure.
    • The system’s extracorporeal blood volume does not exceed 10% of the patient’s total blood volume (TBV).


    Spectra Optia® Exchange Kit. Cat No: 10220

    tubing blood volume

    185 mL  
    “Blood Prime” required if Patients’ weighs <25kg

    TBV ≤ 1,900 mL

    [consider patient’s pre procedure Hb, i.e. anaemia]


    • Appropriate vascular access: Vascath, Femoral CVC, Permcath or AV Fistula.
    • Consider prophylactic Ca2+ supplements.
    • Calculations:

    • Calculate TBV (weight (kg) x circulating blood volume (i.e. 70mls/kg) required to determine volumes of replacement fluid to achieve programmed outcome. (Note, Spectra Optia will automatically calculate TBV for patients >25kg)


    Guide for Circulating Blood Volume

    <9.1kg 100mls/kg

    9.2-22.7 Kg


    >22.7 Kg


    • Baseline investigations:

    • FBE
    • LFTs, ionised Ca2+,  Mg2+, U&Es and Cr, Albumin
    • APTT, INR and Fibrinogen


    • As applicable:
      • Titres for ABO incompatible indications
      • At first Exchange Procedure-Pre and post procedure immunoglobulins levels (IgG and IgM) to assess quantitative efficacy of the procedure.
      • At every 7th procedure check pre and post procedure immunoglobulins.


    Check documentation and / or confirm with Nephrologist or delegate, that the patient’s;

     clinical evaluation is complete, request for the procedure is valid, procedure medications are charted, exchange blood products are available, consents and all investigations are complete and valid.


    The scheduled Plasma exchange procedure must be authorised by the Nephrologist or delegate to proceed.

    • Complete acknowledgment of consents, eligibility, safety of performing the procedure, valid pre collection investigations, batch number of all consumables, procedure details, inclusive of adverse events on Apheresis Procedure Record.


    Refer to:

    • Spectra Optia® Apheresis System Essentials Guide
    • Spectra Optia® Apheresis System Plasma Exchange.


    Machine Set-Up

    Gather equipment (critical materials are “released” and stored in the designated trolley) check and record all batch numbers, expiry dates and sign as indicated on the Apheresis Procedure Record.


    Prime the machine with 0.9%NaCl and complete alarm testing. This step must be completed prior to setting up the blood prime equipment. Check primary priming fluids.


    Pre Plasma Exchange

    The Apheresis Nurse will explain the procedure to the patient according to the age and development level and to the parent / caregiver.


    Complete a Blood Bank Release Order requesting exchange solution. Request FFP or albumin solution as applicable, when procedure underway (Blood Bank Ext: 55829).


    Ensure that the patient has been assessed and any applicable clinical care management and medication orders have been completed. Administer Pre Meds[BC2]  as charted. [Pre Meds include Zyrtec, Hydrocortisone]


    Ensure that baseline investigations have been done- FBE (Check that Hb is acceptable, note HB maybe corrected with blood prime and transfusion of remaining unit over course of treatment), Albumin (28g/L or higher) and ionised Ca2+ are a minimum. If testing has not been requested, organise specimens and request, marked URGENT according to Laboratory Services requirements.


    Document baseline observations (Temperature, Pulse, Respiration, Blood Pressure, and SaO2) and machine calculations of total blood and plasma volumes according to the child’s height and weight.

    Report ANY abnormal baseline investigations or observations to the Nephrologist or Delegate and treat accordingly.


    NOTE:  Where patient has documented previous transfusion reactions, consider and discuss with doctor pre medication.

    Check blood products according to organisational requirements RCH Clinical Guideline. Blood Transfusion – Administration of Fresh Blood Products [cited 2014 Dec 19]. Available from:


    Blood Prime

    Set up the blood prime equipment using aseptic technique; ensure that all clamps are closed before attaching the unit of crossmatched packed red blood cells.


    NOTE: For Blood Prime using ARCBS Packed Cells, use Haematocrit value of 0.60. No predilution, of the packed cells is required.


    Connect the blood to the machine access line.


    Attach a blood warmer set and an empty waste collection bag to the end of the return line.


    When prompted, on the Spectra Optia, select “custom prime” to divert the saline instead of connecting the access line to the donor.


    Follow the machine prompts to enter data for the “custom prime”.


    Continue priming with the “custom prime” until the blood has primed the return line as far as possible.


    When the “custom prime” is complete, remove “custom prime set-up” from the access and return lines. The machine access and return lines are now available to be connected to the donor. If there is a delay in commencing the procedure, seal lines with sterile caps.


    Turn on rinse back facility as it is turned off when custom prime is selected.


    Connecting the Patient

    Prepare the patient for connection; check that the dressing trolley has all required equipment. Using aseptic technique clean both Vascath/Permcath ends with chlorhexidine solution, obtain blood return to confirm patency of the Vascath/Permcath and take blood for ANY outstanding blood testing. Flush both lumens with 5-10mls each of 0.9% NaCl.  If there is doubt of correct placement or adequacy of line placement, notify the Nephrologist or delegate for review. Document outcome in the record.

    Connect the patient via the Vascular accessor AV fistula.


    Connect the machine access and return lines to the patient.


    NOTE: Patient receives homologous blood during blood prime procedures.

    Monitor patient closely for any symptoms associated with a possible transfusion reaction.


    Ensure air is not introduced into the system, continually check volume of exchanging product.


    Monitor ionised Ca2+ after initial 30 or 40 minutes, but more often in the patient has liver failure or fasting or symptomatic of hypocalcaemia. If ionised Ca2+ is low, notify Clinician and refer to stat Ca2+ order. Complete the Apheresis Record as indicated.


    Monitor vital signs (Temperature, Pulse, Respiration, Blood Pressure, SaO2) at 15minute intervals or more or less often as indicated by donor’s condition. Regularly assess donor for signs of citrate toxicity, if hypocalcaemia (Ca2+ <1.17mmol/L) develops, mild to moderate symptoms to note are;

    • Anxiety
    • Tingling in fingers, toes and lips
    • Peripheral paraesthesia and tingling
    • Nausea and vomiting
    • Acute Abdominal Pain
    • Carpopedal spasm
    • Agitation
    • Pallor and sweating


    Pause Procedure and urgently take and despatch additional samples for analysis (FBE, electrolytes and ionised Ca2+) at the first onset of symptoms suggestive of hypocalcaemia (anxiety, restlessness, tingling, paraesthesia or tetany[SM3] ).


    Refer to: HSCT Programme standard operating procedure: Management of Hypocalcaemia during Apheresis  (AP-P-004).


    Appropriate actions for symptoms of hypocalcaemia include slowing the processing rate, decreasing Ca2+:Blood ratio, administration of single infusion of 0.5ml/kg, 10% Calcium Gluconate (2.2 mmol of Ca in 10ml) to a maximum of 30mls, diluted in 20-50mls of 0.9% Normal Saline, infused over one hour.


    Symptoms of hypotension and other adverse reactions to note and respond to include;

    Pain (access/return sites)

    Check dressing and Consider repositioning lines.

    Check observations to exclude transfusion reaction.

    Consider Paracetamol.

    Pain (chest or back) Slow citrate. Check ICa+ and notify RMO.
    Fever ,Chills, complications of transfusion  

    Consider investigations for transfusion reaction.

    Stop procedure, notify Nephrology Registrar or Fellow for review.

    Refer to RCH Clinical Practice Guideline Blood Product Transfusion [cited 2016 February 5. Available from:

    Hypotension/Hypertension   Stop procedure. For hypotension, consider fluid bolus of 10mls/kg. Notify Registrar or Fellow. Consider slowing rate of procedure.
    Electrolyte disturbance Check Ionised Ca2+, K+, Mg2+ Notify Registrar or Fellow.
    Fluid overload Stop procedure. Assess. Notify Registrar or Fellow.
    Acute respiratory distress/stridor/wheeze Stop procedure. Assess. Notify Registrar or Fellow.
    Allergic reaction (anaphylaxis)  

    Stop procedure. Call MET. Refer to RCH Clinical Practice Guideline Anaphylaxis [cited 2016 February 5]. Available from:


    Refer to: RCH Clinical Practice Guideline MET Criteria-Call 777 for help [cited 2016 February 5]. Available from:


    Encourage light food and fluids as per the childs request throughout the procedure.


    At completion, if satisfactory target achieved press DISCONNECT (DO NOT START RINSEBACK for blood prime), proceed to DISCONNECT and CONFIRM.


    Obtain post exchange investigations[BC4] , as applicable to the medical condition;

    • Antibody Titres
    • Immunoglobulin (IgG and IgM) levels
    • FBE
    • LFTs, ionised Ca2+, Mg2+, Glucose, U&Es and Cr
    • APTT, INR and Fibrinogen


    Post Procedure

    Complete post procedure vital signs, observations and clinical review.


    Disconnect patient from the machine.


    Repeat the patient’s vital signs (Temperature, Pulse, Respiration, Blood Pressure, and SaO2).


    As required, the Nephrologist or Delegate, may review the patient before transfer to the primary ward.


    Clean and decontaminate the Spectra Optia according to manufacturer’s recommendations, note room temperature readings and complete the Maintenance Record, AP-F-006.


    Print 2 copies of the procedure report, label with patient details and include one in the patient medical records and the other in the Apheresis Log Book.



    Haemo dynamically stable patient during and following Plasma exchange procedure.

    Targets may include:

    • 75% reduction in immunoglobulins demonstrating effective clearance of disease mediators-for 1.5 plasma volume exchange. (allow for value variation according to exchange volume)

    Documentation summary;

    • Completed Hospital Consents for Apheresis Procedure.

    • Completed Pathology Requests as applicable, sent to Laboratory Services.
    • Completed Blood Bank Release Order, to collect exchange products; Albumin or Fresh Frozen Plasma.
    • Completed Order for Medication.
    • Completed Apheresis Record.
    • Completed Apheresis System General Maintenance Record. AP-F-006.
    • Completed Apheresis Procedures Log. AP-F-005.






    Spectra Optia® Apheresis System. Plasma Exchange Procedure Guide.


    HSCT Programme standard operating procedure; Staff Training and Assessment. QS-P-005.


    HSCT Programme standard operating procedure; Apheresis Training Procedure. AP-P-003.


    HSCT Programme standard operating procedure; Management of Hypocalaemia during Apheresis. AP-P-004.


    RCH Clinical Practice Guideline Blood Product Transfusion [cited 2016 February 5]. Available from:


    RCH Clinical Practice Guideline Anaphylaxis [cited 2016 February 5]. Available from:


    RCH Clinical Practice Guideline MET Criteria-Call 777 for help [cited 2016 February 5]. Available from: