The management of anticoagulation in patients undergoing therapeutic plasma exchange: A concise review

Abstract

We surveyed multiple apheresis centers represented by the authors for their clinical approach to the management of anticoagulation issues during therapeutic plasma exchange (TPE). We present the results of their practices and a review of the pertinent literature. As plasma is removed during TPE, replacement with all or partial non-plasma-containing fluids (eg, 5% albumin) may lead to significant changes in hemostasis. These changes are amplified in patients who are receiving anticoagulation. We discuss various anticoagulants as well as the monitoring and adjustment of anticoagulation before, during, and after TPE. No single guideline can be applied, but rather, patients must be monitored individually, taking into account their often complex clinical conditions and medication profiles.

The apheresis management of patients undergoing transplantation: a concise review

“…TPE can be performed daily for the first 2 to 3 days and then every other day for a total of five to seven procedures, with the goal to quickly remove implicated donor‐specific antibodies (DSAs) and/or inflammatory mediators . The replacement fluid usually is 5% albumin unless the patient is on an anticoagulant medication and/or there are abnormalities of the coagulation profile (e.g., hypofibrinogenemia, high PT/INR/aPTT), active bleeding, and/or immediately before or after an invasive procedure, when plasma may be indicated for at least part of the replacement fluid, usually toward the end of the procedure …”

“…5 The replacement fluid usually is 5% albumin unless the patient is on an anticoagulant medication and/or there are abnormalities of the coagulation profile (e.g., hypofibrinogenemia, high PT/INR/aPTT), active bleeding, and/or immediately before or after an invasive procedure, when plasma may be indicated for at least part of the replacement fluid, usually toward the end of the procedure. 10 Acute and chronic cellular rejection of the allograft can be treated with ECP. Despite cutaneous T-cell lymphoma being the only FDA-approved indication for ECP, this procedure for cardiac transplant rejection is covered by thirdparty payers and the Centers for Medicare and Medicaid Services (CMS).…”

Hemostasis management and therapeutic plasma exchange: Results of a practice survey

“…There is very limited data published on the anticoagulant management in patients undergoing TPE . As illustrated in Table , replacement fluid containing some or all plasma or cryoprecipitate would be used by 34.5%‐67.1% of respondents with the common anticoagulants unfractionated heparin, low molecular weight heparin, and warfarin.…”

“…There is very limited data published on the anticoagulant management in patients undergoing TPE. [14][15][16][17][18][19][20][21][22] As illustrated in Table 2, replacement fluid containing some or all plasma or cryoprecipitate would be used by 34.5%-67.1% of respondents with the common anticoagulants unfractionated heparin, low molecular weight heparin, and warfarin. Several respondents would use plasma as the replacement fluid (solely 6.9% or with albumin 35.6%) in a patient who is therapeutic (INR 2.5) on warfarin, a vitamin K antagonist (VKA).…”

Hemostasis testing and therapeutic plasma exchange: Results of a practice survey

“…Consistent with this lack of guidelines is the wide variation in practice on when laboratory testing is obtained, what tests are obtained, and what are important actionable thresholds. A survey on pediatric practice and a small survey on anticoagulation and apheresis also reported practice variation among centers. However, the survey on pediatric practice did not survey coagulation screening or monitoring practice …”