Indications for Plasma Exchange in the Intensive Care Unit

Abstract

Aims: To specify the current indications for plasma exchanges (PE) in the intensive care unit (ICU) patients and their degree of emergency.

Methods: Critical review of the literature concerning the indication for PE in conditions that can affect ICU patients.

Results: Considering the general recommendations regarding PE use as first line treatment, four groups of indications are potentially relevant for intensive care specialists: 1) neurological diseases including Guillain-Barré syndrome, chronic inflammatory demyelinisating polyradiculoneuropathies and bouts of myasthenia gravis; 2) renal diseases including antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis with severe renal involvement, Goodpasture disease and pulmonary-renal syndromes; 3) hematological diseases including thrombotic microangiopathies as thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome, hyperviscosity syndrome of monoclonal gammo- pathies; 4) complications of solid organ transplantation including the treatment of antibody-mediated rejection. Regarding the emergency to start PE therapy, critically-ill patients with a suspicion of TTP, pulmonary-renal syndrome and severe hyperviscosity syndrome should receive PE as soon as possible. In all the other indications, a definitive confirmation of the diagnosis can usually be obtained and a multidisciplinary collegial discussion be sought before PE initiation.

Conclusion: There are only a few indications for PE in ICU patients that have no therapeutic alternative and that have to be started in emergency (namely TTP, pulmonary-renal syndrome and hyperviscosity syndrome).