Multiple consecutive daily therapeutic plasma exchange using exclusively albumin replacement fluid in low bleeding risk patients is associated with only rare and mild bleeds.

BACKGROUND

Therapeutic plasma exchange (TPE) using exclusively albumin replacement fluid depletes coagulation factors, particularly fibrinogen, and concerns about performing multiple consecutive daily procedures due to iatrogenic bleeding exist. Fibrinogen testing to guide bleeding risk stratification is vague. We characterize our experience of changing our standard clinical practice by performing up to five consecutive daily TPE using exclusively albumin replacement fluid in conjunction with halting empiric coagulation testing (including fibrinogen testing) and fibrinogen supplementation.

METHODS

In this 5-year prospectively monitored experience, patients received 3-5 consecutive daily TPE using exclusively albumin replacement fluid. Patients with active bleeding, personal or family bleeding history, therapeutic anticoagulant or antiplatelet drugs, thrombocytopenia, or major interventional procedure within 24 h of TPE did not receive this updated treatment plan. Coagulation testing (including fibrinogen testing) was not ordered prior to any TPE. Events of interest were bleeding within 72 h after any TPE procedure.

RESULTS

Overall, 228 unique patients had a total of 264 treatment series with a total of 1351 TPE performed. Sixty-eight patients had 84 series, 101 patients had 116 series, and 59 patients had 64 series with 3, 4, and 5 consecutive daily TPE, respectively. Fourteen early and minor bleeds, predominantly central venous catheter-associated, occurred within 24 h after TPE and were mild (bleeding rate 1.4% per consecutive daily TPE and 6.1% per patient).

CONCLUSIONS

Our findings indicate that patients with low bleeding risk receiving up to five consecutive daily TPE using exclusively albumin replacement fluid without empiric coagulation testing (including fibrinogen testing) or fibrinogen supplementation experience only rare and mild bleeds.