APHAERESIS GUIDELINES: BSH 2025 – CLINICAL SUMMARY & ALGORITHMS

1. Methodology & Evidence Grading

Goal: Removal of pathogenic antibodies, macromolecules, or albumin-bound toxins.
Indications classified per ASFA:
- Category I: First-line (e.g., TTP, myasthenia gravis, anti-GBM, autoimmune encephalitis)
- Category II: Second-line (e.g., cryoglobulinaemia, neuromyelitis optica)
- Category III: Some evidence; individualized use (e.g., ANCA vasculitis)
- Category IV: Should not be used where evidence of harm/lack of efficacy

Indication	Regimen	Replacement Fluid	Evidence Level
TTP/atypical HUS	Daily, start <4h, 150% PV, reduce to 100% after response	SD-FFP only	1A
Myasthenia gravis	5x, daily/alt-day for crisis; 3–5x pre-op	4.5–5% albumin solution	1A–1C
Autoimmune encephalitis	5–10x, daily/alt-day	Albumin solution	1A
Anti-GBM/Goodpasture	10x in 14d, 100% PV	Albumin/FFP per risk	1A
ANCA vasculitis	7–8x in 10-12d, avoid post-biopsy	Albumin/FFP per risk	1C
Hyperviscosity (WM etc.)	1–3x, 100–150% PV	Albumin	1A

Key Recommendations:

For TTP, start TPE <4h of diagnosis (1A); initiate with 150% PV, then 100%.
Use SD-FFP in TTP/aHUS; albumin elsewhere unless risk/contraindication.
Monitor fibrinogen, coagulation throughout TPE, particularly per hemorrhagic risk.
Drugs removed by exchange: dose adjust or infuse post-procedure.