[New aspects of therapeutic plasma exchange in critical care medicine]

Therapeutic plasma exchange (TPE) is used to eliminate toxins, hormones or antibodies from the blood and replace the lost volume with fresh frozen plasma, albumin or crystalloids. In this article, recent advances in the usage for TPE for four different critical disease entities are explored: Septic shock, acute liver failure, catastrophic antiphospholipid syndrome (CAPS) and thyrotoxic storm.

Even though randomized controlled trials have not been able to demonstrate a clear benefit of TPE in septic shock, recent data demonstrates a sufficient safety profile for usage in critically ill, highly catecholamine dependent individuals. Moreover, an improvement in several surrogate parameters has been demonstrated.

High volume TPE has been shown to improve outcome in patients in acute liver failure in a multicenter, randomized controlled trial. However, this was only true for a subgroup of patients which did not receive a liver transplant. This raises the question about the effectiveness for TPE as a bridge to transplant therapy. CAPS:  Retrospective data analysis demonstrates a clear benefit in survival when a triple therapy containing anticoagulation, corticosteroids and TPE or intravenous immunoglobulin is used. However, there was no difference in survival between the usage of intravenous immunoglobulin or TPE and no added benefit in using both.

Thyroid hormones can be eliminated using TPE. This has been shown in a retrospective data analysis of 2018 and caused the ASFA to view TPE as a second line therapy for thyrotoxic storm in the most recent 2019 guidelines.