Autoimmune hemolytic anemia (AIHA) is an autoimmune disease that attacks your body’s red blood cells (RBCs). Your immune system creates antibodies that target RBCs for destruction. Doctors and researchers are now trying to figure out whether plasma exchange — a procedure that filters antibodies from the blood — can help treat AIHA.

Thus far, there haven’t been clinical trials or large studies that support plasma exchange as a viable treatment for AIHA — it’s mainly been studied in small case reports. In this article, we’ll cover what’s known about plasma exchange for AIHA and how the treatment works. It’s important to understand your different treatment options so you can talk to your hematologist.

Antibodies and AIHA

To understand how plasma exchange can help treat AIHA, it is helpful to know how antibodies play a role in the disease.

Antibodies — also known as immunoglobulins (Igs) — are proteins made by your immune system that recognize and bind to foreign invaders like bacteria and viruses. They act as tags that tell other immune cells to destroy these invaders. Your immune system makes five different antibodies, each with its own function. Two antibodies involved in AIHA are IgG and IgM.

Warm AIHA is a type of hemolytic anemia caused by IgG antibodies binding to RBCs at a normal body temperature (around 98 degrees Fahrenheit). Cold agglutinin disease is caused by IgM antibodies binding to RBCs and causing clumping at colder temperatures (between 32 F and 50 F).

All types of AIHA destroy RBCs, causing symptoms of anemia such as fatigue, dizziness, and shortness of breath. If your doctor believes you have AIHA, they will perform a direct antiglobulin test to look for antibodies attached to your RBCs.

What Is Plasma Exchange?

Plasma is one of the four components that make up blood, along with platelets, RBCs, and white blood cells. It’s the liquid component of your blood that contains water, electrolytes (salts like sodium and potassium), and antibodies. Since AIHA is caused by antibodies that destroy RBCs, doctors believe filtering them out of plasma may be useful in treating the disease.

Therapeutic plasma exchange (also called TPE or plasmapheresis) is a treatment that filters the plasma that contains antibodies that target your RBCs. TPE is used to treat several blood disorders and cancers, including thrombotic thrombocytopenic purpura, myelomas, and lymphomas.

How Does Plasma Exchange Work?

Before a plasma exchange, you’ll need to drink plenty of noncarbonated fluids to stay hydrated. Cleveland Clinic recommends starting around three days (72 hours) before your procedure. It’s also a good idea to eat something about an hour before your appointment to avoid feeling faint or dizzy afterward.

Plasma exchange typically takes between two to four hours, so wear comfortable clothing and bring something to pass the time. At your appointment, you’ll sit in a chair and have an IV needle inserted in a large vein in each arm. One needle will draw blood out through a tube connected to a specialized machine that separates plasma from other blood components — this technique is known as apheresis.

Once the plasma is separated, the machine adds a fluid and a protein substitute, typically a saline solution and albumin. In some cases, you may receive plasma from a healthy donor instead. The filtered blood is then returned to your vein through the other needle in your arm.

In general, plasmapheresis is a safe procedure with mild side effects. During the procedure, it’s not uncommon to feel numbness or tingling in your arms and hands. It’s also normal to feel cold, nauseated, or lightheaded during and shortly after the procedure. If you begin to notice these symptoms during plasmapheresis, let the doctor or nurse know so they can help. Plasma is your body’s source of water, so it’s important to drink plenty of fluid for a few days following your procedure.

Some people may develop complications during or after plasmapheresis treatment, including low blood pressure or low body temperature. Plasmapheresis may also filter out electrolytes found in plasma, putting you at risk of low magnesium or calcium levels. Your doctor can add extra electrolytes back through the IV to treat these conditions.

Plasma Exchange for AIHA

For moderate to severe cases of AIHA that require treatment, the first-line therapy is high-dose corticosteroids. If they aren’t an effective treatment, your hematologist may choose one of many second-line or third-line treatments. These include:

• Rituximab (Rituxan)
• Splenectomy (spleen removal)
• Blood transfusion with RBCs
• Intravenous immunoglobulin (IVIG)
• Immunosuppressive therapy, such as cyclosporine or azathioprine

For resistant or refractory AIHA that can’t be treated with corticosteroids or blood transfusion, hematologists may use plasma exchange. This can also be used to treat a severe, sudden type of AIHA known as fulminant hemolysis.

Studies Show Mixed Results for Treating AIHA With Plasma Exchange

It’s important to note that plasma exchange hasn’t been as well studied as other treatment options for AIHA. Doctors and researchers have done only a few large studies comparing it to other methods. One analysis of 13 clinical trials found that plasma exchange improved AIHA remission rates by 22 percent. However, the authors of the study noted there is a need for more studies.

Some case reports of one or a few people living with the disease have shown some benefits. However, others show mixed results. For example, one small study compared people with AIHA who received plasma exchange before a blood transfusion to those who didn’t receive one. The researchers found that the plasma exchange made no difference and didn’t improve the efficacy of the blood transfusion.

Other single-person case reports show plasma exchange may be able to help people with severe AIHA who urgently need treatment. One report discussed a person whose AIHA didn’t respond to corticosteroids, rituximab, or IVIG. Their condition continued to worsen and eventually became life-threatening. After four days of plasma exchange, their condition improved significantly.

Considerations for Plasma Exchange in AIHA

While plasma exchange has some potential as a treatment for AIHA, there are drawbacks. Plasma exchange doesn’t treat AIHA at its source — it treats only the symptoms. Other therapies target the antibodies or immune system directly to stop it from making more harmful antibodies. Plasma exchange only filters them out, but your body will keep making them. As a result, the effects of plasma exchange are typically short-lived.

Doctors and researchers continue to learn more about how plasma exchange may be useful, and someday it may be a more established treatment option for AIHA.

Talk With Others Who Understand

At myAIHAteam, you have access to a social network for people with autoimmune hemolytic anemia and their loved ones. Members come together on myAIHAteam to ask questions, give advice, and share their experiences with others who understand life with AIHA.

Have you received a plasma exchange to treat your AIHA? What treatments have been helpful for you? Share in the comments below, or start a conversation by posting on your Activities page.