The article by Vermeulen et al1 proposes guidelines for the use of albumin, nonprotein colloid, and crystalloid solutions for various clinical indications. Unfortunately, the report contains a dangerous flaw in the guidelines listed in Table 4.
Under the listing for plasmapheresis, the table states that albumin and crystalloid solutions are "appropriate" for large-volume plasma exchange. However, in the case of microangiopathic syndromes such as thrombotic thrombocytopenic purpura and hemolytic uremic syndrome, plasma is the replacement fluid of choice for large-volume plasmapheresis.2,3 Substitution of albumin or crystalloid may have life-threatening consequences for patients with these diseases and would be inappropriate.
Although the authors may not have intended this interpretation, an obvious concern is that the guidelines in Table 4 might be used to exclude appropriate replacement fluids for plasma exchange, resulting in a fatal outcome for severely ill patients. To avoid this problem, alternative therapeutic options need to be