Impediments that Challenged Therapeutic Plasma Exchange: Experience at a Tertiary Care Hospital in Bangladesh

Abstract

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique that removes circulating antibodies, toxin and mediators from the plasma of the patients. This study was conducted to assess the safety, type and frequency of complications with regard to the indications and technical aspects of the TPE procedure performed in patients referred with different indications. A total of 127 patients’ clinical data treated with 424 TPE cycles over a period of 6 years from June 2016 to July 2022 at the apheresis unit of the Department of Transfusion Medicine, Bangabandhu Sheikh Mujib Medical University in Bangladesh, were enrolled in this retrospective observational study. The median age was 35.26 years (range 19–63) with a male predominance. The indications were mostly American Society for Apheresis (ASFA) category I (81.895%) and the most common indications were neurological indications including Guillain–Barré Syndrome (GBS) (61.41%), Myasthenia Gravis (MG) (10.24%) followed by Acute Liver Failure (7.09%). Venous access was established with the femoral vein maintaining blood flow at 70 ml/min using acid citrate-dextrose solution A (ACD-A) anticoagulant. TPE was frontline therapy in 55.91% of the patients. Human albumin was used as a replacement fluid in 88% and fresh frozen plasma in 12% of the cycles. Incidence of procedural complication was 49% (n = 206) and majority of them were mild (n = 191; 45%) with only 3% and 0.47% being moderate and severe, respectively. Mild complications were hypocalcemia (n = 127; 29.95%), anxiety (n = 109; 25.70%), restlessness (n = 68; 16.04%) and hypotension (n = 46; 10.85%) in albumin group and anxiety (n = 31; 7.31%), hypocalcemia (n = 23; 5.42%), muscle cramp (n = 23; 5.42%) in FFP group. Interestingly, complications were almost similar in albumin and FFP groups except for allergic reactions and mild reactions which were mostly manageable and preventable with continuous, cautious monitoring. Our findings suggest that TPE is a relatively safe procedure and severe complications such as hypotension and anaphylaxis is preventable through continuous and dedicated monitoring by expert personnel.