Time from suspected thrombotic thrombocytopenic purpura to initiation of plasma exchange and impact on survival: A 10-year provincial retrospective cohort study

Abstract

BackgroundThrombotic thrombocytopenic purpura (TTP) is a thrombotic microangiopathy (TMA) with significant morbidity and mortality. Guidelines recommend initiating plasma exchange within 4–8 h of suspected diagnosis. It is unclear what are real-world practice patterns and whether delays >8 h increases mortality. ObjectivesTo determine if delayed initiation of plasma exchange is associated with increased risk of death and complications. MethodsIn this retrospective cohort study, we evaluated the time from suspected diagnosis to plasma exchange in all adults presenting with suspected TTP to apheresis centres in Alberta, Canada (2008–2018). Among patients with acquired TTP, the association between delayed plasma exchange and risk of death was evaluated using Cox regression. ResultsOverall 190 episodes of suspected TTP were included among 163 individuals. Acquired TTP was confirmed in 61 patients. Inappropriate Emergency Department triage occurred in 59%. The median time from suspected diagnosis to first plasma exchange was 10.7 h; 59% had delayed plasma exchange >8 h, among whom plasma infusion was administered in only 45%. 36% of suspected TTP and 13% of confirmed TTP patients died. Delayed plasma exchange between 8 and 24 h was not associated with a significantly higher risk of death (adjusted hazards ratio; aHR 0.63, 95% CI 0.08–4.83) in confirmed TTP. On the other hand, the risks of death (aHR 1.40, 95% CI 0.20–9.79) and major thrombotic events (aHR 2.9, 95% CI 0.6–12.8) were markedly increased with >24 h delay. ConclusionsOur study demonstrated that TTP care in a real-world setting is discordant with expert guidelines due to multiple barriers. There is a gradient of increased mortality risk and thrombotic complications with longer treatment delays, although the study is likely underpowered.