Efficacy Of Therapeutic Plasma Exchange Research Articles

Management of pediatric liver failure with therapeutic plasma exchange and continuous renal replacement therapy: A retrospective observational study.

Liver failure represents a critical medical condition, marked by the rapid decline of hepatic functions. Emerging therapies, notably therapeutic plasma exchange (TPE) and continuous venovenous hemodiafiltration (CVVHDF), have demonstrated potential in mitigating these conditions through their roles in detoxification and hepatic support. The utility of these treatments, whether applied individually or in tandem, constitutes a significant area of research concerning the management of liver failure in pediatric patients. This study aims to evaluate the role and efficacy of TPE or TPE combined with CVVHDF in the treatment of liver failure among children. This retrospective study was conducted in a LTICU by reviewing the medical history of pediatric patients aged 1 month to 18 years. Patients were admitted between January 1, 2021 and December 1, 2023 due to acute liver failure or acute-chronic liver failure. The study evaluated those who received TPE or continuous renal replacement therapy combined with TPE. In statistical analyses, a P-value of <.05 was considered statistically significant. The study involved 24 patients with liver failure, comprising 13 males and 11 females. Sixteen patients (66.6%) received only TPE, while 8 patients (33.4%) were treated with TPE and CVVHDF. For patients treated only with TPE, the median INR reduced from 3.1 to 1.26, alanine aminotransferase from 1255 to 148, and aspartate aminotransferase from 2189 to 62. Similar significant reductions were observed in the TPE and CVVHDF group: INR from 3.9 to 1.26, alanine aminotransferase from 1749 to 1148, and aspartate aminotransferase from 1489 to 62. These changes were statistically significant with P-values of .01 for each parameter in both groups. Overall, 14 patients survived without requiring a liver transplant, while 4 patients underwent liver transplantation. Our study on pediatric liver failure treatment shows that both standalone TPE and its combination with CVVHDF are effective, especially as a bridge to transplantation. With 58% transplant-free survival, these therapies demonstrate significant clinical improvements. Future multicentric studies are needed for broader validation of these findings in liver failure management.

Hypertriglyceridemia induced acute pancreatitis and efficacy of therapeutic plasma exchange

Acute pancreatitis is a condition in which the pancreas becomes inflamed suddenly within a short period of time. Typically, this condition lasts less than 6 weeks, with most cases resolving within 1-2 weeks. The major causes of acute pancreatitis are ethanol, gallstones, and hypertriglyceridemia. Acute pancreatitis that is caused by hypertriglyceridemia can be severe and life-threatening. Compared to other causes of pancreatitis, studies have shown that the acute pancreatitis induced by hypertriglyceridemia is more serious and can lead to recurrent episodes of pancreatitis, eventually leading to chronic pancreatitis. Here, we report a clinical experience with a patient of high triglyceride induced pancreatitis. He was treated with two sessions of Therapeutic Plasma exchange along with intravenous insulin, statins, and fibrates. In recent times, plasmapheresis has been used to treat severe cases of hypertriglyceridemia-induced acute pancreatitis with success. Early initiation, along with appropriate supportive measures, may lead to favourable outcomes and reduce the risk of complications. However, further research is needed to determine the exact role and timing of plasmapheresis in managing acute pancreatitis caused by hypertriglyceridemia. Bangladesh Crit Care J March 2024; 12 (1): 58-61

Efficacy of therapeutic plasma exchange in patients with Crimean-Congo hemorrhagic fever

Efficacy of therapeutic plasma exchange in patients with Crimean-Congo hemorrhagic fever

Therapeutic plasma exchange decreases serum triglyceride level rapidly and reduces early recurrence rate but no advantages in improving outcomes for patients with hyperlipidemic acute pancreatitis: a retrospective propensity score matching analysis based on twenty year’s experience

BackgroundHyperlipidaemic acute pancreatitis (HLAP) has become the most common cause of acute pancreatitis (AP) not due to gallstones or alcohol (Mosztbacher et al, Pancreatology 20:608-616, 2020; Yin et al, Pancreas 46:504-509, 2017). Therapeutic plasma exchange (TPE) has been reported to be effective in reducing serum TG levels which is important in management of HLAP (World J Clin Cases 9:5794-803, 2021). However, studies on TPE are mostly focusing on cases reports, TPE remains poorly evaluated till date and need to be compared with conservative therapy with a well-designed study.MethodsA retrospectively cohort study on HLAP patients between January 2003 and July 2023 was conducted. Factors correlated with efficacy of TPE were included in a propensity model to balance the confounding factors and minimize selection bias. Patients with and without TPE were matched 1:2 based on the propensity score to generate the compared groups. Lipid profiles were detected on admission and consecutive 7 days. The triglyceride (TG) level decline rates, percentage of patients to reach the target TG levels, early recurrence rate, local complications and mortality were compared between groups.ResultsA total of 504 HLAP patients were identified. Since TPE was scarcely performed on patients with TG < 11.3 mmol/L, 152 patients with TG level 5.65 to 11.3 mmol/L were excluded while 352 with TG ≧11.3 mmol/L were enrolled. After excluding 25 cases with incomplete data or pregnancy, 327 patients, of whom 109 treated without TPE while 218 treated with TPE, were included in data analysis. One-to-two propensity-score matching generated 78 pairs, 194 patients with well-balanced baseline characteristics. Of 194 patients enrolled after matching done, 78 were treated without while 116 with TPE. In the matched cohort (n = 194), patients treated with TPE had a higher TG decline rate in 48 h than those without TPE (70.00% vs 54.00%, P = 0.001); the early recurrence rates were 8.96% vs 1.83%, p = 0.055. If only SAP patients were analyzed, the early recurrence rates were 14.81% vs 0.00% (p = 0.026) respectively. For patients with CT severity index (CTSI) rechecked within 14 days, early CTSI improment rate were 40.90% vs 31.91%. Local complications checked 6 months after discharge were 44.12% vs 38.30%. Mortality was 1.28% vs 1.72%. No differences were found in early stage CTSI improment rate (P = .589), local complications (P = .451) or motality between two groups.ConclusionsTPE reduces TG levels more quickly in 48 h compared with those with conservative treatment, but no difference in the consecutive days. TPE tends to reduce the early recurrence rate comparing with conventional therapy, but TPE has no advantages in improving CTSI in early stage, and no improvement for outcomes including local complications and mortalty.

Efficacy of therapeutic plasma exchange in pediatric cases of acute liver failure as an extracorporeal liver support system

BackgroundAcute liver failure in the pediatric population is often accompanied by deranged metabolism, severe encephalopathy and coagulopathy. A liver transplant is the most viable option for the management of such patients. Therapeutic plasma exchange (TPE) is helpful in improving the liver biochemistry profile, thereby, increasing their likelihood of undergoing a liver transplant MethodThe study was conducted over a period of 3 years (January 2018 to December 2021). Indications mainly consisted of ALF with hepatic encephalopathy, worsening liver parameters in spite of medical management, and candidacy for undergoing a liver transplant. Plasma exchange was performed daily or alternatively until the patient recovered, succumbed, or was stable enough to undergo a transplant. Biochemical parameters serum bilirubin, ALT, AST serum ammonia serum urea, serum creatinine were recorded before and after TPE sessions. ResultsThe study group comprised 14 patients of which a total of 28 TPE was performed. There were a total of 5 cases of cryptogenic ALF, 4 of Wilson disease, 2 cases each of infection-related ALF and autoimmune hepatitis, and a single case of drug-induced hepatitis. A total of 5 out of 14 patients underwent a liver transplant and amongst the 9 who did not undergo a transplant, 4 patients expired due to septic shock syndrome; the remaining 5 were discharged in a stable condition following TPE sessions. The disease-free survival was 78.9% and the transplant-free survival was 35.71%. ConclusionTPE plays a crucial role in improving the biochemistry profile of the liver in children with liver failure.

Evaluating the Efficacy of Therapeutic Plasma Exchange in the Management of HELLP Syndrome: A Single-Center Experience

HELLP sendromu, hemoliz, yüksek karaciğer enzimleri ve düşük trombosit sayısı ile karakterize, gebelikle ilişkili ciddi bir komplikasyondur. Kompleman düzensizliği, HELLP sendromunun etiyopatogenezine katkıda bulunur. Terapötik plazma değişimi (TPE), anormal kompleman yolu bileşenlerini ortadan kaldırır ve bunları normal fizyolojik bileşenlerle değiştirir. Bu çalışma, destekleyici tedavi ve kortikosteroidlere yanıt vermeyen HELLP sendromlu hastalarda TPE'nin hastalığın ilerlemesi üzerindeki etkisini değerlendirmeyi amaçladı. Bu retrospektif çalışma, Mississippi sistemine göre Sınıf 1 HELLP sendromu teşhisi konan 13 hastayı içermektedir. Bu hastalara 2012-2015 yılları arasında doğum sonrası dönemde TPE uygulandı. On üç hastadan üçü çoklu organ yetmezliğinden öldü. TPE sonrası hemoglobin ve trombosit sayıları artarken AST, ALT ve LDH seviyeleri azaldı. Bu değişiklikler istatistiksel olarak anlamlıydı (p

MPN-238 Evaluating the Efficacy of Therapeutic Plasma Exchange in the Management of HELLP Syndrome: A Single-Center Experience

MPN-238 Evaluating the Efficacy of Therapeutic Plasma Exchange in the Management of HELLP Syndrome: A Single-Center Experience

The efficacy of therapeutic plasma exchange in COVID-19 patients on endothelial tightness in vitro is hindered by platelet activation.

Coronavirus disease (COVID)-19 is characterised in particular by vascular inflammation with platelet activation and endothelial dysfunction. During the pandemic, therapeutic plasma exchange (TPE) was used to reduce the cytokine storm in the circulation and delay or prevent ICU admissions. This procedure consists in replacing the inflammatory plasma by fresh frozen plasma from healthy donors and is often used to remove pathogenic molecules from plasma (autoantibodies, immune complexes, toxins, etc.). This study uses an in vitro model of platelet-endothelial cell interactions to assess changes in these interactions by plasma from COVID-19 patients and to determine the extent to which TPE reduces such changes. We noted that exposure of an endothelial monolayer to plasmas from COVID-19 patients post-TPE induced less endothelial permeability compared to COVID-19 control plasmas. Yet, when endothelial cells were co-cultured with healthy platelets and exposed to the plasma, the beneficial effect of TPE on endothelial permeability was somewhat reduced. This was linked to platelet and endothelial phenotypical activation but not with inflammatory molecule secretion. Our work shows that, in parallel to the beneficial removal of inflammatory factors from the circulation, TPE triggers cellular activation which may partly explain the reduction in efficacy in terms of endothelial dysfunction. These findings provide new insights for improving the efficacy of TPE using supporting treatments targeting platelet activation, for instance.

Efficacy of therapeutic plasma exchange in patients with severe COVID-19: A systematic review and meta-analysis.

We conducted this systematic review and meta-analysis to evaluate the existing evidence and to quantitatively synthesise evidence on the impact of therapeutic plasma exchange (TPE) on severe COVID-19 patients. This systematic review andmeta-analysis protocol was prospectively registered on PROSPERO (CRD42022316331). We systemically searched six electronic databases (PubMed, Scopus, Web of Science, ScienceDirect, clinicaltrial.gov, and Cochrane Central Register of Controlled Trials) from inception until 1 June 2022. We included studies comparing patients who received TPE versus those who received the standard treatment. For risk of bias assessment, we used the Cochrane risk of bias assessment tool, the ROBINS1 tool, and the Newcastle Ottawa scale for RCTs, non-RCTs, and observational studies, respectively. Continuous data were pooled as standardized mean difference (SMD), and dichotomous data were pooled as risk ratio in the random effect model with the corresponding 95% confidence intervals (CI). Thirteen studies (one randomized controlled trials (RCT) and 12 non-RCTs) were included in the meta-analysis, with a total of 829 patients. There is a moderate-quality evidence from one RCT that TPE reduces the lactic dehydrogenase (LDH) levels (SMD -1.09, 95% CI [-1.59 to -0.60]), D-dimer (SMD -0.86, 95% CI [-1.34 to -0.37]), and ferritin (SMD -0.70, 95% CI [-1.18 to -0.23]), and increases the absolute lymphocyte count (SMD 0.54, 95% CI [0.07-1.01]), There is low-quality evidence from mixed-design studies that TPE was associated with lower mortality (relative risk 0.51, 95% CI [0.35-0.74]), lower IL-6 (SMD -0.91, 95% CI [-1.19 to -0.63]), and lower ferritin (SMD -0.51, 95% CI [-0.80 to -0.22]) compared to the standard control. Among severely affected COVID-19 patients, TPE might provide benefits such as decreasing the mortality rate, LDH, D-dimer, IL-6, and ferritin, in addition to increasing the higher absolute lymphocyte count. Further well-designed RCTs are needed.

Therapeutic plasma exchange in the management of stiff person syndrome spectrum disorders: a case series and review of the literature.

Stiff person syndrome spectrum disorders (SPSD) are a rare group of disabling neuroimmunological disorders. SPSD often requires immune therapies, especially in the setting of inadequate response to symptomatic treatments. The safety and efficacy of therapeutic plasma exchange (TPE) in SPSD remains uncertain. To describe the safety, tolerability, and efficacy of TPE in patients with SPSD. A retrospective observational study. A retrospective review of SPSD patients seen at Johns Hopkins Hospital (JHH) from 1997 to 2021 was performed. Patient demographics/history, examination/diagnostic findings, treatment response, and TPE-related complications were recorded. Assessment for any associations between clinical characteristics, including age, sex, clinical phenotype, and time on immunotherapy, and response to TPE 3 months after treatment was performed. A subgroup of 18 patients treated with TPE at JHH and 6 patients treated with TPE at outside institutions were evaluated for any change in usage of symptomatic medications 3 months after the TPE treatment. Literature review of SPSD and TPE was also conducted. Thirty-nine SPSD patients were treated with TPE (21 at JHH and 18 at outside institutions); median age 48 years, 77% female, median modified Rankin Scale 3; mean initial anti-GAD65 antibody titer was 23,508 U/mL. Twenty-four patients (62%) had classic SPS, 10 (26%) had SPS-plus, 2 (5%) had progressive encephalomyelitis with rigidity and myoclonus, and 3 (8%) had pure cerebellar ataxia. All patients were on symptomatic treatments, 30 (77%) previously received IVIg, and 3 (8%) previously received rituximab. Four patients (10%) had a TPE-related adverse event. One developed asymptomatic hypotension, another had both line thrombosis and infection, and two had non-life-threatening bleeding events. Twenty-three (59%) patients reported improvement in symptoms after TPE. Of the subgroup of 24 patients evaluated for any change in usage of symptomatic medications 3 months after the TPE treatment, 14 (58%) required fewer GABAergic symptomatic medications. Literature review identified 57 additional patients with SPSD; 43 (75%) reported temporary improvement after TPE. The majority of patients treated with TPE had improvement. Moreover, most patients evaluated for any change in usage of symptomatic medications after the TPE treatment no longer required as much symptomatic medications months after TPE. TPE appears safe and well-tolerated in SPSD. Further studies are needed to assess the long-term efficacy of TPE in SPSD and identify which patients may benefit the most from TPE.

Therapeutic Plasma Exchange in the Management of Stiff Person Syndrome Spectrum Disorders: A Case Series and Review of the Literature

Objective To describe the safety, tolerability, and response to TPE in patients with SPSD. Background Stiff person syndrome spectrum disorders (SPSD) are a rare group of disabling neuroimmunological disorders. SPSD often require immune therapies especially in the setting of inadequate response to symptomatic treatments. The safety and efficacy of therapeutic plasma exchange (TPE) in SPSD is unclear. Design/Methods A retrospective review of medical records for patients with SPSD seen at Johns Hopkins Hospital was performed. Patient characteristics, exam findings, diagnostic studies, treatment response and TPE-related complications were recorded. We also conducted linear regression models to assess for possible predictive factors for TPE response. Literature review of SPSD and TPE was also conducted. Results Thirty-six SPSD patients were treated with TPE; mean age was 48 years, 81% female, and average anti-GAD65 antibody titer was 42352 U/mL (range, 0-309,902). Twenty-two patients had classic SPS, 10 had SPS-plus, and 3 had other phenotypes. Thirty-three patients were treated for acute exacerbations, and 3 were on maintenance TPE. There were 4 (11.1%) TPE-related complications (catheter infection, catheter thrombosis, hemorrhage), but no deaths or anaphylaxis. Twenty patients (55.6%) reported improvement in symptoms after TPE, 13 reported no change, and 3 reported worsening of symptoms. Of the 36 total patients who received TPE, 21 received TPE at Johns Hopkins Hospital for an acute exacerbation of their condition, with 12 requiring fewer anti-spasmodic medications 3 months after TPE treatment. There were no predictive factors in a positive treatment response to TPE. Literature review identified 42 more patients; 69% of these patients reported a temporary improvement in their condition. Conclusions We describe the safety and tolerability of TPE in patients with SPSD and show that TPE-related complications are uncommon and manageable. Additionally, many patients with SPSD derived improvement with TPE. Further studies could help inform clinicians when to use TPE in SPSD.

Efficacy of Therapeutic Plasma Exchange in Severe Acute Respiratory Distress Syndrome in COVID-19 Patients from the Western Part of Romania.

Background and Objectives: The COVID-19 pandemic, caused by the SARS-CoV-2 virus, has surprised the medical world with its devastating effects such as severe acute respiratory distress syndrome (ARDS) and cytokine storm, but also with the scant therapeutic solutions which have proven to be effective against the disease. Therapeutic plasma exchange (TPE) has been proposed from the very beginning as a possible adjuvant treatment in severe cases. Our objective was to analyze the evolution of specific biological markers of the COVID-19 disease before and one day after a therapeutic plasma exchange session, how a change in these parameters influences the patient's respiratory status, as well as the impact of TPE on the survival rate. Materials and Methods: In this retrospective study, we include 65 patients with COVID-19 admitted to the intensive care unit department of our hospital between March 2020 and December 2021, and who received a total of 120 sessions of TPE. Results: TPE significantly reduced the following inflammation markers (p &lt; 0.001): interleukin-6 (IL-6), C-reactive protein (CRP), lactate dehydrogenase (LDH), fibrinogen, ferritin, and erythrocyte sedimentation rate. This procedure significantly increased the number of lymphocytes and decreased D-dimers levels (p = 0.0024). TPE significantly improved the PaO2/FiO2 ratio (p &lt; 0.001) in patients with severe acute respiratory distress syndrome (PaO2/FiO2 &lt; 100). Survival was improved in intubated patients who received TPE. Conclusions: TPE involved the reduction in inflammatory markers in critical patients with COVID-19 disease and the improvement of the PaO2/FiO2 ratio in patients with severe ARDS and had a potential benefit on the survival of patients with extremely severe COVID-19 disease.

Efficacy of therapeutic plasma exchange in severe COVID-19 disease: A meta-analysis.

Therapeutic plasma exchange (TPE) has been used in severe COVID-19 disease to eliminate the cytokine storm. This meta-analysis aims to assess the effectiveness of TPE in reducing mortality in severe COVID-19 disease compared to standard treatment. A comprehensive literature search was performed in PubMed, the Cochrane database and the International Clinical Trial Registry Platform (ICTRP). The random-effect model was used to calculate the risk ratio and standardized mean difference (SMD) as pooled effect size for the difference in mortality and length of the intensive care unit (ICU) stay. The risk of bias and publication bias were assessed in R version 4.1.0. The certainty of the evidence was calculated using the GradePro tool. The database identified 382 participants from six studies, including one randomized control trial. Egger's test did not detect any publication bias (p=0.178). The random model analysis for mortality evaluated a risk ratio of 0.38 (95% CI: 0.28-0.52) with a significant reduction in the TPE group. The certainty of the evidence was moderate, with a risk ratio of 0.34 (95% CI: 0.24-0.49). Length of ICU stays between TPE versus standard care showed an SMD of 0.08 (95% CI: -0.38, 0.55) and was not significant. The length of ICU stay in the TPE group was not different from standard care. However, this meta-analysis revealed a significant benefit of TPE in reducing mortality in severe COVID-19 disease compared to standard treatment.

Efficacy of therapeutic plasma exchange and convalescent plasma therapy in moderate-to-severe COVID-19 patients

Background: Coronavirus disease 2019 (COVID-19) has emerged as a global health catastrophe since its first reported cases in late December 2019. Critically ill COVID-19 patients have been related to cytokine storms leading to acute respiratory distress syndrome and high mortality rates. Therapeutic plasma exchange (TPE) and convalescent plasma (CP) therapy improve clinically by removing inflammatory cytokines excess and using passive antibody-containing blood, respectively. This study aimed to evaluate TPE and CP treatment for moderate-to-severe COVID-19 infection. Method: The patients were randomly divided into TPE group (n = 10), CP group (n = 11), and control group (n = 10). This 1-week quasi-experimental study with a pretest–post-test control group design was conducted in the Intensive Care Unit (ICU) of Dr. Moewardi General Hospital and Universitas Sebelas Maret (UNS) Hospital. The study comparison between groups included blood gas analysis profile (pH, base excess, PaCO2, PaO2, hematocrit, HCO3, total CO2, SaO2), FiO2, P/F ratio, COVID-19 severity, and D-dimer. The paired t-test was used to analyze every group's pretest–post-test mean difference. One-way ANOVA was performed to analyze the mean difference across the three groups. SPSS version 22.0 for Windows was used to perform statistical analyses. Result: TPE and CP groups showed significant clinical-laboratory improvement than control (p &gt; 0.05). Furthermore, high clinical-laboratory improvement tendency was observed in CP therapy than TPE. Conclusion: The use of TPE and CP in moderate-to-severe COVID-19 patients has been related to improving clinical-laboratory outcomes.

Efectiveness of Therapeutic Plasma Exchange in Patients Suffering from COVID-19 Requiring Admission in Critical Care Setting

Objective: To determine the efficacy of therapeutic plasma exchange in patients suffering from COVID-19 requiring admission in the critical care setting.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Setting and Duration of Study: Critical Care Unit, Pak Emirates Military Hospital Rawalpindi, from Apr 2020 to Jun 2020.&#x0D; Methodology: The study was carried out on 160 patients managed at the Critical Care setting of our hospital in three months. Data were extracted from the record regarding the patients who underwent therapeutic plasma exchange and others who were only given supportive management. Overall mortality, duration of hospital stay, duration of Intensive Care Unit stay and duration of oxygen supplementation was compared in both the groups.&#x0D; Results: A total of 160 patients met the inclusion/exclusion criteria. Of these, 100 (62.5%) underwent therapeutic plasma exchange, while 60 (37.5%) did not undergo this procedure. The mean age of participants was 62.19 ± 5.192 years. Out of 15 (15%) patients died who underwent therapeutic plasma exchange, while 51 (85%) patients died who did not undergo plasma exchange (p-value &lt;0.001). Length of hospital and Intensive Care unit stay and duration of oxygen supplementation were significantly less among those who underwent therapeutic plasma exchange than those who did not undergo this procedure (pvalue &lt;0.05).&#x0D; Conclusion: Therapeutic plasma exchange emerged as an effective procedure for patients of COVID-19 requiring Critical Care admission and organ support due to complications of this infection. Overall mortality and other clinical parameters were also significantly improved among patients undergoing therapeutic plasma exchange.

Treatment outcome and efficacy of therapeutic plasma exchange for transplant-associated thrombotic microangiopathy in a large real-world cohort study.

The efficacy and outcome of therapeutic plasma exchange (TPE) for transplant-associated thrombotic microangiopathy (TA-TMA) remain controversial. We therefore sought to evaluate the outcome and efficacy of TPE in patients with TA-TMA and to identify TA-TMA patients who would benefit from TPE management. Eighty-two patients with TA-TMA were treated with TPE. We reported a response rate of 52% and overall survival rates of 20% and 15% at 100 days and 1 year after TA-TMA, respectively, in TPE-treated patients, with a significantly lower survival in gastrointestinal (GI) bleeding patients (5% vs. 41% in non-GI bleeding patients, P = 0.003). Multivariate analysis revealed that patients with GI bleeding, grade III-IV aGVHD, severe anemia, and a lower cumulative volume of TPE were less likely to respond to TPE. GI bleeding, a lower initial volume of TPE, and elevated total bilirubin were independently associated with 100-day mortality. The leading causes of death were infection, active TA-TMA, and MODS. The results of this large cohort of real-world practice indicate that the efficacy and outcome of TPE for TA-TMA patients without GI bleeding are encouraging, and a higher volume of TPE is warranted to achieve favorable outcomes.

Assessing safety and efficacy of therapeutic plasma exchange in pediatric patients: A single-center experience.

INTRODUCTION:Therapeutic plasma exchange has been widely employed by clinicians for removal of the toxic constituents from plasma by filtration of whole blood and subsequent removal of plasma and reinfusion of cellular components along with a replacement fluid. It has become an accepted therapeutic modality in paediatric patients for numerous indications including but not limited to renal transplant, haemolytic uremic syndrome and Guillain Barre Syndrome. But, data on safety and efficacy are mainly derived from studies in the adult population with very limited data available in the paediatric age group. However, it is technically challenging in children due to their small circulating volume. This study discusses the clinical indications, efficacy, and safety of therapeutic plasma exchange in paediatric population.METHOD:We retrospectively reviewed the data of children (up to 18 years of age) who underwent TPE between January 2017 and March 2019 at our Hospital. Main features of the TPE procedures i.e. frequency of TPE, site of vascular access, type of replacement fluid used, instrument used, plasma volume processed, priming of the circuit, adverse events if any and outcome of the patients were analysed.RESULTS AND CONCLUSION:A total of 114 procedures were performed on these 24 patients. Fifteen patients with Category I indication showed good clinical outcome in terms of attainment of target ABO titre and/or decrease in the donor specific antibody. TPE is an effective therapeutic option in selected paediatric disorders. Our series of data on TPE procedures from paediatric perspective has shown safety and efficacy of the therapy.

Safety and efficacy of therapeutic plasma exchange in neuromyelitis optica: A retrospective study from South India

Safety and efficacy of therapeutic plasma exchange in neuromyelitis optica: A retrospective study from South India

Treatment Outcome and Efficacy of Therapeutic Plasma Exchange for Transplant-Associated Thrombotic Microangiopathy in a Real-World Large Cohort Study

IntroductionTransplant-associated thrombotic microangiopathy (TA-TMA) is a severe complication following allogeneic hematopoietic stem cell transplantation (allo-HSCT), with mortality over 80%. Effective management of TA-TMA is hampered by obscure pathogenesis and delayed diagnosis. There are no well-acknowledged therapeutic strategies for TA-TMA. TA-TMA-directed therapy includes therapeutic plasma exchange (TPE), eculizumab, rituximab, and defibrotide. The efficacy and outcome of TPE for the treatment of TA-TMA remain controversial. To our knowledge, this is the largest cohort to date of patients treated with TPE for TA-TMA after allo-HSCT. We aimed to identify predictors of response and mortality in patients with TA-TMA who received TPE, and to recognize patients who will benefit from TPE management.MethodsA total of 6241 subjects who underwent allo-HSCT were performed at Peking University People's Hospital from January 2010 to December 2019, of whom 538 patients were diagnosed with TA-TMA, with a cumulative incidence of 8.6%. Among them, 82 consecutive critically ill TA-TMA patients received TPE. TA-TMA was diagnosed using the criteria proposed by Cho et al. TPE was not performed in a protocol-defined manner. Patients were classified as achieving complete response (CR) if they showed disappearance of schistocytes, resolution of any changes in mental status, normalization of lactic dehydrogenase, and were not receiving red blood cells and platelet transfusions. Patients were considered to have achieved no response (NR) when they showed no improvement of laboratory features, remained dependent on red blood cell and/or platelet transfusions, or died with active TA-TMA. Subjects were considered to have a partial response (PR) when they did not meet the criteria for either CR or NR (BMT 2010; Blood 2020).ResultsTA-TMA was diagnosed at a median time of 64.5 [IQR 38.8-158] days post-HSCT. The 42 men (51.2%) and 40 women (48.8%) had an average age of 35.3 years. Renal involvement (59.8%), central nervous system dysfunction (70.7%), gastrointestinal (GI) bleeding (73.2%), and concomitant acute graft-versus-host disease (aGVHD, 78%) were common in our cohort of TA-TMA patients.All 82 patients in our analysis received TPE, and adjunctive TA-TMA-targeted therapy included the use of rituximab (11 patients), rituximab plus eculizumab (1 patient), and defibrotide (1 patient). However, the additional therapy showed no significant difference between the response and nonresponse groups. The median time from TA-TMA to TPE initiation was 8 days [IQR 2.0-16.5], and the cumulative volume of TPE was 6 L [IQR 3.6-8.5]. Our data revealed that the overall response was 52.4% (43/82), comprising 4 CRs and 39 PRs. Early TPE initiation trended towards a better response, but this difference was not statistically significant. The multivariate analysis showed that patients with GI bleeding (OR, 6.26; 95% CI, 1.30-30.12), grade III-IV aGVHD (OR, 5.00; 95% CI, 1.50-16.68), lower cumulative volume of TPE (OR, 8.51; 95% CI, 1.91-38.05), and severe anemia (OR, 7.48; 95% CI, 2.20-25.49) were less likely to respond to TPE.Regarding treatment outcome, 57% (47/82) of cases survived 100 days post HSCT, and 20% (16/82) survived 100 days after the diagnosis of TA-TMA. With a median follow-up of 467 days [IQR 248-1002], the OS at 1 year after TA-TMA was 15%. The leading causes of death were infection, active TA-TMA, and multiple organ dysfunction syndrome (MODS). The Kaplan-Meier analysis showed that GI bleeding, grade III-IV aGVHD, and no response to TPE were associated with poor survival at 1-year post TA-TMA (Figure 1). By multivariate analysis, TA-TMA patients treated with TPE had dismal survival with GI bleeding, lower loading volume of TPE, and elevated total bilirubin.ConclusionsThe results of this large cohort of real-world practice indicate that TPE may be effective for TA-TMA depending on given clinical circumstances. Our data underscore that GI bleeding is independently associated with poor response to TPE and mortality, while grade III-IV aGVHD is again confirmed as predicting a dismal response to TPE. We hypothesize that higher volume of TPE is warranted to achieve resolution and favorable outcome of TA-TMA. Multicenter prospective studies are required to further verify whether these patients could benefit from TPE and seek a paradigm for TPE in the management of TA-TMA. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Therapeutic Plasma Exchange is Safe and Efficacious in Normalizing Increased Plasma Viscosity Associated with COVID-19

BackgroundCOVID-19 associated hyperviscosity is a potential driver for the increased rates of thrombotic complications and multi-organ failure associated with severe COVID-19. Limited experience suggests a promising role for Therapeutic Plasma Exchange (TPE) in COVID-19 management based on the hypothesis that clinical benefit is derived from reduction in plasma viscosity. However, systematic study evaluating the safety and efficacy of TPE in these patients has not been done.ObjectiveTo evaluate the safety and efficacy of TPE in a subset of critically ill patients with COVID-19 and elevated blood viscosity in a randomized controlled trial (RCT).Study Design and MethodsThis study was conducted in the intensive care units (ICUs) of 3 hospitals in our health system, with a limited initial enrollment target of 20 patients. Participants included adult COVID-19 patients with moderate elevation in plasma viscosity (2.3-3.5 centipoise) or significant hyperfibrinogenemia (>800 mg/dL) that were not improving despite standard supportive care. Patients with bacterial or fungal coinfection or moribund patients were specifically excluded. Upon enrollment, patients were randomized 1:1 to the treatment group (1 plasma volume TPE with frozen plasma (FP) replacement on 2 consecutive days) or control group (continued standard of care (SOC)). Primary measures included the safety/tolerability of TPE and change in plasma viscosity levels after TPE versus SOC. Secondary measures included evaluation of various clinical and laboratory parameters, including fibrinogen and other coagulation-related markers, mortality, bleeding and thromboembolic complications, ICU length of stay and time to discharge after enrollment.ResultsPreliminary analysis of collected data demonstrates that TPE is safe and well-tolerated in these patients, with adverse events limited to one mild occurrence of tachycardia that improved upon decreasing the flow rate. There was significant decrease in plasma viscosity in the TPE treatment group, compared to the SOC control group. Secondary measures of select laboratory parameters also show a significant decrease in fibrinogen, von Willebrand factor (vWF), Factor VIII, and erythrocyte sedimentation rate in the TPE treatment group. No significant differences were seen in levels of fibrin monomer, total IgG, total IgM, total protein, or total albumin between the two groups. Data collection and analysis for clinical parameters are ongoing. Conclusions and RelevanceHere we report preliminary results suggesting that TPE is safe and effective for normalizing plasma viscosity in critically ill COVID-19 patients. Concomitant removal of large plasma proteins (fibrinogen, vWF) hints at their role in driving the increased viscosity associated with severe disease, which may contribute to clotting and end-organ damage in COVID-19. Based on lack of change in total IgG/IgM levels, TPE is not anticipated to hinder the patient’s humoral immunity by removing existing anti-SARS-CoV-2 specific antibodies. These results warrant further studies on the utility of TPE to mitigate critical illness in COVID-19 patients.