Indications For Therapeutic Plasma Exchange Research Articles

Exploring the role of plasmapheresis prior to thyroidectomy in managing thyrotoxicosis: a comprehensive scoping review.

A thyroid storm is the most extreme and life-threatening presentation of thyrotoxicosis. Thyroidectomy can be used for definitive treatment. It should be performed after euthyroidism is accomplished. The use of therapeutic plasma exchange (TPE) is a last resort option in cases where standard pharmacological therapy proves to be ineffective. Due to its rare prevalence, there are limited data evaluating the usefulness and efficacy of TPE as a bridging therapy to thyroidectomy. The absence of relevant literature prompted us to conduct a scoping review. The following bibliographic databases were searched for articles dated 30 November 2023: Medline, EMBASE, Web of Science and Google Scholar. The search identified 1047 records, of which 42 articles were accepted with a total of 234 patients. The dominant indications for TPE were side effects due to conventional treatment. The mean fT4 level decreased 51.9% of baseline after TPE, while the mean fT3 level decreased 66.6% of baseline. The main side effects observed with FFP were allergic reactions, while the use of an albumin solution was associated with perioperative bleeding. Based on the limited data available in the literature, we recognize plasmapheresis as an effective treatment option for reducing thyroid hormone levels prior to thyroidectomy in patients with thyrotoxicosis. Available data suggest that it might be reasonable to limit the number of sessions in favor of an earlier surgical intervention. To reduce the risk of bleeding, FFP may be a better option as a replacement fluid, especially in the session prior to thyroidectomy.

Therapeutic Plasma Exchange in Neurological Conditions: An Observation from the Eastern Part of India.

Therapeutic plasma exchange (TPE) is an extracorporeal process of separation of plasma from the cellular components of blood and its replacement with analogous fluids. This process is effective in treatment of disease conditions from dysregulation of the humoral immune system by removal of various humoral pathogenic substances like antibodies, immune complexes, monoclonal proteins, toxins or cytokine(s) and/or the replenishment of a specific plasma factor. To evaluate major indications of therapeutic plasma exchange in neurological disorders. To identify major complications associated and factors associated with premature cessation of the therapeutic plasma exchange cycle. Materials and Methods: This is a hospital based retrospective study conducted by analyzing medical records of patients, who had undergone therapeutic plasma exchange (TPE) for various neurological disorders at IMS & SUM hospital. Medical records total 118 patients who underwent TPE from January 2016 to December 2021 were analyzed. The demographic data, blood group pattern and indications for TPE were enumerated from the records. Various complications of TPE and reasons for incomplete TPE cycle were documented and analyzed. A total of 508 TPE procedures were performed on 118 patients. In this study 61 patients were male and 57 patients were female. O-blood group was commonest blood group among the patients. GBS is the commonest indication of TPE. 57.6 % of patients could complete all sessions TPE cycle. Blockage of vascular access is the commonest cause of incomplete TPE session. Cramps (33%) and mild transient hypotension (27.1%0 were the commonest complications observed. TPE is a safe and effective treatment option for various immune-mediated neurological disorders and should be considered in managing these disorders.

Complications of therapeutic plasma exchange: A retrospective, single-center study of 2505 procedures performed in 338 patients over 15 years.

Therapeutic plasma exchange (TPE) may involve complications. We aimed to review the demographic data, indications, technical information, and complications. Data for TPE procedures (TPEPs) performed between 2004 and 2018 were retrospectively. This study covered 2505 TPEPs performed on 338 patients; 55% of them were female (n = 186), and the median age was 36 years (range, 11-93 years). Most TPEPs were administered for hematological (40.6%) indications. The incidence of complications on the first procedure was 3.2% (n = 80); only 16 procedures (0.6%) were failed. The complication incidence was 19.8% (n = 497), with 789 total complications. Most of the complications were patient-related (90.4%), and the most of them were urticaria (29.1%), occlusion (3.2%), and faulty systems (1.01%), respectively. The use of only fresh frozen plasma as replacement fluid caused a higher complication rate (22.1%, p < 0.01). The number of TPEPs is increasing every day. Hematologic indications for TPE and the use of fresh frozen plasma may increase the risk of complications.

Evaluation of the results of the patients who underwent plasmapheresis in the pediatric intensive care unit.

Therapeutic plasma exchange (TPE) is an extracorporeal treatment method that removes large molecular weight substances from plasma. In our study, we aimed to retrospectively examine the indications and procedural methods of the patients who had undergone TPE, and the complications that occurred during the procedure. Forty-one patients who were monitored in thePICU of Gazi Yaşargil Training and Research Hospital and had indications for TPE between 2017 and 2021 were included in the study. Laboratory parameters were checked before and after the TPE procedure. In addition to these, patients' diagnosis, weight, type of procedure and type of device, where the procedure was performed, duration of the procedure, amount of blood and plasma processed, complications, number of procedures, and death during the procedure or independent of the procedure were evaluated. The median age was 93.0 (14.0-167.0) months. Hemolytic uremic syndrome (HUS) was the most common TPE indication with nine patients. The most common complication related to TPE was fever (11 patients), while no complication was observed in 18 patients.When laboratory results were evaluated according to American Society for Apheresis (ASFA) categories, a significant improvement was observed in the values of platelet, AST, ALT, LDH, urea, and creatinine in ASFA1 after TPE. No significant improvement was observed in ASFA2 (p > 0.05). In ASFA3, a significant improvement was observed in INR, AST, ALT, LDH, total bilirubin, creatinine, pH, and lactate values after TPE (p < 0.05). Five patients died from ASFA1, one from ASFA2, and three patients from ASFA3. Since significant adjustments are observed in clinical and laboratory values in sepsis-MOF, which is in the ASFA3 category, we believe that it should be evaluated in the ASFA2 or ASFA1 category in the early treatment of these diseases. In addition, we think that MIS-C cases, which have not been in any category according to ASFA, should be included in the ASFA2 or ASFA3 category, considering our TPE results.

Therapeutic plasma exchange in critically ill children: A single center experience.

Therapeutic plasma exchange (TPE) is used in a wide spectrum of diseases in critically ill pediatric patients. We aim to review the indications, complications, safety, and outcomes of critically ill children who received TPE. All of the TPE procedures performed in a pediatric intensive care unit providing tertiary care during 19 years (January 2013-January 2023) were evaluated retrospectively. A total of 154 patients underwent 486 TPE sessions. Median age was 6 years (2-12.5) and 35 children had a body weight of <10 kg (22.7%). Number of organ failure was 4 (2-6). Liver diseases were the most common indication for TPE (31.2%) followed by sepsis with multiorgan dysfunction syndrome (27.3%). Overall survival rate was 72.7%. The highest mortality was observed in hemophagocytic lymphohistiocytosis group. Non-survivors had significantly higher number of organ failure (p < 0.001), higher PRISM score (p < 0.001), and higher PELOD score on admission (p < 0.001). Adverse events were observed in 68 (13.9%) sessions. Hypotension (7.8%) and hypocalcemia (5.1%) were the most frequent adverse events. TPE is safe for critically ill pediatric patients with experienced staff. Survival rate may vary depending on the underlying disease. Survival decreases with the increase in the number of failed organs.

Retrospective evaluation of indications for therapeutic plasmapheresis procedures applied in our center

Aims: Therapeutic plasma exchange (TPE) is a process in which pathological substances (autoantibodies, alloantibodies, immune complexes, lipoproteins, cryoglobulins, etc.) in the patient's plasma are removed from the body along with the patient's plasma and replaced with replacement fluid (allogeneic donor plasma, colloid, crystalloid). It is applied as a complementary treatment method in many diseases that can cause high morbidity and mortality, either in the primary treatment of the disease (main treatment) or as an adjunctive treatment in the main treatment of the disease. Today, TPE is increasingly used in various clinics (toxicology, endocrinology, etc.) for different diseases/causes, especially in hematological, neurological, and nephrological diseases. Methods: Adult patients who underwent therapeutic plasma exchange in our therapeutic apheresis center between May 2017 and May 2019 were included in the study, and the data were obtained by retrospectively reviewing patient records in the therapeutic apheresis center and our hospital's automation system. Results: In the two-year period, a total of 1957 TPE procedures were performed on 441 patients. It was determined that 255 of the patients undergoing TPE procedures (57.8%) had indications related to liver diseases (acute liver failure, acute exacerbation of chronic liver failure, and rejection after liver transplantation), while 186 (42.2%) had indications related to non-liver diseases. Among the 186 patients undergoing TPE for non-liver diseases, it was found that 69 (37.1%) were for hematological, 38 (20.4%) for neurological, 32 (17.2%) for renal, and 47 (25.3%) for other diseases. Conclusion: Due to the large number of liver transplants performed in our Liver Transplant Institute, the majority of TPE indications at our hospital are related to liver diseases. However, the evaluation of TPE indications excluding liver diseases revealed that the indications and frequencies of patients undergoing TPE were consistent with the overall results reported in studies from both our country and abroad.

Reusing Plasma Filters in Resource-Poor Settings: Experience From a Tertiary Care Hospital.

Therapeutic plasma exchange (TPE) is used to manage various life-threatening illnesses. It is widely performed by nephrologists, intensivists, pathologists, or experts in transfusion medicine worldwide. However, the costs of TPE sessions are exceedingly high, and they have a huge impact on patients' financial burden. Herein, we investigated the outcomes of the reuse of plasma filters in TPE on several occasions. This is a retrospective analysis of patients receiving TPE from January 1, 2020, to April 30, 2023, in the Department of Nephrology. A formulation of 4.5% peracetic acid and 24% hydrogen peroxide acid with RO water dilution was used for reprocessing. Clinical outcomes, risks, and cost-benefit were evaluated and compared between the plasma filter reuse group (GP-1) and the no-reuse group (GP-2). A total of 70 patients were included in this study. 200 and 112 TPE sessions were performed in GP-1 and GP-2, respectively. The most common indication for TPE in both groups was neurological. The clinical efficacy of TPE was similar in both groups. There was no difference in the clotting of the plasma filter, any allergic reaction, infection, or bleeding in the group. However, there was a significant difference in levels of fibrinogen (p=0.03) pre and post-procedure in both groups. The incidence of hypotension was found to be higher in GP-1 (26%) compared to GP-2 (15.6%), p = 0.05. The cost of overall treatment was 38% less in GP-1. The reuse of plasma filters is a safe and effective method for cost minimization in patients requiring TPE. This method can be effectively utilized in resource-poor settings without any increased risk of adverse effects.

A 15-year report of indications, adverse events, and effectiveness of therapeutic plasma exchange in patients with rheumatic diseases

Therapeutic plasma exchange (TPE) is a type of treatment, which eliminates harmful antibodies, immune complexes, cytokines, and inflammatory products. Due to the lack of sufficient data on indications, effectiveness, and side effects of TPE in patients with rheumatic disease, we evaluated TPE in our center. All consecutive patients registered in university hospitals with definite rheumatologic indications for TPE during 15 years were evaluated. 680 sessions of TPE were performed on 166 patients, aged between 19 and 83 years. The most common underlying causes were collagen vascular diseases (60%) including systemic lupus erythematosus (SLE) (98%), and antiphospholipid antibody syndrome (APS) (1%); and then, primary small vessel vasculitis (SVV) (39.8%). The main indications for TPE in all patients were rapidly progressive glomerulonephritis (RPGN) (69.8%) and pulmonary hemorrhage (39.1%). During 12 months follow-up, in SLE and SVV patients 17 (17.3%) and 20 (30.3%) entered complete remission; 37 (37.3%) and 12 (18.1%) entered partial remission; 44 (44.8%) and 34 (51.5%) had no recovery; and 37(37%) and 19 (28.7%) died, respectively. A total of 18 (10.8%) patients experienced TPE-related adverse events during TPE [hypotension 15 (9%), allergic reaction 1 (0.6%), fever 1 (0.6%), and hypocalcemia 1 (0.6%)]. The most common indication for TPE is SLE and primary vasculitis. The RPGN and pulmonary hemorrhage were the main indications. Although the rate of response to treatment was acceptable according to the fatal nature of these complications, further case-control studies are suggested to assess the effectiveness of TPE.

Adverse Events and Infectious Complications in the Critically Ill Treated by Plasma Exchange: A Five-Year Multicenter Cohort Study.

The aim of this study was to determine, in critically ill patients treated with therapeutic plasma exchange (TPE), the incidence of adverse events as well as the incidence of secondary infections and its predictive factors. A multicenter retrospective cohort study of an intensive care population treated with TPE to collect adverse events and infectious complications. The characteristics of patients who developed an infection after plasma exchange were compared with those of patients who did not. Four ICUs of French university hospitals. All adults admitted between January 1, 2015, and December 31, 2019, who received at least one plasma exchange session were included. None. A total of 711 TPE sessions were performed on 124 patients. The most frequent TPE indications were thrombotic microangiopathies (n = 32, 26%), myasthenia gravis (n = 25, 20%), and acute polyradiculoneuropathy (n = 12, 10%). Among the 124 patients, 22 (21%) developed arterial hypotension, 12 (12%) fever, and 9 (9%) electrolyte disturbance during TPE. Moreover, 60 (48%) presented at least one infectious complication: ventilator-associated pneumonia 42, pneumonia 13, bacteremia 18 (of which 6 catheter-related infections) viral reactivation 14. Independent risk factors for ICU-acquired infection were the ICU length of stay (24 vs. 7 d; hazard ratio [HR]: 1.09 [1.04-1.15], p < 0.001) and invasive mechanical ventilation (92% vs. 35%; HR: 16.2 [5.0-53.0], p < 0.001). In critically ill patients treated with TPE, adverse events occurring during the procedure remain moderately frequent and are mostly not life-threatening. Infectious complications, mainly ventilation-associated pneumonia, are frequent in this population. The need of mechanical ventilation and longer ICU stay is associated with an increased risk of infection.

#6167 THERAPEUTIC PLASMA EXCHANGE AS A TOOL IN THE TREATMENT OF NEUROLOGICAL DISEASES: A SINGLE CENTER EXPERIENCE

Abstract Background and Aims Plasmapheresis is an extracorporeal technique that removes immunological active substances, such as antibodies or immune complexes, from plasma. Simultaneously, it can provide essential factors in deficit, when supplementing with plasma. Therapeutic plasma exchange (TPE) can be used in numerous diseases with systemic involvement and, more recently, it has assumed an increasingly relevant role in the treatment of neurological diseases. Our aim was to review neurological indications, technique prescription, clinical outcomes and complications of these procedures. Methods We conducted an observational retrospective single-center study of the neurological diseases treated with TPE in our unit. We analyzed all procedures performed between January 2010 and December 2012 and collected indications, technical factors, complications and clinical outcomes of all treatments conducted. TPE was performed removing 1 to 1.5 of plasma volume per session. All procedures used Human Albumin 5% as replacement fluid and two units of fresh frozen plasma (FFP) were given in the end of each session. Hypocoagulation of the extracorporeal circuit was maintained with unfractionated heparin. Results Seventy-seven cycles of TPE (a total of 421 procedures) were performed on 45 patients [55.6% female; median age of 51 years (SD±16.8)]. The main indications of TPE in neurological diseases included myasthenia gravis (n = 35), Anti-N-methyl-d-aspartate (NMDA) encephalitis (n = 7), Guillain-Barré syndrome (n = 7), neuromyelitis optica spectrum disorders (n = 6), acute disseminated encephalomyelitis (n = 5), paraneoplastic syndromes (n = 4) and multiple sclerosis (n = 2). Intravenous immunoglobulin was given before TPE in 25 cases, 34 patients were on steroid and 6 patients had received pyridostigmine. Eighteen patients had coadjuvant immunosuppression [Mycophenolate mofetil or Azathioprine (n = 13), Rituximab (n = 3), tacrolimus (n = 1), Tocilizumab (n = 1) or Eculizumab (n = 1)]. The median number of TPE sessions per patient was 5 (range 1-20) and most cycles (63.6%) were performed every day for 3 sessions and 2 sessions every other day. Most of TPE (59.7%) was performed in ward, 27.3% in Intensive Care Unit (ICU) and 10 treatments were conducted in ambulatory. Near 84% of treatments were done through central venous catheters (CVC) and one patient had an arteriovenous (AV) fistula. Twenty-four (5.7%) complications were seen in 421 procedures. These complications were infection (18.2%), catheter-related (7.8%) and allergic reactions (1.3%). TPE procedure was terminated in 7.8% of sessions depending on these complications. Overall responses to TPE were noted in 81.8% of patients and 6 patients had at least one relapse during follow-up. Conclusion TPE is an effective and safe treatment option in several neurologic diseases. In our center, principal indications for TPE were myasthenia gravis, NMDA encephalitis and Guillain-Barré syndrome. In this study, clinical outcomes were favorable in the majority of the cases, with a minimum rate of complications per procedure. Therefore TPE should be considered in an early phase of presentation of disease. In relapsing diseases like myasthenia gravis, refractory to immunosuppression therapy, an AV fistula could be an alternative access to minimize the CVC-related complications.

#3242 OUTCOMES OF THERAPEUTIC PLASMA EXCHANGE: A ONE-YEAR EXPERIENCE IN AN INTERNAL MEDICINE INTENSIVE CARE UNIT

Abstract Background and Aims There is uncertainty regarding the best indication, device type, frequency, length of time, kind of replacement fluid, and criteria for ceasing therapeutic plasma exchange (TPE) for various disorders. TPE is an intrusive technique that has the potential to save lives, but it also has a risk of unfavorable outcomes and complications, necessitating close supervision by professional teams. In the intensive care unit (ICU), there are three categories of indications for TPE: (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy; (2) relative; for which TPE is a recognized second-line treatment (alone or in combination) and (3) rescue therapy; for which TPE is used with a limited or theoretical evidence base. The purpose of this study is to continue our evaluation of the outcome of nephrology care in internal medicine ICU regarding bedside membrane therapeutic plasma exchange. Method In the continuity of our previous work in the analysis of the outcome of TPE. From August 2021 to August 2022, 425 membrane plasma exchange sessions were performed on 69 patients in the internal medicine department's ICU-Cairo University Hospitals-Egypt. Results Closely similar to what we found before; the most frequent diagnosis was thrombotic microangiopathies (24 (34.8%) patients) with complete recovery seen in 18/24 patients (75%); followed by systemic vasculitis with pulmonary renal involvement (14 (20.3%) patients) with partial remission was seen in 9/14 patients (64.3%); Guillain-Barré syndrome (13 (18.8%) patients) with complete recovery was seen in 8/13 patients (61.5%); Proliferative Lupus Nephritis with crescents [10 (14.5%) patients] with partial remission in 8/10 patients (80%), and myasthenia gravis [8 (11.6%) patients] with complete recovery in 6/8 patients (75%). Hypotension occurred during 69/425 (16.2%) sessions and hypocalcemia in 8/69 (11.5%) patients during treatment. Infection of vascular access occurred in 4/69 (5.8%) patients. 6/69 (8.7%) patients died during their stay in ICU none during treatment with TPE, all of them were diagnosed to have severe sepsis as a cause of death. Conclusion According to our experience, membrane therapeutic plasma exchange is a successful and secure treatment for a variety of illnesses including thrombotic microangiopathies, systemic vasculitis, myasthenia gravis, proliferative lupus nephritis, and Guillain-Barré syndrome. The main reason for death was sepsis.

Retrospective evaluation of therapeutic plasma exchange treatment in a pediatric intensive care unit: Single-center experience.

The aim of this study is to characterize the clinical indications, outcomes, and complications of therapeutic plasma exchange (TPE) in pediatric intensive care unit. A retrospective study was conducted on critically ill patients who received TPE. A dataset of 672 treatments administered to 102 patients was analyzed. The most common indication for TPE was COVID-19-related clinical conditions, followed by sepsis (24.5%), neurological diseases (9.8%) and renal diseases (6.9%). None of our patients died due to TPE-related complications, and the most common complication during and after the TPE was hypotension (21.7%). Although TPE is riskier to provide to critically ill children, our experience indicates that it can be performed relatively safely in critically ill children with appropriate treatment indications. In particular, indications, onset time, number of sessions and other procedures should be standardized for the pediatric age group.

Indications and Outcomes of Patients Receiving Therapeutic Plasma Exchange under Critical Care Conditions: A Retrospective Eleven-Year Single-Center Study at a Tertiary Care Center.

Background: Therapeutic plasma exchange (TPE) is frequently performed in critical care settings for heterogenous indications. However, specific intensive care unit (ICU) data regarding TPE indications, patient characteristics and technical details are sparse. Methods: We performed a retrospective, single-center study using data from January 2010 until August 2021 for patients treated with TPE in an ICU setting at the University Hospital Zurich. Data collected included patient characteristics and outcomes, ICU-specific parameters, as well as apheresis-specific technical parameters and complications. Results: We identified n = 105 patients receiving n = 408 TPEs for n = 24 indications during the study period. The most common was thrombotic microangiopathies (TMA) (38%), transplant-associated complications (16.3%) and vasculitis (14%). One-third of indications (35.2%) could not be classified according to ASFA. Anaphylaxis was the most common TPE-related complication (6.7%), while bleeding complications were rare (1%). The median duration of ICU stay was 8 ± 14 days. Ventilator support, renal replacement therapy or vasopressors were required in 59 (56.2%), 26 (24.8%), and 35 (33.3%) patients, respectively, and 6 (5.7%) patients required extracorporeal membrane oxygenation. The overall hospital survival rate was 88.6%. Conclusion: Our study provides valuable real-world data on heterogenous TPE indications for patients in the ICU setting, potentially supporting decision-making.

Therapeutic plasma exchange in the pediatric intensive care unit: a single-center retrospective study

To study the indication for therapeutic plasma exchange (TPE) and related complications in children admitted to the pediatric intensive care unit. A retrospective analysis was performed on the medical records of the children who received TPE in the Pediatric Intensive Care Unit, Hunan Children's Hospital, from March 2015 to March 2021. The indication for TPE and related complications were analyzed and compared with the American Society for Apheresis (ASFA) indication categories. A total of 405 TPE treatment sessions were performed for 196 children, among whom 76 children (38.8%) also received continuous renal replacement therapy and 147 children (75.0%) survived. The children with neurological diseases had the highest survival rate of 93.1% (27/29). The top three indications for TPE were hematologic diseases (61/196, 31.1%), sepsis with multiple organ dysfunction (41/196, 20.9%), and liver diseases (36/196, 18.4%). The children with hematologic diseases received the highest number of 129 TPE treatment sessions. The subjects with ASFA category Ⅲ indications accounted for the highest proportion of 76.5% (150/196), followed by those with ASFA category Ⅰ indications (11.2%, 22/196), ASFA category Ⅱ indications (7.1%, 14/196), and unknown category (5.1%, 10/196), and no ASFA category Ⅳ indications were observed. The incidence rate of TPE complications was 12.3% (50/405), and the most common complications were pipeline coagulation (4.2%, 17/405) and hypotension (3.7%, 15/405). No serious adverse events were observed. TPE can be safely used for the treatment of critically ill children with indications in an experienced pediatric intensive care unit.

Therapeutic plasma exchange in hyperthyroidism prior to surgery.

Therapeutic plasma exchange (TPE) is a treatment option to reduce thyroid hormones in the event of contraindication or unresponsiveness to antithyroid drugs (ATDs). We analyzed 11 patients with hyperthyroidism who received TPE prior to surgery between January 2008 and December 2016 at our center. In total, 41 processes were applied to 11 patients with hyperthyroidism. The median age was 40years, and 90.9% of the patients were female. Seven patients had Graves' disease, while four had a toxic multinodular goiter. The distribution of TPE indications comprised contraindication to ATDs (64%) and insufficient response to ATDs (36%). An adequate response was not obtained with TPE in two patients, and cholestyramine plus methimazole and Lugol solution were applied. The median number of TPE sessions was 3. During the TPE period, a β-blocker was applied concurrently except in one patient who was contraindicated for the drug. The reduction in FT3 and FT4 hormones and the increase in TSH levels were statistically significant after TPE application (p values of 0.003, 0.033 and 0.008, respectively). Regarding adverse events of TPE application, an allergic reaction was seen in one patient, while prolongation of prothrombin time without any clinical findings was seen in another patient. Ten patients underwent total thyroidectomy, and one patient underwent a gynecological surgery procedure without any major complications. The American Society for Apheresis guideline, which is the most referenced guideline, mentions the utilization of TPE before thyroid surgery, only in patients with thyrotoxicosis despite the wider necessity of this treatment choice under the condition of uncontrolled hyperthyroidism prior to any kind of surgery. We concluded that TPE is a reliable and effective application in patients with hyperthyroidism before any surgical procedure, according to our study results.

Plasma exchange in the intensive care unit: a narrative review.

In this narrative review, we discuss the relevant issues of therapeutic plasma exchange (TPE) in critically ill patients. For many conditions, the optimal indication, device type, frequency, duration, type of replacement fluid and criteria for stopping TPE are uncertain. TPE is a potentially lifesaving but also invasive procedure with risk of adverse events and complications and requires close monitoring by experienced teams. In the intensive care unit (ICU), the indications for TPE can be divided into (1) absolute, well-established, and evidence-based, for which TPE is recognized as first-line therapy, (2) relative, for which TPE is a recognized second-line treatment (alone or combined) and (3) rescue therapy, where TPE is used with a limited or theoretical evidence base. New indications are emerging and ongoing knowledge gaps, notably regarding the use of TPE during critical illness, support the establishment of a TPE registry dedicated to intensive care medicine.Supplementary InformationThe online version contains supplementary material available at 10.1007/s00134-022-06793-z.

Therapeutic Plasma Exchange for Treating Pediatric Neurological Diseases

Objective: Therapeutic plasma exchange (TPE) is performed in various neurological, hematological, renal and autoimmune diseases. This study was conducted to determine the indications, efficacy, safety and complications of TPE in pediatric autoimmune neurological diseases. Methods: In this study, patients who were hospitalized in the pediatric intensive care unit of a tertiary university hospital between January 2017 and December 2021 and underwent TPE due to neurological diseases were evaluated retrospectively. Results: A total of 20 patients were included in the study. Their ages ranged from 6 to 237 months, with a mean age of 63.16±183.12 months. Neurological TPE indications of the patients were autoimmune encephalitis (50%, n=10), Guillain-Barre Syndrome (45%, n=9) and Acute Demyelinating Encephalomyelitis (6.7%, n=1), respectively. Catheter occlusion was observed in 2 (10%) patients, allergic reaction in 1 (5%) patient, and hypotension in 1 (5%) patient as complications of TPE. Muscle strength of patients with GBS was evaluated according to the Medical Research Council scale before transfer to the service. It was determined that the score increased from 0 to 1 in two patients, from 0 to 3 in three patients, and from 1 to 5 in four patients. In 9 of the patients diagnosed with encephalitis, regression of acute phase reactants and improvement in neurological evaluation were observed. Conclusion: When TPE is applied with appropriate indications and by an experienced team in pediatric neurological diseases, treatment results can are satisfactory, its effectiveness increases and the complication rate decreases.

Therapeutic plasma exchange for multiorgan dysfunction among critically ill pediatric patients with leukemia: A single-institutional experience.

Therapeutic plasma exchange (TPE) has well-documented applications in the adult population, outlined by the American Society for Apheresis (ASFA) 2019 guidelines. Limited data exist regarding the use of TPE in critically ill pediatric patients; however, these reports rarely include patients with oncological diseases. We highlight the use of TPE in the acute management of seven pediatric patients with leukemia treated at Children's Mercy Hospital ICU from 2015 to 2020, including TPE specifications, baseline and interval laboratory evaluation, and outcome measures. Analysis compared those who did (n=4) and did not (n=3) survive 30 days post-TPE. Multiorgan failure (MOF) prompted the initiation of TPE in 85.7% of patients, 57.1% of whom were also diagnosed with hemophagocytic lymphohistiocytosis (HLH). Baseline laboratory evaluations prior to initiation of TPE were similar between the two groups. With subsequent TPE treatments, C-reactive protein (CRP) and lactic acid decreased. CRP and lactic acid following the last TPE treatment were significantly higher for those deceased 30 days post-TPE (P = .023 and .031, respectively). No TPE-associated adverse events necessitated discontinuation of TPE treatment. Several surviving patients required chemotherapy dose reductions or alterations. Our cohort demonstrated MOF and HLH consistently as indications for TPE, currently ASFA category III indications (optimal role of apheresis is not yet established). Recognition of this treatment modality earlier in the clinical course for critically ill oncological patients may lead to the development of formal protocols that may result in earlier initiation of TPE and improved outcomes.

Therapeutic plasma exchange in the intensive care unit and with the critically ill, a focus on clinical nursing considerations.

Therapeutic plasma exchange (TPE) is a blood purification technique removing antibodies and plasma proteins to modulate disease and promote recovery. The procedure has different methods, using a membrane or plasma separator with many elements similar to continuous renal replacement therapy (CCRT) in the Intensive Care Unit (ICU). These nursing knowledge and skill sets apply where ICU nurses are providing TPE with increasing need. However, different care models are also in place where TPE is the responsibility of apheresis and nephrology teams visiting the ICU. The plasma replacement volume and prescribing is aligned with published guidelines but is variable when critical illness overlays the primary indication for TPE. There are some important considerations for TPE with respect to anticoagulation, machine settings, prescribing, and associated nursing management. TPE can be performed concurrent with CRRT in acute situations using Y‐piece and valve connectors and is a new and recent advanced blood purification for the ICU.

Therapeutic Plasma Exchange (TPE) Complications in Patients With Multiple Sclerosis (MS) and Clinically Isolated Syndrome (CIS): A Report From a Tertiary Center.

Therapeutic plasma exchange (TPE) is a conventional second-line treatment for patients with multiple sclerosis (MS) or clinically isolated syndrome with steroid-refractory relapses. MS and clinically isolated syndrome patients with a steroid-refractory relapse, who fulfilled the indications for TPE were enrolled in this study. An expert nurse recorded the data comprising age, sex, type of MS, disease modifying therapy, disease duration, relapse rate, vital signs at the beginning, during and at the end of each plasma exchange session, plasma exchange volume, normal saline volume, and TPE complications. Ultimately, the statistical association was estimated amongst the variables. A total of 122 cases were assessed. Twelve cases (9.8%) received plasmapheresis for the second time. The mean age was 32.2±8.7 years and 107 (87.7%) were female. In total, 609 plasma exchange sessions were completed. Hypotension and skin reaction were the most clinical complications. Hemoglobin loss and hypokalemia were the most laboratory complications. Fifty-four cases (44.3%) had no complications, 40 (32.8%) had 1 complication, 21 (17.2%) 2 complications, 6 (4.9%) had 3 complications, and 1 (0.8%) disclosed 4 complications. The relapse rate in the past 12 months and the mean plasma volume exchange were significantly different between the groups. We revealed that TPE could be considered as a safe second-line therapy in MS relapses. Hypotension, skin reaction, hemoglobin loss, and hypokalemia were the most complications of TPE in our patients.