Feasibility & safety of plasma exchange in paediatric neuro-immunology: A single center experience

Therapeutic plasma exchange in critically ill children: 18-year experience of a tertiary care paediatric intensive care unit

BACKGROUND

Therapeutic plasma exchange (TPE) has been used as a primary or supportive treatment in critical paediatric patients during the clinical course of many diseases.

OBJECTIVES

The objective of this study was to characterise the indications, complications, and outcomes of critically ill children who received TPE in a tertiary referral paediatric intensive care unit (PICU).

METHODS

This retrospective observational study was conducted in a tertiary referral 13-bed PICU of a university hospital. Critically ill children, who received at least one TPE procedure, were retrospectively included in the study. TPE was utilised by the same paediatric intensivist in accordance with the American Society for Apheresis (ASFA) guideline between January 2005 and December 2022. The procedures were analysed in terms of technical aspects and complications. Multivariable logistic regression analysis was performed to identify independent risk factors for mortality.

RESULTS

In total, 1528 TPE sessions were performed on a total of 328 children. The overall TPE utility rate was 25 per 1000 PICU admissions. Primary indications for TPE were sepsis, neurological autoimmune, haematological diseases, acute liver failure, drug overdose, and autoimmune rheumatological disorders in 109 (33.2%), 90 (27.4%), 49 (14.9%), 43 (13.1%), 12 (3.7%), and 10 (3%) of patients, respectively. The distribution of TPE indications according to ASFA categories was as follows: 37 patients (11.3%) were in category I, 44 patients (13.4%) were in category II, and 211 (64.3%) were in category III. Complications were observed in 18.7% of sessions, and the most common complications were haemodynamic (10.8%) and circuit-/catheter-related (7.6%) complications. The mortality rate was 28.4% in the study. Moreover, both Pediatric Index of Mortality 3 score and number of organ failures were found as independent risk factors for mortality.

CONCLUSIONS

Our results revealed that TPE may be an effective procedure even in critically ill children in accordance with ASFA recommendations. We also showed that mortality rate increased with Pediatric Index of Mortality 3 score at admission and number of organ failures.

Safety and efficacy of plasma exchange treatment in children with AQP4-IgG positive neuromyelitis optica spectrum disorder

Neuromyelitis optica spectrum disorder (NMOSD), a severe demyelinating disease, is rare among children. Plasma exchange (PE) is widely used as a salvage therapy for severe and corticosteroid-unresponsive patients with NMOSD. Presently, there are limited studies on the safety and efficacy of PE in children with NMOSD. Herein, we report the case of six children with NMOSD who received PE along with the outcomes and adverse events. All six children (female, age at onset 4 years 9 months-13 years 2 months) were AQP4-IgG positive and received standard PE using the COM.TEC Cell Separator. The interval between NMOSD onset and PE was 29 days (range 10-98). Only one patient (P3) who received PE 10 days after acute exacerbations exhibited clinical improvement. Her left visual acuity increased from 0.06 to 0.6 (spectacle-corrected visual acuity was 1.0) and her EDSS score decreased from 4 to 3 points. The other five patients had no clinical improvement and no EDSS scores changes after PE. Adverse events included rashes (P1, P3), acute non-occlusive thrombosis of the internal jugular vein (P1), and thrombocytopenia (P2). In conclusion, the timing of PE initiation as a rescue therapy for severe and corticosteroid-unresponsive pediatric AQP4-IgG positive NMOSD may be crucial to treatment efficacy, and early initiation of PE may be associated with a better outcome. Furthermore, PE has the potential risk for clinically significant adverse effects that should be considered before initiating the therapy and should be weighed against potential benefits.

Therapeutic plasma exchange in clinical pediatric neurology practice: Experience from a tertiary referral hospital

OBJECTIVE

This study aims to retrospectively evaluate the long-term efficacy, tolerability, and safety of therapeutic plasma exchange (TPE) in children with various neuroimmunological disorders.

METHODS

This analysis was a single-center, retrospective cohort study of pediatric patients with neuroimmunological events undergoing TPE procedures in a tertiary referral center.

RESULTS

There were 23 patients, 14 boys (60.9%), aged at diagnosis onset 8 months to 16.8 years. The main indications of TPE were Guillain-Barré syndrome (GBS, n = 8), autoimmune encephalitis (n = 5), febrile infection-related epilepsy syndrome (FIRES, n = 4), and acute disseminated encephalomyelitis (ADEM, n = 3). There was no life-threatening complication due to the TPE procedures. Eight (34.8%) of 23 patients experienced 13 (7%) complications in 186 TPE procedures, mostly electrolyte disturbances (n = 5). None of patients discontinued TPE due to complications. Two (8.7%) of 23 patients had marked improvement, 6 (26.1%) had moderate and 11 (47.8%) had mild improvement after TPE. The last follow-up visit revealed neurological sequelae in 12 (52.2%) patients. Therapeutic plasma exchange was found to be more effective on GBS, autoimmune encephalitis and myasthenia gravis, less effective on ADEM and FIRES. There was no correlation between improvement with TPE and clinical parameters, including age, sex, diagnosis, disease duration before TPE, presence of intubation, and length of stay in the intensive care unit and hospital.

CONCLUSION

Therapeutic plasma exchange was found to be effective and well-tolerated in children with various types of neuroimmunological disorder, with at least mild improvement in approximately 80% of the patients and no life-threatening complications.