Plasma exchange in a 13-year-old male with acute intravascular hemolysis and acute kidney injury after placement of a ventricular assist device

Therapeutic plasma exchange for mechanical red cell hemolysis: A case series

We present three cases of severely elevated plasma free hemoglobin (PFH) in pediatric patients on mechanical circulatory support devices at a tertiary pediatric care center. Due to severe levels of PFH in the setting of critical illness with the inability to pursue immediate mechanical device exchange, membrane filtration therapeutic plasma exchange (TPE) was performed, which resulted in a lowering of PFH levels. However, long-term outcomes were heterogeneous across the cases. This case series reviews patient presentation, organ function before and after TPE, and the overall role of TPE as an effective treatment option to decrease severely elevated PFH levels. In doing so, we hope to add to what is known about the use of TPE for mechanical red cell hemolysis and provide guidance on its use in critically ill patients.

Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy

Objectives

Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC.

Methods

In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed.

Results

In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia.

Conclusion

TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments.

Level of evidence

Level V.

Therapeutic Plasma Exchange Is Associated With Improved Major Adverse Kidney Events in Children and Young Adults With Thrombocytopenia at the Time of Continuous Kidney Replacement Therapy Initiation

Therapeutic plasma exchange (TPE) has been shown to improve organ dysfunction and survival in patients with thrombotic microangiopathy and thrombocytopenia associated with multiple organ failure. There are no known therapies for the prevention of major adverse kidney events after continuous kidney replacement therapy (CKRT). The primary objective of this study was to evaluate the effect of TPE on the rate of adverse kidney events in children and young adults with thrombocytopenia at the time of CKRT initiation.

DESIGN

Retrospective cohort.

SETTING

Two large quaternary care pediatric hospitals.

PATIENTS

All patients less than or equal to 26 years old who received CKRT between 2014 and 2020.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We defined thrombocytopenia as a platelet count less than or equal to 100,000 (cell/mm3) at the time of CKRT initiation. We ascertained major adverse kidney events at 90 days (MAKE90) after CKRT initiation as the composite of death, need for kidney replacement therapy, or a greater than or equal to 25% decline in estimated glomerular filtration rate from baseline. We performed multivariable logistic regression and propensity score weighting to analyze the relationship between the use of TPE and MAKE90. After excluding patients with a diagnosis of thrombotic thrombocytopenia purpura and atypical hemolytic uremic syndrome (n = 6) and with thrombocytopenia due to a chronic illness (n = 2), 284 of 413 total patients (68.8%) had thrombocytopenia at CKRT initiation (51% female). Of the patients with thrombocytopenia, the median (interquartile range) age was 69 months (13-128 mo). MAKE90 occurred in 69.0% and 41.5% received TPE. The use of TPE was independently associated with reduced MAKE90 by multivariable analysis (odds ratio [OR], 0.35; 95% CI, 0.20-0.60) and by propensity score weighting (adjusted OR, 0.31; 95% CI, 0.16-0.59).

CONCLUSIONS

Thrombocytopenia is common in children and young adults at CKRT initiation and is associated with increased MAKE90. In this subset of patients, our data show benefit of TPE in reducing the rate of MAKE90.

Clearance of severely elevated plasma free hemoglobin with total plasma exchange in a pediatric ECMO patient

Extracorporeal membrane oxygenation (ECMO)-related hemolysis is common with reported incidence of 5%-18%. Plasma free hemoglobin (PFH) levels are used as a marker for hemolysis and elevated PFH is associated with acute kidney injury (AKI). Limited literature exists regarding treatment of severe hemolysis and clearance of PFH. We report 8-year-old male child on VA ECMO with severe hemolysis (PFH 895 mg/dL) and worsening AKI showing significant improvement in PFH after single volume exchange plasmapheresis with Fresh Frozen Plasma (FFP) performed in tandem via ECMO circuit.

Hemolysis and methemoglobinemia in a child with left ventricular assist Levitronix PediMag

A 5-month-old male was treated with left ventricular assist device due to cardiac failure secondary to dilated cardiomyopathy. The patient developed acute severe intravascular hemolysis with methemoglobinemia and renal failure, related to a mechanical problem due to pump cylinder misalignment. Secondary severe methemoglobinemia has not been previously described in patients undergoing ventricular assist device. Early detection of the signs and symptoms of hemolysis is crucial to prevent further complications.