Epidemiology of therapeutic apheresis with a multidisciplinary approach at a high volume pediatric center

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.

Role of therapeutic apheresis in the treatment of pediatric kidney diseases

Therapeutic apheresis utilizes apheresis procedures in the treatment of a variety of conditions including kidney disease. Therapeutic plasma exchange (TPE) is the most common modality employed with the rationale of rapid reduction of a pathogenic substance distributed primarily in the intravascular compartment; however other techniques which adsorb such pathogenic substances or alter the immune profile have been utilized in diseases affecting native and transplanted kidneys. This article discusses the modalities and technical details of therapeutic apheresis and summarizes its role in individual diseases affecting the kidney. Complications related to pediatric apheresis procedures and specifically related to apheresis in kidney disease are also discussed. Though therapeutic apheresis modalities are employed frequently in children with kidney disease, most experiences are extrapolated from adult studies. International and national registries need to be established to elucidate the role of apheresis modalities in children with kidney disease.

Tandem plasmapheresis and continuous kidney replacement treatment in pediatric patients

BACKGROUND

The objectives of the study are to describe tandem therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) patients' outcomes in a large institution.

METHODS

We reviewed pediatric patients receiving tandem TPE and CKRT from 2013 to 2016. Over the study period, 63 discrete patients received tandem TPE and CKRT for a total of 378 TPE procedures on 1676 days on CKRT.

RESULTS

Patient age ranged from newborn to 19 years old with weights ranging from 2.31 to 112.3 kg (17 patients were < 10 kg and less than 1 year old). All procedures were completed in intensive care units (ICU) as CKRT can only be done in this environment. All treatments completed successfully; majority of patients (90%) developed hypocalcemia though none were symptomatic. Case mortality rate was 40%. Disease severity scores at ICU admission were higher and time to TPE and CKRT start was longer in the deceased group.

CONCLUSIONS

As a conclusion, though complications including hypocalcemia are common with tandem TPE and CKRT in pediatrics, patients remained asymptomatic. Such treatments have to be carefully planned with interdisciplinary teams to address indications, technicalities, and complications.