Therapeutic plasma exchange in the pediatric intensive care unit: A single-center 5-Year experience

Therapeutic apheresis: is it safe in children with kidney disease?

BACKGROUND

Therapeutic apheresis (TA) is already used to treat various diseases in the field of nephrology. The aim of this study was to evaluate the frequency and types of complications that occur during TA in children with kidney disease.

METHODS

Records of children (≤ 18 years) who underwent TA between 2007 and 2022 were retrospectively reviewed. Children with missing data and those with a diagnosis of nonnephrological disease were excluded.

RESULTS

A total of 1214 TA sessions, including 1147 therapeutic plasma exchange (TPE) sessions and 67 immunoadsorption (IA) sessions, were performed on the 108 patients enrolled in the study. Forty-seven percent of the patients were male, and the mean age was 12.22 ± 4.47 years. Posttransplant antibody-mediated rejection (64.8%) and hemolytic uremic syndrome (14.8%) were the most common diagnoses indicating TA. Overall, 17 different complications occurred in 58 sessions (4.8%), and 53 sessions (4.6%) were not completed because of these complications. The distribution of complications among the patients was as follows: 41.4% had technical complications, 25.9% had allergic complications, and 32.7% had others. The most common technical complication was insufficient flow (37.5%). The incidence of complications was greater in patients aged 3-6 years than in patients in the other age groups (p = 0.031). The primary disease, type of vascular access, and rate of fresh frozen plasma/albumin use were similar between patients with and without complications (p values of 0.359 and 0.125 and 0.118, respectively).

CONCLUSIONS

Our study showed that complications occurred in only 4.8% of TA sessions. The most common complication was technical problems.

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.

Circular RNA circVAPA modulates macrophage pyroptosis in sepsis-induced acute lung injury through targeting miR-212-3p/Sirt1/Nrf2/NLRP3 axis

Sepsis-induced acute lung injury (ALI) is an inflammatory condition involving the pyroptosis of macrophages. This study investigated the role of circular RNA hsa_circ_0006990 (circVAPA) in regulating macrophage pyroptosis in ALI and the underlying mechanisms. The expression pattern of circVAPA was examined in the mouse model of ALI and in the LPS-treated RAW264.7 macrophage cell line. Lung tissue damage was evaluated by haematoxylin and eosin staining, immunohistochemistry and a myeloperoxidase activity assay. The molecular mechanisms were investigated by luciferase reporter assay, western blot, RT-qPCR and ELISA. circVAPA was down-regulated in the lung tissues of ALI mice and LPS-induced RAW264.7 cells. circVAPA over-expression alleviated lung tissue injury and dampened LPS-induced pyroptosis and Th17-associated inflammatory responses. miR-212-3p was identified as a target of circVAPA, and miR-212-3p negatively regulated the expression of Sirt1. Sirt1 knockdown largely abolished the effect of circVAPA over-expression on pyroptosis. CircVAPA/miR-212-3p/Sirt1 axis also regulates Nrf2 and NLRP3 expression upon LPS challenge. By targeting miR-212-3p, circVAPA over-expression negatively regulates the expression of Sirt1 and pyroptosis-related factors (Nrf2 and NLRP3), which alleviates the inflammatory damages in sepsis-induced ALI.

Scope, Safety, and Feasibility of Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience

Background

Indications for therapeutic plasma exchange (TPE) in the pediatric intensive care unit (PICU) are expanding. We aimed to study the demographics, clinical indications, and outcomes of patients who have undergone TPE in our PICU.

Materials and methods

This is a retrospective study performed among children aged from 1 month to 16 years of age. Demographics, indications, therapeutic response, serious adverse events (SAE), PICU length of stay (LOS), and death during hospitalization were studied as outcome variables.

Results

Therapeutic plasma exchange was performed in 115 sessions on 24 patients for 12 different indications falling under various American Society for Apheresis (ASFA) categories. Therapeutic plasma exchange was performed on ten, four, and ten children for ASFA category I, II, and III indications, respectively. The most common indications were thrombotic microangiopathy (TMA) (8/24) and acute liver failure (ALF) (6/24). During those 115 sessions, a total of five serious adverse events (SAEs) occurred, accounting for 4.3% of the cases. Minor adverse events occurred in 12 sessions (10.4%). Therapeutic response was good in 17 patients (71%) including 5 patients who underwent standard volume TPE (SV-TPE) for ALF. Median PICU LOS was 9 (range 2-120) days. The mortality rate was 12.5% (3/24).

Conclusion

Therapeutic plasma exchange is effective in various clinical conditions involving various organ systems. It is an excellent therapeutic modality in children with ALF, irrespective of the exchange volume and TMA. However, SAEs do occur in the minority.

How to cite this article

Balasubramanian KK, Venkatachalapathy P, Margabandhu S, Natraj R, Sridaran VK, Lakshmanan C, et al. Scope, Safety, and Feasibility of Therapeutic Plasma Exchange in Pediatric Intensive Care Unit: A Single-center Experience. Indian J Crit Care Med 2023;27(10):766-770.

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

BACKGROUND

The aim of this study is to characterize the clinical indications, outcomes, and complications of therapeutic plasma exchange (TPE) in pediatric intensive care unit.

METHODS

A retrospective study was conducted on critically ill patients who received TPE. A dataset of 672 treatments administered to 102 patients was analyzed.

RESULTS

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%).

CONCLUSION

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.

Therapeutic plasma exchange in the intensive care unit: Rationale, special considerations, and techniques for combined circuits

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique with proven efficacy in a variety of conditions, including in the intensive care setting. It is not uncommon for a critically ill patient to require more than one extracorporeal procedure in addition to TPE. This review focuses on the combination of TPE with other extracorporeal circuits in a critical care setting via a single vascular access (either in-series, parallel, or a hybrid mode) which is often referred to as performing procedures "in tandem." Authors performed literature review via pubmed.gov using search terms: plasma exchange, plasmapheresis, apheresis, tandem circuits, combined circuits, critical care, ICU, CRRT, hemodialysis, and ECMO. Thirty-eight English-language, peer-reviewed papers were appraised that satisfied the content of this review on techniques for combining circuits with plasma exchange, as well as describing the advantages of tandem procedures and potential complications that can arise. Performing these procedures simultaneously can be advantageous in reducing total procedure and staffing time, avoiding placement of additional central lines, reducing overall need for anticoagulation, and limiting multiple blood primes in certain populations. However, the described combined circuits are complex, associated with higher complications, and require a skilled team to understand and mitigate the potential complications associated with these combined procedures.

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

OBJECTIVES

To study the indication for therapeutic plasma exchange (TPE) and related complications in children admitted to the pediatric intensive care unit.

METHODS

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.

RESULTS

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.

CONCLUSIONS

TPE can be safely used for the treatment of critically ill children with indications in an experienced pediatric intensive care unit.

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

INTRODUCTION

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.

METHODS

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.

RESULTS

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.

CONCLUSION

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.

Emodin alleviates sepsis-mediated lung injury via inhibition and reduction of NF-kB and HMGB1 pathways mediated by SIRT1

Inflammation plays an important role during sepsis, and excessive inflammation can result in organ damage, chronic inflammation, fibrosis, and scarring. The study aimed to investigate the specific mechanism of emodin by constructing in vivo and in vitro septic lung injury models via inhibition and reduction of NF-kB and high mobility group box 1 (HMGB1) pathways. A cecal ligation and puncture (CLP) model was built for adult male Sprague-Dawley rats. Concentrations of TNF-α, IL-1β, and IL-6 in bronchoalveolar lavage fluid were determined using commercially available ELISA kits. Hematoxylin and eosin staining was used for the right lung inferior lobes. Myeloperoxidase (MPO) activity of the lung tissue was detected by using the MPO kit. Murine alveolar epithelial cell line (MLE-12) cells were used for flow cytometry and Western blot to analyze the apoptosis rate and protein expression. Emodin significantly decreased CLP-induced cell apoptosis, upregulated expression of sirtuin 1 (SIRT1), and inhibited p-p65/p65 and HMGB1. In lipopolysaccharide (LPS) treated cell model, emodin treatment markedly decreased LPS-induced release of IL-1, IL-6, and tumor necrosis factor (TNF)-α, inhibited LPS-induced cell apoptosis and suppressed protein levels of P-P65/P65 and HMGB1. However, science of SIRT1 reversed the above effects by treatment of emodin. In summarize, this study found that emodin can alleviate sepsis-induced lung injury in vivo and in vitro through regulation of SIRT1.

Safety of Therapeutic Apheresis in Children and Adolescents

BACKGROUND

Therapeutic apheresis (TA) is based on the principles of either removing dissolved pathogenic substances (e.g., antibodies) from the blood plasma or replacing plasma factors. It expands the therapeutic scope for a variety of diseases. Safety analysis in the pediatric field are scant. The aim of this analysis was to analyze specific complications of TA modalities - plasma exchange (PE) and immunoadsorption (IA) - in children and adolescents.

METHODS

Children and adolescents (n = 298) who had received TA from 2008 to 2018 in five pediatric nephrology centers were analyzed retrospectively. In total, 4.004 treatments (2.287 PE and 1.717 IA) were evaluated.

RESULTS

Indications for TA were mainly nephrological and neurological diseases. The three main indications were antibody-mediated graft rejection (13.4%), hemolytic uremic syndrome mainly with neurological involvement (12.8%), and AB0-incompatible transplantation (11.7%). Complications developed in 440 of the 4004 sessions (11%), of which one third were non-specific (nausea, headache). IA was better tolerated than PE. Complications were reported in 9.5% (n = 163) of the IA versus 12.1% (277) of the PE sessions (p < 0.001). When considering different types of complications, significantly more non-specific/non-allergic events (p = 0.02) and allergic reactions occurred in PE sessions (p < 0.001). More complications occurred with PE, when using fresh frozen plasma (16.2%; n = 145) in comparison to human albumin (14.5%; n = 115) (p < 0.001).

CONCLUSIONS

Therapeutic apheresis in childhood and adolescence is a safe treatment procedure. IA showed a lower complication rate than PE. Therefore, IA may be preferably provided if the underlying disease pathomechanisms do not require PE.

Therapeutic plasma exchange in critically ill children: experience of the pediatric intensive care unit of two centers in Chile

INTRODUCTION

Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique used in a wide spectrum of diseases. We aim to review the indications, complications, and outcomes of critically ill children who received TPE and to compare a membrane versus centrifugal method in this cohort.

METHODS

A retrospective observational study in two pediatric intensive care units in Chile during eight years (2011-2019) Results: A total of 36 patients underwent 167 TPE sessions (20 centrifugation and 16 membrane-based). The more frequent indications for TPE were autoimmune neurological diseases in 14 cases, renal diseases (9), and rheumatological disorders (5). 58 % of children received other immunomodulatory therapy. According to ASFA, 45 % of cases were I-II category, 50 % to III, and 5% not classified. Response to treatment was complete in 64 % (23/36) and partial in 33 % (12/36). Complications occurred in 17.4 % of sessions, and the most frequent was transient hypotension during the procedure. Overall survival at discharge from the PICU was 92 %. Patients who received TPE as a single therapy (n = 26) survived 96 %. The clinical outcomes between the two apheresis methods were similar. Survivors had a significantly lower PELOD score on admission (14.5 vs. 6.5, p = 0.004).

CONCLUSIONS

TPE is mainly indicated as a rescue treatment in neurological autoimmune diseases refractory to conventional immunomodulatory treatment. Complications in critically ill children are mild and low. The outcome in children requiring TPE as a single therapy is good, and no differences were observed with centrifugation or membrane method.