Efficacy of therapeutic plasma exchange in severe COVID‐19 disease: A meta‐analysis

Abstract

Background and Objectives Therapeutic plasma exchange (TPE) has been used in severe COVID‐19 disease to eliminate the cytokine storm. This meta‐analysis aims to assess the effectiveness of TPE in reducing mortality in severe COVID‐19 disease compared to standard treatment. Materials and Methods A comprehensive literature search was performed in PubMed, the Cochrane database and the International Clinical Trial Registry Platform (ICTRP). The random‐effect model was used to calculate the risk ratio and standardized mean difference (SMD) as pooled effect size for the difference in mortality and length of the intensive care unit (ICU) stay. The risk of bias and publication bias were assessed in R version 4.1.0. The certainty of the evidence was calculated using the GradePro tool. Results The database identified 382 participants from six studies, including one randomized control trial. Egger's test did not detect any publication bias (p = 0.178). The random model analysis for mortality evaluated a risk ratio of 0.38 (95% CI: 0.28–0.52) with a significant reduction in the TPE group. The certainty of the evidence was moderate, with a risk ratio of 0.34 (95% CI: 0.24–0.49). Length of ICU stays between TPE versus standard care showed an SMD of 0.08 (95% CI: −0.38, 0.55) and was not significant. Conclusion The length of ICU stay in the TPE group was not different from standard care. However, this meta‐analysis revealed a significant benefit of TPE in reducing mortality in severe COVID‐19 disease compared to standard treatment.

Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis

“…Our meta-analysis demonstrates a significant reduction in short-term mortality when adjunct TPE is added to the standard therapy of critically ill patients with sepsis-induced organ dysfunction. These findings, combined with those of three recently published meta-analyses [66][67][68] add to the current body of evidence reflected in the 2023 ASFA guidelines which allow TPE to be considered on a case to case basis for sepsis with multiple organ dysfunction (category III, 2A recommendation) [41]. In addition, a large propensity-score matched analysis [69] demonstrating reduced 28-day and 1-year mortality associated with TPE in septic patients with MODS was published in November 2023, but was not included in the current analysis so as to avoid deviations from the predefined protocol and to avoid bias.…”

“…However, prospective, randomized data are scarce and inconclusive [35,36]. Previous attempts to clarify have resulted in five meta-analyses [37][38][39][40][41] with the authors of these analyses concluding there is insufficient evidence to recommend TPE as routine therapy for patients with sepsis-induced organ dysfunction. Currently, the American Society for Apheresis (ASFA) 2023 guidelines [42] provide a category III, 2A recommendation for the use of TPE for patients with sepsis-induced organ dysfunction, allowing for individualized use on a case-by-case basis.…”

Plasmapheresis as therapeutic option in a 16-year-old with EVALI

“…14,20 The results of a meta-analysis indicated that TPE can reduce mortality in severe COVID-19 but with no change in ICU length of stay. 21 TPE has also been successfully used for the treatment of inflammatory syndromes after SARS-CoV-2-infections in adults and children. 14,22 As a result, many authors consider TPE to be the last therapeutic resort when standard (immunomodulatory) therapy fails.…”

“…Therefore, TPE is one of the therapies suggested for PIMS or severe SARS-CoV-2 infections when other therapeutic options fail 14,20 . The results of a meta-analysis indicated that TPE can reduce mortality in severe COVID-19 but with no change in ICU length of stay 21 . TPE has also been successfully used for the treatment of inflammatory syndromes after SARS-CoV-2-infections in adults and children 14,22 .…”

The efficacy of therapeutic plasma exchange in COVID-19 patients on endothelial tightness in vitro is hindered by platelet activation

“…The main advantage of this approach is that it triggers a significant, albeit transient, decrease in thrombo-inflammatory blood molecules without inducing immunosuppression. If implemented in the early stages, this strategy could improve thrombo-inflammation in patients with severe COVID-19 by replacing inflammatory molecules and accumulated activated haemostatic factors with healthy plasma components, thereby delaying or preventing ICU admission ( 21 ). The ongoing Therapeutic Plasma Exchange to Alleviate the Hyperinflammatory Condition During Severe Covid-19 Infections (CovidEP) trial (ClinicalTrials Identifier: NCT04751643) addresses this issue and assesses the requirement for intubation and invasive ventilation in patients undergoing 3 TPE sessions in 3 consecutive days compared to patients receiving standard treatments including assisted ventilation, oxygen supplementation, non-invasive ventilation, vasopressive support and corticosteroids, etc.…”