Therapeutic plasma exchange as a nephrological procedure: A single-center experience

Abstract

In the United States, therapeutic plasma exchange (TPE) is both performed and requested by a wide range of services, often on an empiric basis (before a diagnosis is established). Whether empiric therapy is beneficial has not been established. Patients were identified from an electronic procedure log that included those patients who received plasmapheresis at Walter Reed Army Medical Center from 1996 to 2003. The clinical indications, referring service, and outcomes (including deaths) that occurred were tabulated. Between March 1997 and August 2003, 568 TPE treatments were performed in 54 patients. The majority of the diagnoses were either neurologic (48%) or hematologic (37%). Thirty-three patients (61%) received TPE for a Category I indication. Twelve cases were performed empirically (without an established diagnosis) at the request of the referring service, most (7) performed for presumed thrombotic thrombocytopenic purpura (TTP). Almost 80% of patients required central venous catheters for treatment. Twelve patients (22%) experienced a major complication including death, and six patients (11%) died. Of the patients who died, 5 (83%) were treated empirically versus one death (17%) among patients not treated empirically, P < 0.001 by Chi Square. Only one of the seven patients treated empirically for TTP died, however. In logistic regression analysis, empiric treatment was the only factor independently associated with death, adjusted odds ratio, 34.2, 95% CI, 3.4, 334.8, P = 0.003. The most common indication for TPE was neurological disease, which also accounted for the highest proportion of complications. With the exception of presumed TTP, performing TPE in the absence of a confirmed diagnosis was not beneficial.

Complications of therapeutic plasma exchange: A prospective study of 1,727 procedures

“…There was a severe complication rate of 22%, and a mortality rate of 11%. The underlying diagnosis may have had an effect on morbidity and mortality; however, 39% of patients had a diagnosis for which TPE was not standard and acceptable treatment [17]. In a study limited to TPE treatment for TTP (a disease with a very high mortality rate if untreated), there were 73 major complications in 206 consecutively treated patients, and 5 patients (2.4% of the total) died of complications that may have been related to TPE [18].…”

Introduction and overview of therapeutic apheresis

“…Most large registries report a relatively low incidence (5 to 12%) of complications associated with TA procedures, with the exception of two, relatively small, single center series [21][22][23][24][25][26][27][28][29][30] (Figure 2). Most adverse events are categorized as Grade 1: Mild (no intervention required, 1.5%) or Grade II: Moderate (intervention required but treatment completed, 2.5%) (Table III).…”

“…Hemolytic anemia has been reported in cases, in which albumin was improperly diluted with sterile water, instead of saline. Hypotension has been reported when albumin is rendered hypo-oncotic (3.3%) when diluted with saline, and may explain the high incidence of total adverse events in one of the single-center series [30]. Both can be avoided by using 5% albumin.…”

Effects of therapeutic plasma exchange on anticoagulants in patients receiving therapeutic anticoagulation: a systematic review

“…The coagulation profile is further modified by TPE‐related factors such as procedure frequency and duration, procedural plasma volume, and replacement fluid . Despite TPE's effects on coagulation, studies have consistently demonstrated that TPE‐associated bleeding risk is low …”