Intensive plasma exchange therapy with fresh-frozen plasma as the replacement fluid was used to manage ten patients, five with acute and five with chronic immune thrombocytopenic purpura (ITP). Therapy was started because of severe hemorrhage (1 case), failure to respond to steroid therapy (6 cases), or steroid dependence (3 cases). After a median of four exchanges over 6 days (median total volume removed, 11.7 liters), initial responses, defined as a platelet count greater than 100,000 per microliter at the end of the exchange series, were observed in 80 percent of the patients treated. Two adolescents, ages 16 and 17 years, with chronic ITP failed to respond to plasma exchange therapy and subsequently responded to splenectomy. Prolonged remissions of 9 months and greater than 2 years were observed in two patients with acute ITP; in patients with chronic ITP, no prolonged remissions occurred. Neither pre-exchange levels of platelet-associated immunoglobulin G (PAIgG) nor circulating immune complexes predicted the response to plasma exchange, although serially determined PAIgG levels correlated with the severity of ITP and response, or lack of response, to plasma exchange. We conclude that intensive plasma exchange merits further study in patients with acute ITP unresponsive to steroid therapy to determine if the need for splenectomy is reduced. In selected patients with chronic ITP, exchange therapy may provide short-term adjunctive benefit.

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INTRODUCTION: Hospitalizations and readmissions in cirrhosis patients pose a significant economic burden to the health care system. Readmission rates are high for patients with decompensated cirrhosis; 30-day rates are as high as 30–40%. We aimed to identify the frequency and predictors of 30-day readmission rates in patients with decompensated cirrhosis admitted to two academic hospitals. METHODS: Using research informatics and validated ICD-10 codes, we identified cirrhosis patients admitted to the University of Miami Hospital (UMH) from 10/1/2017 to 10/1/2018. (Figure 1) After retrospective chart review, we excluded patients without cirrhosis or qualifying admissions. As patients from UMH are often admitted to Jackson Memorial Hospital, those records were also reviewed for admissions during the study period. Univariate analysis was conducted to describe demographics and disease-specific characteristics and identify variables associated with 30-day readmission rates. RESULTS: In our sample, 105 patients met inclusion criteria with 208 eligible admissions. Median age was 63 and 67.6% were male. During the index admission, the primary admission diagnosis was ascites in 36 patients, upper GI bleed in 15, and hepatic encephalopathy (HE) in 13. For 41 patients, the reason for admission is listed as other. (Table 1) The average length of stay (LOS) during the index admission was 7 days (±7.5). The readmission rate was 52.7%; the 30-day readmission rate was 25.8%. Twelve patients died during the index admission. Fifty patients had at least one readmission; range (1–8). A higher proportion of ascites patients were readmitted within 30 days, 35.3%, compared to 23.1% in those with GI bleed, 27.7% of HE patients and 17.1% of those with other diagnoses. Those with ascites also had the longest LOS, mean 7.67 days (±10). Noting the above results, we focused on the 47 patients with a primary or secondary diagnosis of ascites. Average time to paracentesis was 2 days. Only one patient with ascites (2.1%) was scheduled for paracentesis prior to discharge; 38 (81.8%) were discharged on diuretics. Fourteen patients (29.8%) were readmitted with a primary diagnosis of ascites (Table 2). CONCLUSION: Patients with decompensated cirrhosis are frequently readmitted in less than 30 days; ascites contributed to increased LOS and readmission rates. Additional study is needed to determine if Implementation of core quality measures decreases readmission rates and/or improves quality of life.