Exchange Transfusion for Severe Malaria

Abstract

Despite definitive data from controlled trials, we suggest that ET should be considered in severe malaria cases with very high parasitemia and severity criteria or worsening clinical condition despite adequate chemotherapy.

Considerations on the use of adjunct red blood cell exchange transfusion in the treatment of severe Plasmodium falciparum malaria

“…First, due to the small sample size 19,27 and the retrospective nature of the studies, it was challenging to adequately match the treatment groups. Second, there was variability within and between studies as to when ET was used, how standardized the ET protocols were with respect to the number of RBC volumes exchanged (considering the total blood volume and Hct levels of the patients and the replacement fluid), 12 and the methods used (automated vs. manual) 12,19‐22,27‐29 . Third, the studies often suffered from treatment bias, wherein sicker patients with higher parasitemia levels and more WHO criteria tended to receive adjunct ET versus antimalarials alone 20,26,28 .…”

“…However, the effect of ET on TNF-a levels is variable and unpredictable and does not correlate clinically (Table 3). 18 Despite the pathophysiologic evidence of its utility and several cases demonstrating clinical improvement with adjunct ET when appropriate antimalarial therapy alone had failed, [19][20][21][22] there is debate if and when ET should be recommended as an adjunct therapy for severe P. falciparum malaria. 7,23 For example, critics contend that adjunct ET is not necessary since improved antimalarial medications, such as artemisinin derivatives, can reduce mortality in severe malaria (Table 3).…”

“…12,[19][20][21][22][27][28][29] For several reasons, these studies could not definitively conclude that ET improved outcome, although a lower mortality was clearly seen in some studies. 19,20 First, due to the small sample size 19,27 and the retrospective nature of the studies, it was challenging to adequately match the treatment groups. Second, there was variability within and between studies as to when ET was used, how standardized the ET protocols were with respect to the number of RBC volumes exchanged (considering the total blood volume and Hct levels of the patients and the replacement fluid), 12 and the methods used (automated vs. manual).…”

“…Second, there was variability within and between studies as to when ET was used, how standardized the ET protocols were with respect to the number of RBC volumes exchanged (considering the total blood volume and Hct levels of the patients and the replacement fluid), 12 and the methods used (automated vs. manual). 12,[19][20][21][22][27][28][29] Third, the studies often suffered from treatment bias, wherein sicker patients with higher parasitemia levels and more WHO criteria tended to receive adjunct ET versus antimalarials alone. 20,26,28 In aggregate, some studies favored adjunct ET [19][20][21][22] while others favored antimalarials alone.…”

Therapeutic Cytapheresis

“…The most severe infections are due to P. falciparum, which can infect circulating red cells of any age and therefore causes higher levels of parasitemia than other species that can infect only reticulocytes. [197][198][199][200][201][202][203] The only randomized study unfortunately had insufficient power to be meaningful. Parasitized red cells swell and develop increased adherence to vascular endothelium; they may therefore contribute directly to organ failure via microvascular obstruction and ischemia.…”