The establishment of in‐house neurology driven therapeutic plasma exchange infrastructure in a resource‐limited public hospital in Malaysia: Adopting and integrating evidenced‐based health care technology through time

Abstract

There has been an increase in the use of therapeutic plasma exchange (TPE) in immune‐mediated neurological disorders in recent years. However, accessibility and availability of TPE remains low and costly, especially for a country with limited healthcare funding like Malaysia. With expanding clinical indications in neurological disorders, and increasingly expensive conventional immunomodulatory treatment such as intravenous immunoglobulin and monoclonal antibodies, TPE remains an effective part of first or second‐line treatment. In this article, we detailed the historical aspects of the use of TPE in neurological disorders in Malaysia over the last four decades and discussed the challenges behind the establishment of the first in‐house neurology‐driven TPE service in the country. Local TPE database from a national neurology centre in Kuala Lumpur over the past 20 years was analyzed. We observed a remarkable three folds increase in the use of TPE at our center over the past 10 years (total 131 TPE treatments) compared to a decade prior, with expanding clinical indications predominantly for central nervous system demyelinating disorders. Besides using membrane filtration method, centrifugal technique was adopted, providing new opportunities for other clinical beneficiaries such as a neurologist driven “in‐house TPE unit”. However, there were real world challenges, especially having to provide services with limited funding, human resources, and space. In addition, much has to be done to improve accessibility, availability, and sustainability of TPE services at our center and nationwide. Nevertheless, even with limited resources and support, it is possible with concerted efforts to work within the confines of these limitations to establish a safe, successful, and sustainable TPE service.

Therapeutic plasma exchange (TPE) for semi-critical neurology presentations in a non-acute neurology set-up: clinical practice and challenges

“…We converted a non-acute single bedded air-conditioned room into a TPE suit, equipped with a centrifugal TPE machine and vital sign monitoring equipment. Full TPE unit set-up and protocol are available on our previous publication elsewhere 9. Patients requiring TPE therapy were assessed and stratified by treating designated TPE neurologists and the TPE team.…”

“…In addition, neurology set-up in our institution lacked critical care beds, and there was no mobile TPE support available outside critical care set-up. Thus, being cognizant of these limitations, our department established an in-house non-acute TPE unit using single centrifugation device in 2014, supported by a local TPE team comprised of trained neurology nurses and neurologists 9. This TPE unit was designed to support TPE procedures with basic vital signs monitoring equipment on haemodynamically stable neurology patients without respiratory failure.…”

Sequential intermittent therapeutic plasma exchange: A possible induction and maintenance therapy in the management of adult patients with neuromyelitis optica spectrum disorder

“…Therefore, alternatives in NMOSD maintenance therapy are urgently needed, especially for patients who warrant early and urgent escalation in therapy. Maintenance TPE, advocated by Miyamoto et al 42 and Khatri et al, 43 particularly SITPE in this study, represents a more affordable and accessible alternative in our center 46 . The frequency and intervals between each cycle of TPE were set after considering multiple factors as explained in Table 9.…”

“…Prior to 2015, TPE for KLGH neurology patients was done through membrane ultrafiltration method utilizing renal replacement machines in nephrology department 46 . From 2015 onward, TPE for our neurology patients was done through centrifugal method utilizing Spectra Optia Apheresis System (Terumo BCT) in the specified TPE suite in KLGH neurology ward 46 . Such change allowed for improved access and increased frequency of TPE use in our patients.…”

“…One ampoule of intravenous calcium gluconate diluted into one pint of normal saline was infused during each exchange session. Vital signs monitoring for every 15 minutes during the procedures, in addition to the continuous cardiac monitoring throughout the procedures, were enforced as per protocol 46 . All prior immunosuppressants were continued with adjusted timing as the medications were administered after the exchange session on the particular day.…”