The role of red blood cell exchange for severe imported malaria in the artesunate era: a retrospective cohort study in a referral centre

Abstract

BackgroundIntravenous artesunate has replaced quinine as the first-line therapy for severe imported malaria, given its anti-malarial superiority shown in clinical trials conducted in endemic countries. Evidence for red blood cell (RBC) exchange in patients with severe malaria treated with artesunate is lacking. This retrospective cohort study describes the experience at Hospital Clinic of Barcelona with the use of artesunate for severe malaria and the joint use of RBC exchange in selected cases.MethodsPatients treated for severe malaria at Hospital Clinic of Barcelona between August 2013 and January 2015 were included in this retrospective study. Severe malaria was defined according to WHO criteria. Data were extracted from electronic hospital records. A log-linear mixed model approach was used to estimate parasite clearance times.ResultsWithin the study period, 42 patients were diagnosed of malaria at this centre, of which 38 had Plasmodium falciparum (90.5 %). Sixteen patients (42 %) had severe malaria cases and were treated with intravenous artesunate. Four patients underwent RBC exchange within a period of 15 h after the first dose of artesunate (range 9–21 h). The procedure lasted a median of 2 h (IQR 1.8–2 h), using a median of 12 (IQR 11–14) units of packed RBCs to replace a median of 3794 ml (IQR 2977–4343). The technique was well-tolerated without haemodynamic complications. There were no deaths. The regression model showed an estimated time to 95 % decay of 21.6 h (95 % CI 17.3–28.8). When assessing effect modification by RBC exchange, there was no difference in the parasite elimination rate (p = 0.286).Discussion and conclusionIn this study RBC exchange failed to show benefits in terms of parasite clearance probably due to the small number of patients analysed. The evidence for exchange transfusion remains limited.

Red blood cell exchange in treatment of severe cerebral P. falciparum malaria: A case report

“…Published data regarding reduction in parasitemia using artesunate have suggested a mean parasite clearance time of 33.2 hours to reach 99% reduction in parasite load is a reasonable goal. 10 However, it should be noted that the average parasitemia reported (12.5%) was significantly lower than our patient's (53.33%). Hence, while several studies have recently cast doubt regarding the usefulness of RBC exchange transfusion treatment of severe malaria in comparison to artesunate based therapies alone, 10,11 this case report indicates exchange transfusion may be helpful in treatment of P. falciparum malaria with extremely high parasite loads.…”

“…This case report illustrates the use of RBC exchange transfusion as an adjunctive treatment for severe P. falciparum malaria complicated by cerebral involvement and hyperparasitemia, with dramatic reduction in parasitemia and marked improvement in clinical markers within 24 hours of treatment. Published data regarding reduction in parasitemia using artesunate have suggested a mean parasite clearance time of 33.2 hours to reach 99% reduction in parasite load is a reasonable goal . However, it should be noted that the average parasitemia reported (12.5%) was significantly lower than our patient's (53.33%).…”

“…Red blood cells exchange transfusions have shown to be safe and effective in several case reports and small clinical trials . Unfortunately, no large scale randomized clinical trials comparing RBC exchange transfusion as an adjunct therapy for malaria have been conducted to date, and this type of treatment as an adjunct therapy for severe P. falciparum remains controversial …”

“…[6][7][8] Unfortunately, no large scale randomized clinical trials comparing RBC exchange transfusion as an adjunct therapy for malaria have been conducted to date, and this type of treatment as an adjunct therapy for severe P. falciparum remains controversial. [9][10][11] All work for this article was performed at Loma Linda University.…”

The use of cytapheresis in the treatment of infectious diseases

“…Indeed, it is possible that continued improvements in pharmacologic and supportive therapies may obviate the need for adjunctive malaria treatments entirely. A recent study has shown no discernable difference in parasite elimination rates with AET and intravenous artesunate compared with intravenous artesunate alone . Conversely, the continued evolution and spread of drug resistant Plasmodium strains may, in time, necessitate further investigations into the role of mechanical parasite removal in the treatment of severe malaria.…”