Utility and safety of plasma exchange in paediatric neuroimmune disorders

Abstract

Aim Our aim was to ascertain the indications, side effects, and outcomes in children receiving therapeutic plasma exchange (TPE) for neurological disorders. Method Medical records were retrospectively reviewed for 58 consecutive children (age ≤16y) undergoing 67 courses of TPE across four tertiary centres. Patient characteristics, treatment schedules, complications, and outcomes were analysed. Results Median age at initiation of TPE was 9 years (range 1–15y). Indications included peripheral nervous system (PNS; n=18) and central nervous system (CNS; n=40) disorders. Courses comprised a median six exchanges (range 2–179) over 8 days (range 3–466). Forty‐two out of 58 (73%) children were severely disabled (bedridden) at initiation and 24 out of 58 (41%) were admitted to intensive care units. Treating clinicians’ impression of response was positive in 16 out of 18 of those with PNS disorders versus 22 out of 40 with CNS disorders (p=0.016). Improvements in disability (modified Rankin Scale) occurred in 13 out of 58 (22%) children by completion of TPE (p=0.003). Complications occurred in 40 out of 67 (60%) courses, of which 16 out of 67 (24%) were line related. Potentially life‐threatening complications occurred in 2 out of 67 (3%) courses. Interpretation This cohort study provides safety and efficacy information for clinicians and families and a basis for future prospective studies. What this paper adds Disability scores for severe neuroimmune disorders remained stable or improved during therapeutic plasma exchange treatment. Complications occurred frequently but were typically mild and correctable.

Therapeutic plasma exchange in paediatric neuroimmunology: some evidence but more is needed

“…There remain major uncertainties on several aspects of TPE efficacy and use in paediatric neurology, such as the best treatment combination with other agents. In the Eyre et al . cohort, neither mRS improvement nor clinician's impression of response was influenced using intravenous corticosteroids before TPE, although this may be due to the heterogeneity of the treated conditions and the coarse neurological score used (mRS).…”

“…TPE is relatively invasive, often requiring central venous catheter and intensive care setting. Complications occurred in 60% of TPE courses (66% of children) in the Eyre et al . cohort, including 3% life‐threatening (septic shock secondary to presumed line infection) and 27% severe/medically significant but not immediately life‐threatening complications (anaemia, hypotension, thrombocytopaenia, bradycardia, hyperkalaemia, suspected line infection, anaesthetic complications).…”

“…Quality evidence on therapeutic plasma exchange (TPE) efficacy and safety in paediatric neuroimmunology is limited. Eyre et al . have helped close this gap in the literature with original data on a large neuroimmunology cohort of 58 children undergoing TPE in four UK centres, which follows‐up an extremely useful critical literature review on TPE in paediatric neurology …”

“…TPE is often used as a rescue therapy in severely disabled patients . In the Eyre et al . cohort, 66% of clinicians reported an immediate benefit with TPE, more manifest in peripheral nervous system (PNS) rather than central nervous system (CNS) disorders, despite similar modified Rankin Scale (mRS) change at TPE completion.…”

“…Furthermore, given the non‐controlled design, the Eyre et al . study cannot fill the knowledge gap on TPE efficacy compared with other treatments.…”