Therapeutic Plasma Exchange in Pediatrics for Immunologic Disorders; Tolerated and Safe Process for Pediatric Life-Threatening Conditions

Therapeutic plasma exchange (TPE) is advocated as a treatment to several conditions and applications: solid organs transplantation, kidney and pediatric immune disorder. Apheresis for children diseases has been poorly investigated in mostly small, uncontrolled studies.The purpose was to report our experience, and provide uniform and relatable data, in order to improve disease management.

We included 94 patients, aged under 18 years old, who underwent TPE in the pediatric center of Necker-Enfants-Malades hospital from January 2005 to December 2014. Data were retrospectively collected in an electronic case report form via a web-based data collection system. 78 patients were selected, including 36 females and 42 males with a median age of 9.78 years [range 0.53; 17.93]. They achieved a total number of 731 procedures. Indications were antibody-mediated rejection (n= 33; 42%) or desensitization therapy (n= 5; 6%) for solid organ or hematopoietic transplantations; microangiopathy (n= 17; 22%); renal diseases (n= 6; 8%) and pediatric inflammatory diseases (n= 16; 21%); or hyperviscosity syndrome (n = 1; 1%). Each patient had an average of 6 procedures for the first session [range 1; 19] with a median volume of 1834 ml [range 500; 5000 ml] corresponding to a median total plasma volume (TPV) equivalent of 1.39 l/m²[range: 0.58; 2.1 l/m²].Within 15 days in the beginning of the sessions, 72 patients (92%) presented a total of 311 Advers Events(AEs) potentially related to TPE. 94 AEs were not related to TPE sessions.There was a median of 5 AEs/patients [range: 0; 24]. There was no significant increased risk of AEs due to diseases, intensity of care, venous access, plasma substitute and body weight. Few of AEs were potentially life-threatening and concerned pediatric critical care situations. Allergic reactions represented only 20 AEs for 14 patients (grade I n= 18; grade II n= 1; grade III n= 1). At the endpoint of M12, 15 (19%) patients had died, no death had been related to the TPE process. Nine patients performed a second or a third session of procedures and 10 (13%) patients had severe persistent clinical disease.

We describe one of the largest retrospective pediatric cohort to date, to the last international recommendations. Our experience on children TPE feasibility concern specific life‐threatening conditions and otherwise potential refractory diseases. TPE were generally well tolerated and the majority of the adverse effects were anticipated and could therefore be avoided. Based on this work, and in order to progress in the understanding of the TPE field, it would be interesting to increase pediatric data with prospective and multicenter cohort.