Background: Therapeutic plasma exchange (TPE) plays a critical role in pediatric intensive care, providing lifesaving support for a wide range of renal and hepatic conditions. This study aims to share real-world experience with TPE in a pediatric transplant care setting, recognizing both its therapeutic benefits and the potential complications that may arise depending on the child’s diagnosis and clinical context.
Materials and Methods: This retrospective observational study included 88 pediatric patients who underwent a total of 702 therapeutic plasma exchange (TPE) sessions in the Pediatric Intensive Care Unit (PICU) of Başkent University Hospital, Ankara, between December 2018 and December 2023. The effectiveness of TPE was evaluated based on clinical response and laboratory improvement, in accordance with the therapeutic goals outlined in the 2019 guidelines of the American Society for Apheresis (ASFA). These outcome measures correspond to the established indications for ASFA Category I and II, while in Category III and IV cases, clinical decisions were individualized based on multidisciplinary judgment and patient-specific factors. Patient demographics, clinical characteristics, laboratory findings, TPE indications, and related complications were retrospectively collected and analyzed using SPSS version 25.
Results: The median age of patients was 7.5 years (range: 0–18), with 46 (52.3%) males and 42 (47.7%) females. Each child underwent an average of 7.98 TPE sessions (range: 1–32), with fresh frozen plasma used in 79 patients (89.8%) and albumin in 21 patients (23.9%). According to the 2019 guidelines of the ASFA, the indications were classified into four categories: Category II in 43 patients (48.9%), Category III in 38 patients (43.2%), Category IV in 6 patients (6.8%), and Category I in 1 patient (1.1%). Renal-related indications were identified in 49 patients (55.7%), including atypical hemolytic uremic syndrome, FSGS and post-transplant scenarios (antibody mediated rejections or BKvirus infection etc). Liver-related conditions were treated in 38 patients (43.2%), including acute/chronic liver failure and post-transplant dysfunction. Adverse events were relatively uncommon: hypotension occurred in 12 patients (13.6%), fever in 6 (6.8%), allergic reactions in 4 (4.5%), and thrombus formation in 3 (3.4%). In terms of outcomes, 68 patients (77.3%) showed partial improvement, 19 (21.6%) demonstrated full clinical improvement, and only one child (1.1%) showed no response.
Conclusion: Therapeutic plasma exchange appears to be a generally safe and effective intervention in critically ill children. However, potential complications—though infrequent—such as hypotension, fever, and allergic reactions, highlight the importance of close clinical monitoring. Tailoring TPE protocols based on the patient's underlying condition can help mitigate risks and optimize outcomes in the pediatric intensive care setting.