Department of Pediatric Hematology/Oncology/BMT, Children's Mercy Hospital, Kansas City, Missouri, USA.
Children's Mercy Research Institute, Children's Mercy Hospital, Kansas City, Missouri, USA.
J Clin Apher. 2022 Aug;37(4):367-375. doi: 10.1002/jca.21983. Epub 2022 Apr 11.
Therapeutic plasma exchange (TPE) has well-documented applications in the adult population, outlined by the American Society for Apheresis (ASFA) 2019 guidelines. Limited data exist regarding the use of TPE in critically ill pediatric patients; however, these reports rarely include patients with oncological diseases.
We highlight the use of TPE in the acute management of seven pediatric patients with leukemia treated at Children's Mercy Hospital ICU from 2015 to 2020, including TPE specifications, baseline and interval laboratory evaluation, and outcome measures. Analysis compared those who did (n = 4) and did not (n = 3) survive 30 days post-TPE.
Multiorgan failure (MOF) prompted the initiation of TPE in 85.7% of patients, 57.1% of whom were also diagnosed with hemophagocytic lymphohistiocytosis (HLH). Baseline laboratory evaluations prior to initiation of TPE were similar between the two groups. With subsequent TPE treatments, C-reactive protein (CRP) and lactic acid decreased. CRP and lactic acid following the last TPE treatment were significantly higher for those deceased 30 days post-TPE (P = .023 and .031, respectively). No TPE-associated adverse events necessitated discontinuation of TPE treatment. Several surviving patients required chemotherapy dose reductions or alterations.
Our cohort demonstrated MOF and HLH consistently as indications for TPE, currently ASFA category III indications (optimal role of apheresis is not yet established). Recognition of this treatment modality earlier in the clinical course for critically ill oncological patients may lead to the development of formal protocols that may result in earlier initiation of TPE and improved outcomes.
治疗性血浆置换（TPE）在成人中的应用已有充分的文献记载，美国血浆分离治疗协会（ASFA）2019 年的指南对此进行了概述。关于 TPE 在危重症儿科患者中的应用，仅有有限的数据；然而，这些报告很少包括患有肿瘤疾病的患者。
我们强调了 TPE 在 2015 年至 2020 年期间在儿童慈善医院 ICU 接受治疗的七名白血病儿科患者的急性治疗中的应用，包括 TPE 规范、基线和间隔实验室评估以及结果测量。分析比较了那些接受 TPE 治疗后 30 天内存活（n=4）和未存活（n=3）的患者。
多器官功能衰竭（MOF）促使 85.7%的患者开始进行 TPE，其中 57.1%的患者还被诊断为噬血细胞性淋巴组织细胞增多症（HLH）。开始 TPE 治疗前，两组的基线实验室评估相似。随着后续 TPE 治疗，C 反应蛋白（CRP）和乳酸降低。在 TPE 治疗后，那些 30 天后死亡的患者的 CRP 和乳酸水平明显更高（P=0.023 和 0.031）。没有 TPE 相关的不良事件需要停止 TPE 治疗。一些存活的患者需要减少或改变化疗剂量。
我们的队列一致地表现出 MOF 和 HLH 作为 TPE 的指征，目前 ASFA 类别 III 指征（尚未确定血浆分离术的最佳作用）。在危重症肿瘤患者的临床病程中更早地认识到这种治疗方式，可能会制定出正式的方案，从而更早地开始 TPE 治疗并改善结局。
