Safety and Efficacy of Therapeutic Plasma Exchange in Pediatric Non-Neurological Diseases

Introduction: Therapeutic plasma exchange (TPE) is a recognized treatment in pediatric immune-mediated and toxicological disorders, though evidence remains limited. This study assesses the safety and efficacy of TPE in children with non-neurological diseases treated at a tertiary hospital over 27 years. We focused on non-neurological indications to avoid excessive data heterogeneity. Methods: This retrospective analysis included 97 children (51 nephrological, 46 non-nephrological), who underwent 380 TPE procedures between 1997 and 2023. Indications were categorized according to ASFA 2023 guidelines. Effectiveness was evaluated semi-quantitatively based on clinical and laboratory parameters up to 3 months post-treatment. Safety was assessed by incidence of adverse events (AEs), allergic AEs, and mortality. Results: The most common indication was thrombotic microangiopathy (TMA, 23.7%), followed by toxicological and hematological disorders. TPE was effective (complete or partial improvement) in 67% of patients; full recovery occurred in 25.8%. In the nephrology group, eGFR increased 3.8-fold by 3 months post-TPE. However, immunosuppressive therapy was used 7.7 times more often in this group. The non-nephrological group had a higher mortality (26.1% vs 9.8%), mostly due to multiple organ failure. Intensive Care Unit admission and ASFA III indications significantly decreased survival odds. Fresh-frozen plasma (FFP) - based TPE was associated with significantly more AEs and interventions compared to TPE without FFP. Over time, FFP use declined, with 100% of TPEs in 2023 performed without FFP. Conclusion: TPE is a safe and effective therapy in selected pediatric non-neurological conditions when performed in specialized centers.