Therapeutic Plasma Exchange in Children With Thrombocytopenia-Associated Multiple Organ Failure: The Thrombocytopenia-Associated Multiple Organ Failure Network Prospective Experience

• Type of Material: Article
• Authors: James Fortenberry, Emory University; Nguyen Trung, Texas Children’s Hospital; Jocelyn Grunwell, Emory University; Rajesh K Aneja, University of Pittsburgh; Derek Wheeler, University of Cincinnati; Mark Hall, Ohio State University; Geoffrey Fleming, Vanderbilt University; Rod Tarrago, Children’s Hospital and Clinics of Minnesota; Sandra Buttram, Phoenix Children’s Hospital; Heidi Dalton, Children’s National Medical Center; Yong Han, University of Michigan; Kirk Easley, Emory University; Andrea Knezevic, Emory University; Tian Dai, Emory University; Matthew Paden, Emory University; Joseph A Carcillo, University of Pittsburgh
• Language: English
• Date: 2019-03-01
• Publisher: LIPPINCOTT WILLIAMS & WILKINS
• Publication Version: Author Accepted Manuscript (After Peer Review)
• Copyright Statement: © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.
• License: Creative Commons Attribution-NonCommercial 4.0 International
• Final Published Version (URL): http://dx.doi.org/10.1097/CCM.0000000000003559
• Title of Journal or Parent Work: CRITICAL CARE MEDICINE
• Volume: 47
• Issue: 3
• Start Page: E173
• End Page: E181
• Grant/Funding Information: Supported, in part, by a grant from The Children’s Miracle Network. Dr. Grunwell is supported by the Atlanta Pediatric Scholars Program grant K12HD072245. Dr. Carcillo received funding through the National Institutes of Health GM108618
• Keywords: Critical Care Medicine; Science & Technology; SEVERE SEPSIS; VON-WILLEBRAND-FACTOR; EPIDEMIOLOGY; SEPTIC SHOCK; PLASMAPHERESIS; DYSFUNCTION SYNDROME; PATHOPHYSIOLOGY; ADAMTS13; sepsis; Life Sciences & Biomedicine; multiple organ failure; thrombotic microangiopathy; thrombocytopenia-associated multiple organ failure; PURPURA; therapeutic plasma exchange; thrombocytopenia; General & Internal Medicine; FACTOR-CLEAVING PROTEASE

Abstract

Objective: The objective was to compare the resolution of organ dysfunction, 28-day mortality, and biochemical markers in children with thrombocytopenia-associated multiple organ failure who received therapeutic plasma exchange versus no therapeutic plasma exchange. Design: Observational longitudinal cohort study. Setting: Nine U.S. PICUs. Patients: Eighty-one children with sepsis-induced thrombocytopenia-associated multiple organ failure. Interventions: Therapeutic plasma exchange. Measurements and Main Results: Adjusted relative risk for 28-day mortality was modeled using standard multivariate regression with propensity score weighting to reduce covariate confounding. Change from baseline Pediatric Logistic Organ Dysfunction scores between therapeutic plasma exchange and no therapeutic plasma exchange differed in temporal pattern during the first week (p = 0.009). By day 4, mean Pediatric Logistic Organ Dysfunction score declined by 7.9 points (95% CI,-10.8 to-5.1) in the therapeutic plasma exchange-treated group compared with no change with no therapeutic plasma exchange. Use of therapeutic plasma exchange was associated with reduced 28-day mortality by multivariate analysis (adjusted relative risk, 0.45; 95% CI, 0.23-0.90; p = 0.02) and by propensity score weighting (adjusted relative risk, 0.46; 95% CI, 0.22-0.97; p = 0.04). Conclusions: Therapeutic plasma exchange use in thrombocytopenia-associated multiple organ failure was associated with a decrease in organ dysfunction. After accounting for several risk factors, 28-day all-cause mortality was lower in children treated with therapeutic plasma exchange compared with those receiving no therapeutic plasma exchange. A multicenter randomized clinical trial is necessary to determine a causal relationship.