Evolution of Therapeutic Plasma Exchange Use and Outcomes in Children Across American Society for Apheresis...

To characterize pediatric TPE utilization, safety, treatment response, and mortality across American Society for Apheresis (ASFA) categories and over time. Retrospective single-center cohort study of patients aged 0-25 years who underwent therapeutic plasma exchange (TPE) between 2011 and 2024. Primary outcomes included TPE utilization, temporal trends, and procedure-related complications. Secondary outcomes included treatment response according to indication-specific criteria and 28-day mortality overall and by ASFA category. A total of 416 TPE courses were performed in 384 patients (median age 10 years, IQR 2-16). TPE utilization increased over time (Spearman ρ = 0.88; p < 0.001), with ASFA Category II and III indications accounting for approximately 80% of courses throughout the study period. Procedure-related complications occurred in 76 of 3640 procedures (2%) and were more frequent in Category III than Categories I and II (3% vs. 1% and 2%; p < 0.001). Rates of treatment goal achievement were similar across ASFA categories (84.0% in Category I, 84.8% in Category II, and 75.4% in Category III; p = 0.11). Overall, 28-day mortality was 13%, including 4% in Category I, 6% in Category II, and 24% in Category III (p < 0.001). In Category III indications, treatment during 2018-2024 was associated with lower adjusted odds of 28-day mortality compared with 2011-2017 (aOR 0.33; 95% CI 0.13-0.83; p = 0.02). TPE use in our single center has expanded substantially, particularly for lower-evidence indications. Despite this shift, TPE remains safe and is associated with similar response rates across categories. Improved adjusted survival over time was observed in Category III.