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Meta-Analysis
. 2017 Feb 27;2(2):CD001798.
doi: 10.1002/14651858.CD001798.pub3.

Plasma exchange for Guillain-Barré syndrome

Sylvie Chevret  1 , Richard Ac Hughes  2 , Djillali Annane  3
Affiliations
Meta-Analysis

Plasma exchange for Guillain-Barré syndrome

Sylvie Chevret et al. Cochrane Database Syst Rev. .

Abstract

Background: Guillain-Barré syndrome (GBS) is an acute paralysing disease caused by peripheral nerve inflammation. This is an update of a review first published in 2001 and last updated in 2012.

Objectives: To assess the effects of plasma exchange for treating GBS.

Search methods: On 18 January 2016 we searched the Cochrane Neuromuscular Specialised Register, CENTRAL, MEDLINE, and Embase. We also searched clinical trials registries.

Selection criteria: Randomised and quasi-randomised trials of plasma exchange versus sham exchange or supportive treatment, or comparing different regimens or techniques of plasma exchange.

Data collection and analysis: We followed standard Cochrane methodology.

Main results: In the first version of this review there were six eligible trials concerning 649 participants comparing plasma exchange with supportive treatment. No new eligible trials have been identified in subsequent updates. Two other studies compared different numbers of plasma exchanges. Overall the included trials had a moderate risk of bias (in general, the studies were at low risk but all had a high risk of bias from lack of blinding).In one trial with 220 severely affected participants, the median time to recover walking with aid was significantly shorter with plasma exchange (30 days) than without plasma exchange (44 days). In another trial with 91 mildly affected participants, the median time to onset of motor recovery was significantly shorter with plasma exchange (six days) than without plasma exchange (10 days). After four weeks, moderate-quality evidence from the combined data of three trials accounting for a total of 349 patients showed that plasma exchange significantly increased the proportion of patients who recovered the ability to walk with assistance (risk ratio (RR) 1.60, 95% confidence interval (CI) 1.19 to 2.15).In five trials with 623 participants in total, moderate-quality evidence showed that the RR for improvement by one or more disability grades after four weeks was 1.64 (95% CI 1.37 to 1.96) times greater with plasma exchange. Participants treated with plasma exchange also fared better, according to moderate-quality evidence, in time to recover walking without aid (three trials with 349 participants; RR 1.72, 95% CI 1.06 to 2.79) and requirement for artificial ventilation (five trials with 623 participants; RR 0.53, 95% CI 0.39 to 0.74). More participants had relapses by the end of follow-up in the plasma exchange group than in the control group (six trials with 649 participants; RR 2.89, 95% CI 1.05 to 7.93; moderate-quality evidence). Despite this, according to moderate-quality evidence, the likelihood of full muscle strength recovery at one year was greater with plasma exchange than without plasma exchange (five trials with 404 participants; RR 1.24, 95% CI 1.07 to 1.45), and the likelihood of severe motor sequelae was less (six trials with 649 participants; RR 0.65, 95% CI 0.44 to 0.96). High-quality evidence from six trials with 649 participants could not confirm or refute a lower risk of death following plasma exchange compared to control (RR 0.86, 95% CI 0.45 to 1.65).Three trials (N = 556) provided details of serious adverse events during the hospital stay; combined analyses found no increase in serious infectious events compared to the control group (RR 0.91, 95% CI 0.73 to 1.13), nor were there clear differences in blood pressure instability, cardiac arrhythmias or pulmonary emboli.

Authors' conclusions: Moderate-quality evidence shows significantly more improvement with plasma exchange than with supportive care alone in adults with Guillain-Barré syndrome, without a significant increase in serious adverse events. According to moderate-quality evidence, there was a small but significant increase in the risk of relapse during the first six to 12 months after onset in people treated with plasma exchange compared with those who were not treated. Despite this, after one year, full recovery of muscle strength was more likely and severe residual weakness less likely with plasma exchange.

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Conflict of interest statement

SC co‐ordinated two RCTs that reported a beneficial effect. She has no known commercial conflicts of interest.

RACH holds or held consultancies with the following companies that produce IVIg or immunosuppressive drugs: CSL Behring, LFB, and Novartis. He participated in an RCT that did not report any beneficial effect and co‐ordinated another that showed equivalent efficacy of plasma exchange and intravenous immunoglobulin (IVIg).

DA: no known conflicts of interest.

Figures

1
1
Study flow diagram.
2
2
Risk of bias summary: review authors' judgements about each risk of bias item for each included study. Green (+) = low risk of bias, yellow (?) = unclear risk of bias, red (‐) = high risk of bias.
3
3
Forest plot of comparison: 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome, outcome: 1.2 Improved or not by 1 grade after 4 weeks.
4
4
Forest plot of comparison: 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome, outcome: 1.5 On or not on a ventilator after 4 weeks.
5
5
Forest plot of comparison: 2 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome, outcome: 2.1 Full muscle strength recovered or not at 1 year.
6
6
Forest plot of comparison: Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome, outcome: 2.3 Having or not severe motor sequelae after 1 year.
1.1
1.1. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 1 Walking with aid after 4 weeks.
1.2
1.2. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 2 Improvement by 1 grade after 4 weeks.
1.3
1.3. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 3 Mean disability grade improvement after 4 weeks.
1.4
1.4. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 4 Walking without aid after 4 weeks.
1.5
1.5. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 5 Mechanically ventilated after 4 weeks.
1.6
1.6. Analysis
Comparison 1 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: four‐week end points, Outcome 6 Duration of mechanical ventilation.
2.1
2.1. Analysis
Comparison 2 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: one‐year end points, Outcome 1 Full muscle strength recovery at 1 year.
2.2
2.2. Analysis
Comparison 2 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: one‐year end points, Outcome 2 Deaths.
2.3
2.3. Analysis
Comparison 2 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: one‐year end points, Outcome 3 Severe motor sequelae.
2.4
2.4. Analysis
Comparison 2 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: one‐year end points, Outcome 4 Relapses during follow‐up period.
3.1
3.1. Analysis
Comparison 3 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: complications during hospital stay, Outcome 1 Severe infection.
3.2
3.2. Analysis
Comparison 3 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: complications during hospital stay, Outcome 2 Blood pressure instability.
3.3
3.3. Analysis
Comparison 3 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: complications during hospital stay, Outcome 3 Cardiac arrhythmias.
3.4
3.4. Analysis
Comparison 3 Plasma exchange compared to sham exchange or supportive treatment for Guillain‐Barré syndrome: complications during hospital stay, Outcome 4 Pulmonary embolus.
See this image and copyright information in PMC

Update of

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