Therapeutic plasma exchange in critically ill patients in low-income and lower-middle-income countries: medical need and feasibility

Abstract

Background: Therapeutic plasma exchange (TPE) is a blood purification technique designed for the removal of large molecules such as pathogenic antibodies and lipoproteins. The procedure involves removing plasma from the patient in exchange for replacement fluid, and it can be performed either by membrane separation or centrifugation. These conventional techniques are expensive and require the training of skilled personnel. This severely limits their use in low-income countries (LICs) and lower-middle-income countries (LMICs), leading to morbidity and mortality for patients in LICs and LMICs suffering from the diseases where TPE is indicated.

Methods: A novel gravity-driven blood separation method might provide the needed access to TPE for LICs and LMICs. We reviewed the medical need, the practical aspects, as well as the possible complications of applying this novel technology in LICs and LMICs. Furthermore, we describe a feasibility study of implementing TPE in Suriname for various diseases and conditions.

Results: Where data was available (n /N = 10/11), supportive care combined with TPE using the new device resulted in improved values for the disease-specific markers evaluated in these patients. In addition, eight patients showed complete clinical recovery, and one patient showed partial clinical recovery upon TPE within 0.5-6 months of follow-up. Importantly, none of the patients experienced any serious side effects.

Conclusions: This experience in the resource-limited setting in Suriname illustrates that its application is feasible in LICs and LMICs settings, at least for these five diseases with first-line indications for TPE and a significant number of patients.

Figure 1

Schematic diagram of the HemoClear blood separation process.

Figure 2

Flowchart with study enrolment and experimental design.

Figure 3

Visual timeline for each patient included the implementation feasibility study. ALF – acute liver failure, CR – complete recovery, GBS – Guillain-Barré Syndrome, HTG – hypertriglyceridemia, MG – myasthenia gravis, PR – partial recovery, WD – Wilson disease, X – deceased. Panels A−C. Three GBS patients with disease severity reported on GBD-DS scale. Panels D−E. Two ALF patients with disease severity reported using blood ammonia or alanine transaminase levels. Panels F−H. Three HTG patients with disease severity reported using blood triglyceride levels. Panels I−J. Two MG patients with disease severity reported on MG-ADL scale. Panel K. One WD patient with disease severity reported on GCS scale. Each timeline also shows hospital (filled black square) and ICU (filled blue square) admission and hospital (open black square) and ICU (open blue square) discharge dates, TPE treatment sessions (gray triangle), and overall treatment outcome (complete recovery, partial recovery or deceased). Number above the gray triangle indicates plasma volume (mL) exchanged. Time is depicted in days relative to the start of TPE.