title: Changes in hemostasis caused by different replacement fluids and outcome in therapeutic plasma exchange in pediatric patients in a retrospective single center study.
abstract: BACKGROUND
  Therapeutic plasma exchange (TPE) is a generally accepted and frequently performed procedure for numerous therapeutic indications in adults. Slowly, TPE is also becoming more and more popular in the treatment of pediatric patients. Although, we know that TPE is safe in pediatric patients, the outcome of children treated with TPE is rarely reported. Furthermore, there are only general recommendations regarding the plasma replacement fluid for children and these are adopted from adults. Data concerning outcome and the influence of different types of replacement fluids on hemostasis in children are scarce.
  
  
  METHODS
  We retrospectively evaluated 324 TPE treatments performed in 35 patients between 2008 and 2013 in our level 4 institution for pediatric hematology and oncology. The plasmapheresis procedures were categorized into three groups based on the replacement fluid used. The first group received solvent/detergent-treated (S/D) plasma (70.0% of patients), the second group was administered 5% human albumin (7.7% of patients) and the third group was treated with a combination of human albumin 5% and S/D plasma (22.3% of patients). To assess hemostasis, data on INR, aPTT, fibrinogen and ATIII were collected before and after plasmapheresis from the patients' charts. A modified Multi Organ Dysfunction Syndrome (MODS) Index was used to classify organ failure. Patient outcome, survival rate and adverse events were evaluated.
  
  
  RESULTS
  We found a significant increase in the INR by 35.83% and of the aPTT by 18.53% within the human albumin group. The INR and aPTT of patients allocated to the S/D plasma group decreased by 1.58% and 15.77% on average, respectively. The combination group revealed a mild increase of the INR (9.47%), accompanied by a reduction of aPTT (5.97%). Furthermore we found that the survival rate was significantly associated with a MODS Index of <2 (p<0.001). Overall, the number of adverse events was low (1.2%) and none of these were considered life-threatening.
  
  
  CONCLUSIONS
  Hemostasis could be preserved in a clinically acceptable range for a variety of underlying diseases with SD plasma alone or in combination with human albumin. Based on our results we would recommend practitioners to closely pre-estimate the hemostatic situation before using human albumin alone in critically ill pediatric patients with a limited ability to produce coagulation factors. The outcome of the patients in our collective exprience is correlated to the extent of organ dysfunction. Therefore further controlled studies are highly recommended.
authors.affiliation: St. Anna Kinderspital, Department for Pediatrics, Medical University of Vienna (MUW) Kinderspitalgasse 6, 1090 Vienna, Austria. Electronic address: volker.witt@stanna.at.
authors.forename: Volker
authors.initials: V
authors.lastname: Witt
authors.affiliation: St. Anna Kinderspital, Department for Pediatrics, Medical University of Vienna (MUW) Kinderspitalgasse 6, 1090 Vienna, Austria.
authors.forename: Herbert
authors.initials: H
authors.lastname: Pichler
authors.affiliation: St. Anna Kinderspital, Department for Pediatrics, Medical University of Vienna (MUW) Kinderspitalgasse 6, 1090 Vienna, Austria.
authors.forename: Elisabeth
authors.initials: E
authors.lastname: Beiglboeck
authors.affiliation: Clinical Research and Development Department, Octapharma Pharmazeutika Produktionsges.m.b.H, Vienna, Austria.
authors.forename: Friedrich
authors.initials: F
authors.lastname: Kursten
authors.affiliation: St. Anna Kinderspital, Department for Pediatrics, Medical University of Vienna (MUW) Kinderspitalgasse 6, 1090 Vienna, Austria.
authors.forename: Lisa
authors.initials: L
authors.lastname: Weidner
mesh_terms: D000293:Adolescent; D000328:Adult; D002648:Child; D002675:Child, Preschool; D006487:Hemostasis / Q000502:physiology*; D006801:Humans; D007223:Infant; D010952:Plasma Substitutes / Q000008:administration & dosage*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
chemical_list: D010952:Plasma Substitutes