Therapeutic Plasma Exchange in the Pediatric Intensive Care Unit: Analysis of Clinical Outcomes

INTRODUCTION: To evaluate the indications, clinical outcomes, and predictors of mortality associated with therapeutic plasma exchange (TPE) in critically ill pediatric patients. METHODS: A retrospective study including all critically ill children (1 month-18 years) who underwent TPE in a tertiary 30-bed PICU between January 2023 and November 2025. Data collected included demographics, ASFA 2023-based indications, extracorporeal therapy use, complications, and mortality. Primary outcome was PICU mortality; secondary outcomes included complications and predictors of death. RESULTS: Eighty-three patients underwent 242 TPE sessions (median: 3 [IQR 2-4]). The leading indication was sepsis/multiple organ dysfunction syndrome (MODS) (65.1%), followed by neurologic (9.6%) and renal (8.4%) diseases. According to the American Society for Apheresis (ASFA) 2023 guidelines, 81.9% of indications were categorized as Category III. TPE was combined with continuous renal replacement therapy (CRRT) in 19.3% and with extracorporeal membrane oxygenation (ECMO) in 3.6% of patients. Overall mortality was 26.5%, with the highest mortality observed in hematologic and rheumatologic groups (50% each). Higher Pediatric Risk of Mortality (PRISM) scores, higher PELOD-2 scores, elevated Vasoactive-Inotropic Scores (VIS), and the need for ECMO were independent predictors of mortality (p < 0.05). Both CRP and procalcitonin levels decreased significantly following TPE (p < 0.001), with a more pronounced reduction in survivors. TPE-related complications occurred in 47%, most commonly hypotension (21.7%), hypocalcemia (9.6%), allergic reactions (9.6%), and circuit clotting (6.0%), with no procedure-related deaths. CONCLUSION: TPE is feasible and generally safe in critically ill children. Outcomes are primarily influenced by illness severity-particularly high PRISM scores and ECMO requirement-rather than TPE-specific factors. Given the predominance of Category III indications, prospective multicenter studies are needed to refine pediatric TPE criteria, optimal timing, and patient selection.