Therapeutic plasma exchange across multiple organ systems in an Egyptian tertiary center: A seven-year real-world cohort study

BACKGROUND: Real-world evidence on therapeutic plasma exchange (TPE) from low- and middle-income countries remains limited. Egyptian data across multiple organ systems are scarce. This study aimed to evaluate the indications, safety, efficacy, and predictors of outcomes in patients undergoing TPE at a tertiary center in Egypt over 7 years. METHODS AND FINDINGS: This retrospective cohort study included 221 consecutive patients who underwent TPE (2016-2022) at Zagazig University Hospitals, Egypt. Patients were stratified into renal, neurologic, hematologic, and metabolic groups. Primary outcomes were clinical response and all-cause mortality. Multivariate logistic regression, Cox proportional hazards models, and Kaplan-Meier survival analysis were performed. Among 221 patients (57.9% male; mean age 36.0 years), the most frequent indications were Guillain-Barré syndrome, thrombotic thrombocytopenic purpura, and myasthenia gravis crisis. ASFA category I indications constituted 77.8% of procedures, with response rates decreasing significantly across categories (p = 0.03). Overall response rate was 77.9% (complete remission in 93.0% of responders), with mortality 14.5%. Response rates exceeded 85% in autoimmune hemolytic anemia, hyperviscosity syndrome, and TTP. Neurologic indications achieved 81.6% response; renal indications showed lower response (73.2%) and highest mortality (21.3%). Adverse events occurred in 37.2% of patients, all mild-to-moderate with no session terminations. Independent mortality predictors included mechanical ventilation, creatinine >2.5 mg/dL, renal indication, hemoglobin <8 g/dL, while ASFA category I was protective (all aORs 2.67-5.22). In exploratory analyses, PLASMIC score ≥6 and time to TPE ≤ 2 days were associated with complete remission in TTP, while Hughes score ≥4 and time to TPE > 7 days were associated with poor functional outcome in GBS. These findings require external validation before clinical application. Diffuse alveolar hemorrhage (n = 9) demonstrated 100% mortality despite intervention, whereas SLE patients (n = 23) had 52.2% mortality, with 47.8% achieving complete remission or clinical improvement. A three-tier risk model stratified patients into high, intermediate, and low mortality risk groups. Independent predictors of clinical response included neurologic, hematologic, and metabolic indications compared to renal, ASFA category I, and ≥5 TPE sessions, while hemoglobin <8 g/dL and creatinine >2.5 mg/dL predicted poorer response. CONCLUSIONS: This single-center Egyptian TPE cohort demonstrates high efficacy and safety when aligned with ASFA guidelines. Neurologic and hematologic indications achieve optimal outcomes; renal indications and critical illness markers predict poorer prognosis. The PLASMIC score, treatment urgency in TTP and GBS, and the proposed three-tier model represent exploratory findings that, if prospectively validated, could become actionable prognostic tools. These findings suggest that evidence-based TPE expansion in resource-limited settings may be feasible, though multicenter validation is required.