Efficacy of therapeutic plasma exchange in neurological autoimmune diseases at a University Medical Center

Therapeutic plasma exchange (TPE) is used for the extracorporeal removal of plasma and its replacement by plasma derivatives or albumin solution and is a treatment option for autoimmune neurological disorders such as Guillain-Barré-Syndrome (GBS), Chronic inflammatory Demyelinating Polyneuropathy (CIDP), Multiple Sclerosis (MS), Neuromyelitis Optica Spectrum Disorders (NMOSD) and Myasthenia gravis (MG). The aim of this study is to describe the efficacy of TPE in neurological autoimmunity at our centre against the background of adverse effects.

We analyzed 83 patients diagnosed with GBS (n=29), CIDP (n=10), MS (n=23), NMOSD (n=5) or MG (n=16) who received one or more TPE cycles at Leipzig University Hospital between 2018 and 2023. A total of 527 exchanges were performed in 103 exchange cycles. Patients were exchanged with albumin alone (20% of cycles) or albumin/plasma (80%).

The median delay from hospital admission to the first TPE session was one day; the median duration of inpatient treatment was 10 days. In contrast, a median of 12 days elapsed until results of antibody testing were available. The majority of patient had "symptom improvement" in GBS, MS, NMOSD and MG. In contrast, the majority of patients with CIDP had "unchanged symptoms". Over all diagnostic groups, cranial nerve dysfunction improved in 77% and motor weakness in 61% of patients. In contrast, sensory loss improved in 23%, and combined ataxia and areflexia improved in 34% of affected patients. Only a small proportion of patients suffered symptom worsening during TPE treatment (1% to 5%). In 62 of 527 exchanges (11.8%), side effects occurred, consisting of citrate reactions (n=25), circulatory dysregulation (n=12), sensory disturbances (n=11), nausea and vomiting (n=7) and allergic reactions (n=7). None fulfilled GCP criteria for severe adverse event (SAE).

In most autoimmune neurological disorders, TPE is considered as a second line immunotherapy, i.e. as an escalation in case glucocorticoids have failed. Given the observed risk-benefit profile in our cohort, TPE might be taken into account earlier in the treatment of autoimmune neurological disorders.

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