Influencing factors of hypotension during plasma exchange in patients with neuroimmunological diseases: a retrospective cohort study

Introduction

Neuroimmunological disorders are a class of autoimmune diseases characterized primarily by the attack of the nervous system by autoreactive immune cells and molecules (1). These conditions typically present acutely, with a variety of clinical manifestations including psychiatric behavioral abnormalities, cognitive impairments, and dysautonomia (2). They are characterized by high recurrence rates, high mortality, and high disability rates. Although the exact pathogenesis of most neuroimmunological disorders is not fully understood, the pathogenic role of autoantibodies in the disease process has been widely recognized (3). Plasma exchange is a blood purification therapy specifically designed to remove large molecular substances from the blood (4). In this process, the patient’s blood is first processed through a plasma separator, which separates the plasma from the cellular components (5). Subsequently, the pathogenic factors in the plasma are removed, and the cellular components, purified plasma, and necessary supplementary replacement fluids are reinfused into the patient’s body. This therapy can modulate the immune system, alleviate symptoms, and improve the survival rate of patients (6). As a type of blood purification therapy, plasma exchange has been widely applied in the treatment of neuroimmunological disorders in recent years by reducing the concentration of antibodies in the peripheral blood. According to literature reports (7,8), the early application of plasma exchange can significantly improve the clinical symptoms and prognosis of patients. In addition, the nursing care during plasma exchange treatment has a crucial impact on the overall prognosis of the patient. Therefore, comprehensive treatment and meticulous nursing care play an irreplaceable role in improving the quality of life and survival rate of patients with neuroimmunological disorders.

Hypotension is one of the most common complications during plasma exchange. When hypotension occurs, patients may exhibit a decline in consciousness clarity, syncope, seizures, or even sudden cardiac death, which not only threatens the safety of the patient’s life but can also lead to the interruption of plasma exchange treatment (9,10). Current research has indicated that hematological and metabolic disorders are significant factors affecting hypotension during plasma exchange (11). However, there is relatively less reported research on the factors influencing hypotension in patients with neuroimmunological disorders undergoing plasma exchange. The purpose of this study is to investigate the incidence of hypotension in patients with neuroimmunological disorders during plasma exchange treatment and to analyze the potential influencing factors. Through this research, we aim to provide evidence to support clinical nursing care in developing more precise and effective nursing interventions. to reduce the risk of hypotension, ensuring the continuity and safety of plasma exchange. We present this article in accordance with the STROBE reporting checklist (available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-456/rc).

Methods

This study employed a retrospective cohort design. The study has been reviewed and approved by the ethics committee of The First Affiliated Hospital with Nanjing Medical University (approval No. 2024-SR-100). Furthermore, written informed consent was obtained from all participants included in the study. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013).

This study selected patients with neuroimmunological disorders who underwent plasma exchange treatment at a tertiary hospital in Nanjing, China from February 1, 2023, to April 2024. The inclusion criteria were as follows: Firstly, patients had to have been diagnosed with a neuroimmunological disorder, including neuromyelitis optica spectrum disorder, autoimmune encephalitis, myasthenia gravis, Guillain-Baré syndrome, and acute disseminated encephalomyelitis. Secondly, patients had to meet the indications for plasma exchange treatment of neurological diseases as outlined in the clinical application guidelines published by the American Society for Apheresis (ASFA). Additionally, patients had to be aged 18 or above and had completed at least one course of plasma exchange at our hospital. Exclusion criteria included patients with abnormal preoperative blood pressure or those requiring medication to control blood pressure, as well as patients who were unwilling to participate in the study.

In each plasma exchange treatment session, hypotension was operationally defined as a systolic blood pressure reading below 90 mmHg or a reduction of 20 mmHg or greater from baseline systolic blood pressure, in accordance with prior studies (12-14). For the purposes of this analysis, a patient was considered to have experienced an episode of hypotension if they exhibited at least one instance of the aforementioned symptoms during a single plasma exchange treatment session. In the event of hypotension during plasma exchange, a series of evidence-based measures were implemented immediately following the physician’s orders. These measures were designed to address the underlying etiology and mitigate the symptoms of hypotension. The specific therapies included: administration of intravenous fluids to restore blood volume and improve cardiac output, which was crucial in the initial management of hypotension; if the mean arterial pressure (MAP) dropped below 65 mmHg, vasopressors were indicated to support blood pressure; if a medication was suspected to be the cause of hypotension, it should have been discontinued; in cases of suspected anaphylaxis, intramuscular epinephrine was indicated to counteract the drop in blood pressure. These strategies were selected based on the specific cause and severity of hypotension, with the goal of promptly reversing the condition and preventing complications such as organ failure. The implementation of these therapies was guided by the clinical judgment of the treating physician, taking into account the patient’s overall condition and response to treatment.

In this study, we collected the following demographic and clinical data: age, gender, body mass index (BMI), presence of diabetes, hyperlipidemia, type of underlying disease, sedative drug use during plasma exchange, mechanical ventilation status, pre-plasma exchange systolic blood pressure, volume of plasma exchange fluid, plasma exchange rate, and serum electrolyte levels including potassium, sodium, and calcium.

Statistical analysis

In this study, we utilized SPSS 25.0 software for the statistical analysis of the data. Quantitative data were initially subjected to a normality test. Data that conformed to a normal distribution were described using the mean ± standard deviation and compared using analysis of variance (ANOVA); data that did not conform to a normal distribution were described using the median (25th percentile, 75th percentile) and analyzed using the non-parametric rank sum test. Qualitative data were described using frequency counts and proportions, and the χ² or Fisher’s exact test was also applied. For multifactorial analysis, we employed logistic regression models to explore the relationships, considering a P value less than 0.05 as the criterion for statistically significant differences.

Results

A total of 206 patients with neuroimmunological diseases were included in this study, of whom 68 patients had hypotension during plasma exchange, the incidence of hypotension during plasma exchange in patients with neuroimmunological diseases was 33.01%. During plasma exchange treatments for patients with neuroimmunological disorders, a total of 82 episodes of hypotension were recorded. As shown in Table 1, there were statistical difference in the age, use of sedative drugs during plasma exchange, pre-plasma exchange systolic blood pressure and serum calcium between hypotension and control group (all P<0.05). No statistical differences in the gender, BMI, diabetes, hyperlipemia, type of disease, mechanical ventilation, plasma exchange fluid volume, plasma exchange rate, serum potassium and serum sodium between hypotension and control group were found.

As shown in Table 2, Logistic regression analysis revealed that age [odds ratio (OR) =2.851, 95% confidence interval (CI): 1.978–3.194], use of sedative drugs during plasma exchange (OR =3.175, 95% CI: 2.363–4.425), pre-plasma exchange systolic blood pressure (OR =0.857, 95% CI: 0.410–0.932), and serum calcium (OR =0.791, 95% CI: 0.340–0.895) were the influencing factors of hypotension during plasma exchange in patients with neuroimmune diseases.

Discussion

Hypotension is one of the common complications associated with plasma exchange therapy. Clinically, most cases of hypotension present with mild symptoms that can typically be alleviated with appropriate symptomatic treatment (15). However, severe hypotension can lead to ischemia and hypoxia of vital organs, causing clinical manifestations such as shock or syncope in patients. This not only interrupts plasma exchange treatment but also poses a threat to patients’ life safety due to inadequate treatment and increases the economic burden on patients (16,17). The results of this study indicate that the incidence of hypotension in patients with neuroimmunological diseases during plasma exchange is 33.01%, a figure which exceeds that typically seen in the incidence of hypotension of elderly patients with cervical cancer during plasma exchange (23.04%) (18) and patients with diabetic nephropathy (25.11%) (19). This suggests that patients with neuroimmunological diseases may be at a greater risk of hypotension during plasma exchange procedures. The higher incidence could be attributed to the nature of the diseases affecting the autonomic nervous system, which plays a crucial role in blood pressure regulation, or it could be related to the specific treatments and conditions of these patients. Future research should focus on understanding the pathophysiological mechanisms underlying this increased risk and developing strategies to mitigate hypotension in these vulnerable patient populations. Besides, we have found that the occurrence of hypotension is influenced by factors such as age, the use of sedative drugs during plasma exchange, pre-exchange systolic blood pressure, and serum calcium levels. Prevention and treatment of hypotension during plasma exchange therapy are crucial. For patients presenting with symptoms of hypotension, immediate symptomatic measures should be taken, such as properly adjusting the infusion rate of the exchange fluid and administering vasoactive drugs. Concurrently, proactive interventions should be implemented to address risk factors for hypotension, including age, sedative drug use, baseline blood pressure levels, and serum electrolyte levels, in order to reduce the incidence of hypotension during plasma exchange and ensure the safety of the treatment.

With increasing age, the risk of hypotension during plasma exchange therapy significantly elevates for patients. This phenomenon may be associated with a higher comorbidity rate of cardiovascular diseases in elderly patients, which often involves adjustments in hemodynamics and metabolism, making the elderly more susceptible to hypotension during the plasma exchange process (20,21). In particular, the presence of heart dysfunction in the elderly may make hemodynamics more labile during plasma exchange, leading to an increased incidence of hypotension (22). Therefore, when performing plasma exchange therapy on elderly patients, medical staff should closely monitor their blood pressure changes and adjust the treatment plan in a timely manner, in order to minimize the risk of hypotension and ensure the safety and efficacy of the treatment.

The findings of this study indicate that patients using sedative drugs during plasma exchange are at a higher risk of developing hypotension. Neuroimmune disease patients often exhibit clinical manifestations such as psychiatric symptoms, epileptic seizures, central respiratory depression, and involuntary movements, which typically require the use of sedative drugs to be controlled during plasma exchange therapy to prevent potential safety incidents (23). However, the rapid administration or excessive dosage of sedative drugs may induce hemodynamic disturbances, leading to symptoms such as slowed respiratory rate, reduced respiratory depth, bradycardia, and a decrease in blood pressure (24,25). Currently, there is a relative deficiency in clinical research on how to adjust the dosage of sedative drugs, and no universally recognized optimal strategy has been established to guide dosage adjustment during plasma exchange. Therefore, it is recommended that in clinical practice, a gradual approach to increasing the dosage of sedative drugs should be adopted, incrementally raising the injection speed with smaller unit doses to prevent blood pressure drops caused by overly rapid injection or high blood drug concentrations. Concurrently, the frequency of blood pressure monitoring should be increased to closely monitor the patient’s blood pressure changes, and immediate intervention measures should be taken once signs of hypotension are detected (26,27). In our study, we observed that Midazolam was the predominant sedative used in 98 cases, followed by Dexmedetomidine in 15 cases. We did not identify a statistically significant difference in the incidence of hypotension between these sedative agents. However, we acknowledge the relatively small sample size for Dexmedetomidine, which may have affected the power of our study to detect differences. In the future, a more comprehensive investigation with a larger and diverse patient cohort is warranted to elucidate the potential differences in hypotension incidence associated with various sedative drugs. Additionally, exploring the role of non-pharmacological sedation strategies and their effect on hypotension could provide valuable insights into patient safety during plasma exchange procedures.

This study discovered that the lower the systolic blood pressure before plasma exchange, the higher the likelihood of developing hypotension during the procedure. When blood volume is insufficient, patients tend to have lower systolic blood pressure. Once plasma exchange commences, the diversion of blood into the extracorporeal circuitry further reduces intracorporeal blood volume, increasing the risk of hypotension (28). Additionally, literature has reported that as the blood flow rate and exchange ratio increase during plasma exchange, the hemofilter’s consumption of red blood cells also rises, potentially leading to further insufficiency in blood volume (29). For patients with already low systolic blood pressure prior to plasma exchange, it is recommended to take moderate fluid resuscitation measures to enhance blood volume. Moreover, research (30) has indicated that among hemodialysis patients, maintaining systolic blood pressure between 130 to 160 mmHg before dialysis is associated with the lower risk of mortality. Therefore, in clinical practice, it is essential to strengthen the management of patients’ systolic blood pressure before plasma exchange, effectively reducing the incidence of hypotension during the procedure by maintaining an appropriate blood pressure level (31,32). This not only improves the safety of the treatment but is also a key measure in enhancing the overall prognosis of the patient.

This study reveals an association between blood calcium levels and the risk of hypotension: the lower the blood calcium level of a patient, the more susceptible they are to developing hypotension during plasma exchange. In plasma exchange, sodium citrate is commonly used as an anticoagulant for extracorporeal circulation; however, sodium citrate can chelate with ionic calcium in the blood, leading to a decrease in serum calcium ion concentration, potentially inducing hypocalcemia (15,33). Hypocalcemia not only leads to a decrease in myocardial contractility and reduced cardiac output but also causes relaxation of vascular smooth muscle, which may result in systemic hypotension (34-36). Therefore, during plasma exchange, nursing staff must enhance the clinical recognition of hypocalcemia and proactively inquire about and listen to the patient’s complaints. When patients exhibit symptoms such as muscle spasms, tremors, or paraesthesia around the mouth or in the extremities, immediate monitoring of the patient’s blood calcium levels is warranted, along with preemptive intervention measures (37,38). To prevent the occurrence of hypocalcemia, it is recommended to test the patient’s serum ionized calcium levels before plasma exchange (39). Based on the test results, the patient’s anticoagulation method, and the type of replacement fluid used, prophylactic intravenous administration of calcium gluconate or calcium chloride may be considered to reduce the risk of hypotension (40).

There are some limitations in this study. Firstly, it is recognized that the single-center design, the retrospective methodology applied over a constrained period of one year, and the absence of a comparative control group may constrain the statistical power of our study, potentially impacting the generalizability of our findings. Consequently, future collaborative multi-center studies with expanded sample sizes are warranted to substantiate the results of this investigation. Secondly, we concur that MAP is widely recognized as the standard measure for defining arterial hypotension, especially among intensive care unit (ICU) patients receiving mechanical ventilation. Our study employed a definition that was tailored to the specific parameters deemed most pertinent to our research goals and the demographic of patients that we were examining. Nonetheless, we acknowledge the significance of MAP in ICU settings and concede that our selection may not correspond with the practices adopted in all clinical scenarios. Thirdly, our initial analysis did not include a detailed stratification into asymptomatic, symptomatic non-severe, and symptomatic severe hypotension, which is a critical aspect when assessing the clinical implications and management of hypotensive episodes. The severity of hypotension is indeed a significant factor, as asymptomatic cases may not warrant the same level of intervention as those leading to severe outcomes such as cardiac arrest. We recognize that the presentation of asymptomatic hypotension differs markedly from severe hypotension that results in life-threatening conditions like cardiac arrest, which, while rare during plasma exchange sessions, represents a critical endpoint in patient care. This distinction is important for understanding the true impact of hypotension on patient outcomes and for guiding clinical decision-making. Fourthly, we excluded patients who previously had arterial hypotension or were on vasopressor treatment to isolate the effect of plasma exchange treatment on hypotension in a more homogeneous patient population. We sought to minimize confounding variables that could obscure the treatment’s effects, and thus, we focused on patients without prior hypotension or vasopressor use. However, we understand that this exclusion may limit the generalizability of our findings and could potentially overlook important clinical scenarios where hypotension is managed with vasopressors. Additionally, this study did not delve into the mechanisms behind the development of hypotension or how different patient characteristics interact with the risk of hypotension. Future research should employ more sophisticated methods to conduct a more in-depth analysis of these complex biological and clinical issues.

Conclusions

In conclusion, our research has provided a comprehensive examination of the prevalence of hypotension among individuals with neuroimmunological disorders undergoing plasma exchange, identifying a notable incidence rate of 33.01%. This finding underscores the importance of closely monitoring blood pressure during such therapeutic procedures. Our analysis has also revealed that the risk of developing hypotension is significantly influenced by a multitude of factors. Notably, age emerges as a pivotal factor, with older patients exhibiting a heightened vulnerability to blood pressure fluctuations. Additionally, the utilization of sedative drugs during plasma exchange has been identified as a contributing factor, potentially due to their pharmacological properties that can affect cardiovascular stability. Furthermore, the pre-exchange systolic blood pressure serves as a critical baseline indicator, with patients presenting with lower initial readings being at an increased risk for hypotensive episodes. The serum calcium levels also play a significant role, as fluctuations in calcium can directly impact neuromuscular function and cardiovascular dynamics, thereby influencing the likelihood of hypotension. These insights highlight the necessity for a tailored approach to patient care, advocating for proactive measures to mitigate the risk of hypotension. Healthcare providers must consider these contributing factors in the development of individualized treatment plans, ensuring that the administration of sedative drugs and the management of electrolyte balance are carefully orchestrated to safeguard patient well-being.

Acknowledgments

We would like to thank Dr. Shawn Kennedy for his help in polishing our paper.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-456/rc

Data Sharing Statement: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-456/dss

Peer Review File: Available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-456/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cdt.amegroups.com/article/view/10.21037/cdt-24-456/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study has been reviewed and approved by the ethics committee of The First Affiliated Hospital with Nanjing Medical University (approval No. 2024-SR-100). And written informed consents had been obtained from all the included patients.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Graham EL. Neuroimmunological Disorders: The Gender Effect. Neurol Clin 2023;41:315-30. [Crossref] [PubMed]
2. Hartung HP, Aktas O. COVID-19 and management of neuroimmunological disorders. Nat Rev Neurol 2020;16:347-8. [Crossref] [PubMed]
3. Jin H, Lu Q, Gao F, et al. Application of oligoclonal bands and other cerebrospinal fluid variables in multiple sclerosis and other neuroimmunological diseases: a narrative review. Ann Transl Med 2023;11:282. [Crossref] [PubMed]
4. Chalkia A, Petras D. Plasma exchange in patients with ANCA-associated vasculitis. Transfus Apher Sci 2024;63:103847. [Crossref] [PubMed]
5. Beran A, Mohamed MFH, Shaear M, et al. Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis. Liver Transpl 2024;30:127-41. [Crossref] [PubMed]
6. Kuklin V, Sovershaev M, Bjerner J, et al. Influence of therapeutic plasma exchange treatment on short-term mortality of critically ill adult patients with sepsis-induced organ dysfunction: a systematic review and meta-analysis. Crit Care 2024;28:12. [Crossref] [PubMed]
7. Denoon RB, Soares Ferreira A Junior, Tuttle B, et al. Therapeutic plasma exchange for sickle cell disease acute complications: A systematic review. Transfusion 2024;64:1570-87. [Crossref] [PubMed]
8. Rego EM. Therapeutic plasma exchange and HLA desensitization. Hematol Transfus Cell Ther 2024;46:1-2. [Crossref] [PubMed]
9. Wei X. Analysis of adverse reactions and influencing factors of plasma exchange. Contemporary Nurses 2021;28:31-4.
10. Gong L, Chang H, Zhao J. Research progress of influencing factors of hypotension and nursing intervention in plasma exchange. China Blood Purification 2021;26:20-4.
11. Qi X. Causes and nursing care of hypotension caused by severe hepatitis plasma exchange. Journal of Inner Mongolia Traditional Chinese Medicine 2016;35:1-4.
12. Gong L, Chang H, Zhao J. Hypotension in patients with neuroimmune diseases during plasma exchange. China Nursing Management 2021;21:21-5.
13. Bi X, Gu J, Xu Q. Effect of blood magnesium levels on intra-dialysis hypotension in maintenance hemodialysis patients. Shandong Medicine 2024;36:10-4.
14. Yan X, Xie Q, Wang Y. Risk factors for hypotension during dialysis in elderly maintenance hemodialysis patients. Practical Geriatrics 2024;38:549-52.
15. Lemaire A, Parquet N, Galicier L, et al. Plasma exchange in the intensive care unit: Technical aspects and complications. J Clin Apher 2017;32:405-12. [Crossref] [PubMed]
16. Liu X, Wang X, Zhang T. Clinical analysis of hypotension in hemodialysis. China Blood Purification 2021;20:50-3.
17. Zhang W, Jiao Y, Cui L, et al. Therapeutic efficacy and safety of plasmapheresis in elderly patients with neuromyelitis optica spectrum disorder: a single-center observational study. Ther Adv Neurol Disord 2023;16:17562864231162420. [Crossref] [PubMed]
18. Fan S, Fang H, Xu Y. Analysis of risk factors for hypotension during hemodialysis in elderly and elderly patients with cervical cancer. Chinese Journal of Maternal and Child Health Care 2024;39:693-6.
19. Jiang X, Weng L. Predicting significance of pre-dialysis plasma osmolality on frequent hemodialysis hypotension in elderly maintenance hemodialysis patients. Journal of Clinical Nephrology 2024;2:24-7.
20. Honore PM, Barreto Gutierrez L, Kugener L, et al. Plasma exchange in critically ill COVID-19 patients improved inflammation, microcirculatory clot formation, and hypotension, thereby improving clinical outcomes: fact or fiction? Crit Care 2020;24:551. [Crossref] [PubMed]
21. Seyhanli A, Yavuz B, Selimoglu I, et al. Therapeutic plasma exchange in neurological diseases: Eleven years experience at a tertiary care center in Turkey. Ther Apher Dial 2022;26:465-70. [Crossref] [PubMed]
22. Ashok Kumar P, Paulraj S, Udekwu A. Hemodynamic Collapse Following Therapeutic Plasma Exchange in a Patient Receiving an Angiotensin Receptor Blocker. Cureus 2020;12:e7028. [Crossref] [PubMed]
23. Wu K, Yu N, Liu Q. Nursing care of plasma exchange in a patient with rare cold agglutinin syndrome. Journal of Lingnan Emergency Medicine 2023;28:396-8.
24. Song N, Yang Y, Zheng Z, et al. Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirectional Endoscopy: A Randomized Clinical Trial. JAMA Netw Open 2023;6:e2347886. [Crossref] [PubMed]
25. Hung KC, Chen IW, Liu PH. The effect of remimazolam on hypotension risk during procedural sedation. Int J Surg 2024;110:1841-2. [Crossref] [PubMed]
26. Hatfield J, Soto AL, Kelly-Hedrick M, et al. Safety, Efficacy, and Clinical Outcomes of Dexmedetomidine for Sedation in Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2024;36:101-8. [Crossref] [PubMed]
27. Kohaf NA, Harby SA, Abd-Ellatief AF, et al. Premedication with intranasal versus intravenous dexmedetomidine for hypotensive anesthesia during functional endoscopic sinus surgery in adults: A randomized triple-blind trial. Heliyon 2024;10:e25175. [Crossref] [PubMed]
28. Ziemssen T, Langdon DW, Calabrese P. Editorial: Cognitive Disorders in Neuroimmunological Diseases. Front Neurol 2020;11:169. [Crossref] [PubMed]
29. Biswas T, Lal BB, Sood V, et al. Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score-matched analysis. J Clin Apher 2024;39:e22130. [Crossref] [PubMed]
30. The Hemodialysis Adequacy Collaborative Group of the Nephrologists Branch of the Chinese Medical Doctor Association. Chinese Clinical Practice Guidelines for hemodialysis adequacy. Chinese Journal of Medicine 2015;95:2748-53.
31. Nieto-Aristizábal I, Vivas ÁJ, Ruiz-Montaño P, et al. Therapeutic Plasma Exchange as a Treatment for Autoimmune Neurological Disease. Autoimmune Dis 2020;2020:3484659. [Crossref] [PubMed]
32. Wang P. Plasma exchange in the treatment of nervous system diseases. Chinese Medical Engineering 2021;29:101-3.
33. Weinstein R. Basic principles of therapeutic plasma exchange. Transfus Apher Sci 2023;62:103675. [Crossref] [PubMed]
34. Papari M, Tretiakova M, Fedson S, et al. Persistent hypocalcemia associated with therapeutic plasma exchange performed to reduce HLA antibody levels in cardiac transplant recipients. Transfus Apher Sci 2011;44:243-8. [Crossref] [PubMed]
35. Momtaz M, Fayed A, Marzouk K, et al. Therapeutic Plasma Exchange Outcomes in Cairo University Hospitals: 6 Years Experience. Ther Apher Dial 2018;22:666-73. [Crossref] [PubMed]
36. Halpin MR, Chen B, Singer RF. Efficacy, Safety, and Calcium Balance of an Accelerated Citrate Anticoagulated Membrane-Based Plasma Exchange Algorithm. Blood Purif 2022;51:70-4. [Crossref] [PubMed]
37. Wildes DM, Devlin C, Costigan CS, et al. Therapeutic plasma exchange in paediatric nephrology in Ireland. Ir J Med Sci 2024;193:1589-94. [Crossref] [PubMed]
38. Coirier V, Lesouhaitier M, Reizine F, et al. Tolerance and complications of therapeutic plasma exchange by centrifugation: A single center experience. J Clin Apher 2022;37:54-64. [Crossref] [PubMed]
39. Joseph C, Siddiqui S, Shah S, et al. Therapeutic plasma exchange: single-center experience in children with kidney disorders. Pediatr Nephrol 2021;36:621-9. [Crossref] [PubMed]
40. Davies E, Khan S, Mo YD, et al. Modifications to therapeutic plasma exchange to achieve rapid exchange on cardiopulmonary bypass prior to pediatric cardiac transplant. J Clin Apher 2023;38:514-21. [Crossref] [PubMed]