Patients with severe autoimmune hemolytic anemia (AIHA) including cold agglutinin disease (CAD) who receive therapeutic plasma exchange (TPE) during their hospitalization may suffer higher rates of adverse in-hospital outcomes, according to a study published in Transfusion.

The researchers reviewed the National Inpatient Sample (NIS) for 2002 to 2019 and included hospitalized patients with the highest severity subclass identified by All Patient Refined Disease Related Group.

To analyze the outcomes of patients who received TPE and those who did not, they compared in-hospital mortality and other relevant in-hospital outcomes through multivariate regression analysis.

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According to the results, the study included 255 weighted hospitalizations in the TPE group and 4973 in the control group. Patients who did not receive TPE were older than those in the TPE group (median age 67 vs 48 years), had a higher prevalence of several comorbidities, and stayed at the hospital longer (median 19 vs 9 days).

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Patients with AIHA who received TPE had higher rates of all-cause in-hospital mortality and secondary outcomes such as acute stroke, intracranial hemorrhage, urinary tract infections, acute kidney injury, circulatory shock, as well as the need for mechanical ventilation and hemodialysis.

However, there were no notable variations in the rates of acute myocardial infarctions, bacterial pneumonia, sepsis/septicemia, thromboembolic events, and/or other bleeding events between the 2 study groups.

“TPE only removes a fraction of the free antibodies present in the patient’s plasma, while it might not be able to remove the antibodies that are already bound to red blood cells, which are responsible for hemolysis. In patients with rapid autoantibody formation, TPE may be very inefficient and ineffective since it cannot keep up with the production of new antibodies,” Abdelhay and colleagues explained.

“Second, TPE can be associated with procedure-related complications which can complicate the clinical picture and lead to worse outcomes.”

AIHA, marked by red blood cell hemolysis caused by humoral and cellular immune mechanisms, is often treated with steroids and other supportive measures. TPE is not a first-line treatment option, and the evidence to support its use remains limited.


Abdelhay A, Mahmoud AA, Ammari O, et al. Outcomes of therapeutic plasma exchange in severe autoimmune hemolytic anemia hospitalizations: an analysis of the National Inpatient Sample. Transfusion. Published online July 3, 2023. doi:10.1111/trf.17445