Establishing a Safe and Effective Therapeutic Plasma Exchange Program in a Resource-Constrained Transplant Center: A 6-Year Nigerian Experience.

Therapeutic plasma exchange (TPE) is essential for kidney transplant desensitization and management of immune-mediated disorders, yet access remains limited across sub-Saharan Africa due to infrastructure, workforce, and supply chain constraints. While clinical efficacy is well established, there is limited literature describing how such programs can be successfully implemented in resource-constrained environments. This study describes the systematic development, implementation, and operational outcomes of a sustainable TPE program in Nigeria, with emphasis on practical strategies for replication. We conducted a mixed-methods evaluation combining program development analysis (2017-2023) with retrospective clinical data review of all TPE procedures performed between January 2020 and December 2022. Key domains analyzed included infrastructure development, equipment procurement, staff training, protocol adaptation, quality assurance systems, cost structure, and operational challenges. Clinical outcomes included utilization patterns and safety metrics. Program establishment required approximately 24 months and an initial capital investment of $148 000 USD. A total of 150 TPE sessions were performed in 90 patients. The predominant indication was pretransplant desensitization, followed by antibody-mediated rejection, T-cell mediated rejection, and Guillain-Barré syndrome. Procedure-related complications occurred in 2% of sessions and were uniformly mild and reversible, with no mortality. Direct cost per procedure decreased from $685 in 2020 to $550 in 2022, achieving financial sustainability by the third year of operation. Key operational challenges included supply chain delays, power instability, and workforce retention, which were mitigated through structured adaptations including long-term inventory planning, infrastructure redundancy, and staff development strategies. TPE programs can be safely and sustainably established in resource-constrained settings through structured planning, context-specific adaptations, and investment in local capacity building. Transplant outcomes were not analyzed in this study period. This experience provides a practical and replicable framework for expanding access to apheresis services in similar environments.