Therapeutic plasma exchange in immune thrombotic thrombocytopenic purpura: A six-year prospective study on clinical efficacy, laboratory trends, and sex-based differences.

Thrombotic thrombocytopenic purpura (TTP) is a life-threatening thrombotic microangiopathy characterized by severe ADAMTS13 deficiency. Therapeutic plasma exchange (TPE) remains the cornerstone of treatment in immune-mediated TTP. However, limited data are available from India on procedural characteristics, sex-based presentation, and laboratory response dynamics. This six-year prospective observational study enrolled 43 patients with immune TTP at a tertiary care center in Eastern India between January 2019 and December 2024. All patients had ADAMTS13 activity < 10 % and received corticosteroids and daily TPE. Clinical features, laboratory parameters, procedural metrics, and treatment outcomes were analyzed. The cohort had a female predominance (72.1 %) with a mean age of 36.1 ± 9.6 years. All patients underwent ≥ 6 TPE sessions using central venous access. Significant hematologic improvement was observed: hemoglobin rose from 6.6 g/dL to 11.1 g/Dl (p = 0.00001), platelets from 17.4 to 157.7 × 10⁶/mL (p < 0.001), and LDH declined from 1121.6 to 229.7IU/L (p < 0.001). Reticulocyte count and indirect bilirubin levels decreased, indicating hemolysis resolution. Procedure-related adverse events were mild (20.9 %) and manageable. Females exhibited more severe anemia and higher bilirubin levels than males, while LDH levels were higher in males, suggesting sexbased variation in disease severity. The overall mortality rate was 16.3 %, predominantly among females. TPE combined with corticosteroids led to rapid hematologic recovery and was safe and effective in immune TTP. Baseline gender disparities and the lack of adjunctive biologics highlight the need for tailored treatment protocols and improved access to advanced therapies in resource-constrained settings.