Evolution of Therapeutic Plasma Exchange Use and Outcomes in Children Across American Society for Apheresis Categories: A Single-Center Cohort Study.

To characterize pediatric TPE utilization, safety, treatment response, and mortality across American Society for Apheresis (ASFA) categories and over time. Retrospective single-center cohort study of patients aged 0-25 years who underwent therapeutic plasma exchange (TPE) between 2011 and 2024. Primary outcomes included TPE utilization, temporal trends, and procedure-related complications. Secondary outcomes included treatment response according to indication-specific criteria and 28-day mortality overall and by ASFA category. A total of 416 TPE courses were performed in 384 patients (median age 10 years, IQR 2-16). TPE utilization increased over time (Spearman ρ = 0.88; p < 0.001), with ASFA Category II and III indications accounting for approximately 80% of courses throughout the study period. Procedure-related complications occurred in 76 of 3640 procedures (2%) and were more frequent in Category III than Categories I and II (3% vs. 1% and 2%; p < 0.001). Rates of treatment goal achievement were similar across ASFA categories (84.0% in Category I, 84.8% in Category II, and 75.4% in Category III; p = 0.11). Overall, 28-day mortality was 13%, including 4% in Category I, 6% in Category II, and 24% in Category III (p < 0.001). In Category III indications, treatment during 2018-2024 was associated with lower adjusted odds of 28-day mortality compared with 2011-2017 (aOR 0.33; 95% CI 0.13-0.83; p = 0.02). TPE use in our single center has expanded substantially, particularly for lower-evidence indications. Despite this shift, TPE remains safe and is associated with similar response rates across categories. Improved adjusted survival over time was observed in Category III.