Therapeutic Plasma Exchange in Critically Ill Children with Neuroimmunological Disorders: A Single-Center Cohort Study.

Background

Therapeutic plasma exchange (TPE) is increasingly used in pediatric neuroimmunological disorders; however, evidence remains limited, particularly for rare neuroinflammatory and infection-triggered encephalopathy syndromes. We aimed to describe the clinical characteristics, treatment patterns, and outcomes of critically ill children who underwent TPE for neuroimmunological disorders in a tertiary pediatric intensive care unit.

Methods

This retrospective observational study included consecutive patients younger than 18 years who received TPE for neuroimmunological disorders between September 2020 and December 2025. Demographic characteristics, disease spectrum, TPE indications, treatment details, neuroimaging findings, cerebrospinal fluid (CSF) characteristics, and clinical outcomes were reviewed. Neurological outcome at hospital discharge was assessed using the Pediatric Cerebral Performance Category (PCPC) score.

Results

Twenty-two patients were included. The median age was 104 months (IQR, 62.3-151.8), and 50% were female. Guillain-Barré syndrome (GBS) was the most common diagnosis (n = 6), followed by autoimmune encephalitis (n = 6), infection-triggered encephalopathy syndrome (ITES)/acute necrotizing encephalopathy (ANE) spectrum disorders (n = 4), myelin oligodendrocyte glycoprotein antibody-associated disease (MOGAD) (n = 3), acute disseminated encephalomyelitis (ADEM) (n = 2), and mild encephalitis/encephalopathy with a reversible splenial lesion (MERS) (n = 1). The median interval from symptom onset to TPE initiation was 9 days (IQR, 6-13), and patients underwent a median of 7 TPE sessions (IQR, 5-10.5). Nine patients (40.9%) required invasive mechanical ventilation and four (18.1%) required vasoactive support. Favorable neurological outcomes at hospital discharge were observed in 63.6% of patients, whereas 36.4% had unfavorable neurological outcomes. Mortality occurred in 13.6% of patients and was confined to severe encephalopathic syndromes. No major TPE-related complications were observed.

Conclusions

TPE was used across a heterogeneous spectrum of pediatric neuroimmunological disorders, including both guideline-supported and non-standard indications. Approximately one-quarter of patients had conditions not specifically addressed in current ASFA recommendations, highlighting the gap between real-world clinical practice and the available evidence base. Multicenter studies are needed to better define the optimal role, timing, and patient selection criteria for TPE in pediatric neuroimmunology.