Hematopoietic Disorders and TPE, Therapeutic plasma exchange, Clinical Pathology - Full Vignette wit

Описание: Three patients with different hematological disorders are being considered for therapeutic plasma exchange during a busy night when only two procedures can be performed immediately. Each presents unique clinical features such as confusion, bruising, vision changes, or bleeding after a recent illness. How do you identify which patients most urgently need treatment, and what clinical findings should guide your prioritization and decision-making when resources are limited?

VIDEO INFO
Category: Hematopoietic Disorders and TPE, Therapeutic plasma exchange, Clinical Pathology
Difficulty: Easy - Basic level - Suitable for medical students
Question Type: Clinical Pitfalls
Case Type: Multi Patient

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QUESTION
A blood center covering several hospitals asks for real-time input on three patients being considered for therapeutic plasma exchange during a busy evening when staffing allows only two procedures to start now and one to start after midnight. The on-call team wants to avoid common mistakes....

OPTIONS
A. For Patient X with suspected immune TTP, perform daily therapeutic plasma exchange using 5% albumin as the sole replacement fluid to minimize transfusion reactions during the first several sessions.
B. For Patient X with suspected immune TTP, begin daily therapeutic plasma exchange now using fresh frozen plasma as the replacement fluid while ADAMTS13 testing is pending, and avoid prophylactic platelet transfusion.
C. For Patient Y with symptomatic IgM-mediated hyperviscosity, start therapeutic plasma exchange urgently to reduce viscosity and relieve ocular and neurologic symptoms.
D. For Patient Z with likely immune thrombocytopenia and no organ injury, treat with first-line medical therapy such as corticosteroids or IVIG rather than plasma exchange.

CORRECT ANSWER
A. For Patient X with suspected immune TTP, perform daily therapeutic plasma exchange using 5% albumin as the sole replacement fluid to minimize transfusion reactions during the first several sessions.

EXPLANATION
The pitfall is to use albumin-only replacement for suspected immune TTP. In immune TTP, plasma exchange must both remove the inhibitor and replenish ADAMTS13; albumin provides no ADAMTS13 and risks clinical deterioration. ASFA 2023 and the 2025 ISTH focused update continue to emphasize plasma as the replacement fluid for immune TTP and to begin daily exchanges promptly when clinical suspicion is high. The correct pitfall answer proposes daily TPE with 5% albumin as the sole replacement fluid for Patient X-a classic error that should be avoided.

By contrast, starting plasma-based exchange now for Patient X while ADAMTS13 testing is pending and avoiding prophylactic platelets is appropriate. For Patient Y, symptomatic IgM-mediated hyperviscosity with retinal changes warrants urgent TPE to rapidly lower viscosity and relieve symptoms; this is a correct use of TPE where albumin can be acceptable replacement because ADAMTS13 repletion is not the therapeutic target....


Further reading:

Links to sources are provided for optional further reading only. The questions and explanations are independently authored and do not reproduce or adapt any specific third-party text or content.

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