Techniques, indications, and toxicity of therapeutic hemapheresis in children

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Abstract
Although therapeutic hemapheresis has grown dramatically in the past decade, its utilization and popularity in pediatrics remain limited. The lack of well‐defined indications for treatment and technical difficulties in the management of hemapheresis for small patients have prevented its widespread use. However, there have been more than 130 reports describing the use of hemapheresis in children less than 15 years of age, including more than 20 reports describing it in children less than 5 years. Only one controlled trial of hemapheresis in children has been published. It studied the use of plasma exchange for the treatment of diabetes mellitus. In general, practitioners depend upon the accepted indications in adults to justify usage of this therapy in children. Unfortunately, major differences exist in the adult and pediatric presentation of certain diseases and there has not been universal acceptance of the indications for this therapy in children. Numerous technical difficulties continue to plague the development of hemapheresis therapy in pediatrics and therefore continue to limit the number of studies undertaken. The major technical difficulties include vascular access and excessive extracorporeal volume. These problems are not insurmountable since several patients less than 1 year of age have been successfully treated by hemapheresis. The various techniques used in these cases will be discussed. Additional problems unique to the pediatric population are the difficulty in getting approval for research studies that involve minors, the complexity of informed consent, the problem of patient cooperation and compliance, and the difficulty of explaining a complicated procedure to children of varying developmental levels. Although there are a few detailed studies, complications in the treatment of pediatric cases are usually a combination of technical problems and untoward reactions, and it is difficult to compare these studies with those published involving adult patients.