COVID-19 Microangiopathy: Insights into plasma exchange as a therapeutic strategy

Baykara, Yigit; Sevgi, Kaan; Akgun, Yamac

doi:10.1016/j.htct.2025.103963

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Review article • Hematol., Transfus. Cell Ther. 47 (4) • 2025 • https://doi.org/10.1016/j.htct.2025.103963 linkcopy

COVID-19 Microangiopathy: Insights into plasma exchange as a therapeutic strategy

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

COVID-19-associated thrombotic microangiopathy has emerged as a severe complication that exacerbates morbidity and mortality in critical cases. Thrombotic microangiopathy, characterized by microvascular thrombosis and endothelial injury, includes conditions like thrombotic thrombocytopenic purpura and atypical hemolytic uremic syndrome. This review investigates therapeutic plasma exchange as a potential strategy to mitigate COVID-19-induced thrombotic microangiopathy, examining its role in removing pro-inflammatory cytokines, immune complexes, and pro-thrombotic factors. Additionally, it highlights the synergistic effects when therapeutic plasma exchange is combined with treatments such as complement inhibitors and immunosuppressants. Preliminary evidence, drawn from case reports and early trials, supports the efficacy of therapeutic plasma exchange in improving outcomes for COVID-19-associated thrombotic microangiopathy. However, larger randomized controlled trials are necessary to definitively establish its place in COVID-19 management, particularly for high-risk and transplant patients with underlying immunological vulnerabilities.

Keywords
COVID-19; Plasma exchange; Thrombotic microangiopathy; Coagulopathy

Study/Authors	Patients and Condition	Treatment Provided	Clinical Results
Elkayam et al. [⁴¹]	1 patient with severe COVID-19 and TMA	TPE + dexamethasone	Improved renal function, decreased vasopressor requirement, increased platelet counts, normalization of hemolysis parameters
Zhang et al. [⁴²]	3 patients with severe COVID-19 and ARDS	TPE	Resolution of respiratory symptoms, improved CT lesions, negative nucleic acid tests, normalized temperature
Shi et al. [⁴³]	1 patient with COVID-19, respiratory failure, shock, diarrhea	TPE followed by IVIG	Immediate clinical improvement
Arulkumaran et al. [⁴⁴]	5 patients with severe COVID-19 complicated by ARDS	TPE	Improved oxygenation and reversal of thrombo-inflammatory markers; high VWf:ADAMTS13 ratio observed
Eriko et al. [⁴⁵]	1 HIV-positive patient with COVID-19-associated TMA	TPE, glucocorticoids, hemodialysis, antihypertensives	Improved renal function and thrombocytopenia
Vrecko et al. [⁴⁶]	8 patients: 1 with TTP, 7 with aHUS and COVID-19	TTP patient: TPE, steroids, caplacizumab aHUS patients: TPE ± steroids, C5 complement inhibitor, IVIG	Complete hematologic recovery in TTP patient. Rapid hematologic recovery in all aHUS patients; full renal recovery in only one aHUS patient
Cohen et al. [⁴⁷]	1 patient with COVID-19-associated TTP	TPE, steroids, caplacizumab	Improved abdominal pain, normalization of platelets, hemoglobin, and ADAMTS13
Tehrani et al. [⁴⁸]	4 patients with COVID-19-associated TTP (2 treated with TPE)	TPE ± Rituximab	Patient 1: Normalization of hemoglobin and platelets Patient 2: No initial response; later response with Rituximab but eventual death due to hemorrhagic stroke

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Associação Brasileira de Hematologia, Hemoterapia e Terapia Celular (ABHH) R. Dr. Diogo de Faria, 775 cj 133, 04037-002, São Paulo / SP - Brasil - São Paulo - SP - Brazil
E-mail: htct@abhh.org.br

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