Thrombotic Thrombocytopenic Purpura Follow-up

  • Author: Theodore Wun, MD, FACP; Chief Editor: Emmanuel C Besa, MD   more...
 
Updated: Oct 3, 2011
 

Further Inpatient Care

  • Patients with thrombotic thrombocytopenic purpura (TTP) should remain hospitalized until at least a partial response, such as resolution of altered mental status, improved platelet count, and reduced LDH with stable hemoglobin, is achieved.
  • In some patients, intravenous access will become a concern.
    • Large-bore dual-lumen apheresis catheters are now readily available and many are now placed by interventional radiology services.
    • Patients and/or a caregiver can be instructed in the proper care of these catheters.
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Further Outpatient Care

  • The necessary outpatient follow-up for patients with TTP and HUS who have entered a complete or partial response is not well defined.
    • Anecdotal reports of increased relapse rates upon abrupt cessation of plasma exchange have resulted in many apheresis services tapering off plasma exchange over the course of 2-3 weeks.
    • However, this practice has not been validated in any prospective or retrospective analysis.
  • Recommendations are that the patient be seen every week for 2 weeks and, if stable, every 2 weeks for a month.
    • During this time, weekly determination of a complete blood count and LDH are performed.
    • If the platelet count drops or the LDH starts to rise, another course of 5 plasma exchanges is reinstituted.
    • If the patient remains stable for a month, the frequency of the follow-up is decreased.
  • The relapse rate is 13-36%, and recurrences as many as 9 years later have been reported.
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Transfer

  • Transfer to a facility able to perform apheresis therapy is part of the initial management of these patients.
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Complications

  • If patients recover from the acute episode of TTP or HUS, generally, no long-term complications occur.
  • Complications can be divided into disease-related and treatment-related.
    • Disease-related complications are rare. Persistent neurologic abnormalities can occur after otherwise successful treatment of TTP. Abnormalities may result from actual stroke. Persistent renal impairment to the point of requiring dialysis is rare, although mild renal impairment may persist for weeks to months.
    • Treatment-related complications include fluid overload or allergic reactions from plasma infusion. Apheresis catheters can become thrombosed or infected. During the apheresis, hypotension can occur. Paresthesias are related to hypocalcemia from the anticoagulant acid-citrate dextrose (ACD) most commonly used in apheresis procedures; however, this is transient. Long-term complications include the small risk of a blood-borne infection.
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Prognosis

  • The overall response rate to plasma exchange is 75-90%.
  • The early mortality rate is 10-20%.
  • Long-term survival is largely dependent on the presence or absence of serious underlying comorbidities such as cancer, HIV infection, or solid organ transplantation. In the authors' series of 126 patients, the estimated 10-year survival rate of patients without comorbid conditions was 82%, compared to a survival rate of 50% if comorbid conditions were present.
  • A clinical severity score, incorporating the presence or absence of neurologic symptoms, creatinine, platelet count, and hemoglobin, was shown to be predictive of 30-day mortality in the authors' retrospective analysis. The absence of fever and a higher creatinine level was associated with a higher rate of relapse. However, upon further analysis of a larger cohort of patients (as yet unpublished), these factors are no longer predictive.
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Contributor Information and Disclosures
Author

Theodore Wun, MD, FACP  Professor of Medicine, Professor of Pathology and Laboratory Medicine, University of California Davis School of Medicine; Chief of Hematology/Oncology, Program Director, Veterans Affairs Northern California Health Care System; Medical Director, University of California Davis CCRC

Theodore Wun, MD, FACP is a member of the following medical societies: American Association of Blood Banks, American College of Physicians, American Federation for Medical Research, American Society for Blood and Marrow Transplantation, American Society of Hematology, and Southwest Oncology Group

Disclosure: Nothing to disclose.

Coauthor(s)

Wadie F Bahou, MD  Chief, Division of Hematology, Hematology/Oncology Fellowship Director, Professor, Department of Internal Medicine, State University of New York at Stony Brook

Wadie F Bahou, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Nothing to disclose.

Specialty Editor Board

Wadie F Bahou, MD  Chief, Division of Hematology, Hematology/Oncology Fellowship Director, Professor, Department of Internal Medicine, State University of New York at Stony Brook

Wadie F Bahou, MD is a member of the following medical societies: American Society of Hematology

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Marcel E Conrad, MD  Distinguished Professor of Medicine (Retired), University of South Alabama College of Medicine

Marcel E Conrad, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for the Advancement of Science, American Association of Blood Banks, American Chemical Society, American College of Physicians, American Physiological Society, American Society for Clinical Investigation, American Society of Hematology, Association of American Physicians, Association of Military Surgeons of the US, International Society of Hematology, Society for Experimental Biology and Medicine, and Southwest Oncology Group

Disclosure: No financial interests None None

Rajalaxmi McKenna, MD, FACP  Southwest Medical Consultants, SC, Department of Medicine, Good Samaritan Hospital, Advocate Health Systems

Rajalaxmi McKenna, MD, FACP is a member of the following medical societies: American Society of Clinical Oncology, American Society of Hematology, and International Society on Thrombosis and Haemostasis

Disclosure: Nothing to disclose.

Chief Editor

Emmanuel C Besa, MD  Professor, Department of Medicine, Division of Hematologic Malignancies, Kimmel Cancer Center, Jefferson Medical College of Thomas Jefferson University

Emmanuel C Besa, MD is a member of the following medical societies: American Association for Cancer Education, American College of Clinical Pharmacology, American Federation for Medical Research, American Society of Clinical Oncology, American Society of Hematology, and New York Academy of Sciences

Disclosure: Nothing to disclose.

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Differential diagnosis of thrombotic thrombocytopenic purpura/hemolytic-uremic syndrome.
Peripheral smear from a patient with thrombotic thrombocytopenic purpura: Red blood cells are fragmented and appear as schistocytes. Certain schistocytes have the appearance of helmet cells (H). Spheroidal cells often are present (S). Occasional nucleated erythroid precursors may be present.
 
 
 
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