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Research Snapshot Theater: Future of Critical Care, Pediatric I

Earlier Administration of TPE for Pediatric DAH Leading to Improved Outcomes

Tuesday, March 24, 2026
8:45 AM - 9:45 AM Central Time
Location: Connections Central - RST 03

  • Jack S. Thomas, n/a

    University of Tennessee Health Science Center, Tennessee

    Disclosure(s): No relevant financial relationship(s) to disclose.

  • DK

    Dai Kimura, n/a

    M.D.
    University of Tennessee Health Science Center/Le Bonheur Children's Hospital

    Disclosure information not submitted.

Introduction: Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening pulmonary complication in children, presenting with hemoptysis, anemia, diffuse infiltrates, and respiratory failure. Autoimmune diseases such as systemic lupus erythematosus (SLE) and ANCA-associated vasculitis (AAV) account for 30–40% of pediatric DAH cases. Severe presentations often require advanced respiratory support, including mechanical ventilation (MV) or extracorporeal membrane oxygenation (ECMO). Standard immunosuppressive therapy includes high-dose corticosteroids, cyclophosphamide, and rituximab. While prospective studies and treatment algorithms are available for adult autoimmune-associated DAH, pediatric evidence is limited to case reports and small series. We aimed to characterize the clinical course, management, and outcomes of pediatric patients with autoimmune-associated DAH requiring intensive care.


Methods: We conducted a retrospective cohort study at a single tertiary pediatric institution, identifying six patients admitted to the PICU from 2013–2024 with DAH secondary to SLE or AAV.


Results: All six patients (1 male, 5 females; age 14–17 years) were critically ill. Five required MV (13–84 days), two required high-frequency oscillatory ventilation (6–10 days), and three required ECMO (2 VA, 1 VV; 8–45 days). Four had new-onset autoimmune diagnoses on admission. All received high-dose corticosteroids and therapeutic plasma exchange (TPE) (3–8 sessions); adjunctive therapies included cyclophosphamide, rituximab, IVIG, mycophenolate mofetil, and hydroxychloroquine. TPE was initiated early in most cases, with rituximab administered ≥48 hours apart to minimize clearance. All patients on ECMO were successfully decannulated; one died from Pseudomonas sepsis post-decannulation. The remaining patients survived to discharge.


Conclusions: Autoimmune-associated DAH in pediatric patients carries high morbidity, often requiring advanced respiratory support and multimodal immunosuppression. Early initiation of TPE was well-tolerated and may improve outcomes. Larger prospective pediatric studies are warranted to guide standardized treatment protocols for these critically ill children.