# Presentation of HIV‐Associated Thrombotic Microangiopathy and Response to Therapeutic Plasma Exchange: A 10‐year Retrospective Single‐Centre Cohort Study

## TL;DR

This study examines how HIV-associated thrombotic microangiopathy (HIV-TMA) presents and responds to plasma exchange treatment, finding high mortality rates and a need for better treatment strategies.

## Contribution

This is the first large single-center retrospective study analyzing HIV-TMA outcomes, focusing on mortality, treatment complications, and the impact of plasma exchange.

## Key findings

- HIV-TMA is linked to advanced HIV infection and occurs mostly in young Black women without antiretroviral therapy.
- Neurological deficits are the most common symptom, and mortality remains high despite plasma exchange treatment.
- Sepsis is a frequent complication of plasma exchange and contributes significantly to mortality.

## Abstract

HIV is a significant aetiological factor in thrombotic microangiopathy (TMA) in regions of high seroprevalence, but description of HIV‐associated TMA (HIV‐TMA) remains limited to small case series. We sought to describe the presentation, complications of TPE, and mortality and renal outcomes of HIV‐TMA.

We retrospectively reviewed 98 cases of HIV‐TMA treated with therapeutic plasma exchange (TPE) between 1/1/2010 and 31/12/2020. The effect of HIV infection and clinical presentation on mortality, TPE complications, and renal outcomes were analysed using regression analysis.

TMA is associated with advanced HIV infection (median CD4 count 151 × 106/mm3 cells and median viral load 117500 copies/mL), usually occurs in the absence of antiretroviral therapy (ART), and shows a predilection for young Black women, reflecting TMA risk factors and local demographics of the HIV pandemic. Neurological deficit is the most common presenting feature (54.1%). HIV‐TMA mortality is high despite TPE (49% of cases); better renal function reduces risk of TMA‐attributable death (HR 0.97, 95% CI 0.96–0.99, p < 0.001); use of FFP as infusant is associated with increased risk of mortality (HR 3.96, 95% CI 1.60–9.84, p = 0.003). Sepsis frequently complicates TPE (16.3% of courses) and contributes to excess mortality (20.7% of deaths); risk of infection increases with duration of TPE (OR 1.21, 95% CI 1.07–1.37, p = 0.002), implicating augmented immunosuppression in mortality. HIV infection parameters do not significantly affect risk of mortality or sepsis. Residual renal dysfunction is relatively rare in survivors at follow‐up.

Mortality remains high in HIV‐TMA treated with TPE, and sepsis‐related complications are of concern. Randomized prospective studies are needed to evaluate the use of TPE versus plasma infusion (PI) and infusant choice in HIV‐TMA. Longer duration follow‐up studies are needed to evaluate residual renal dysfunction in survivors of HIV‐TMA.

HIV‐TMA is associated with advanced HIV infection.The disorder carries a significant risk of mortality despite treatment with therapeutic plasma exchange.Further prospective studies are needed to delineate the theoretical benefit of therapeutic plasma exchange over plasma infusion in the treatment of HIV‐TMA.

HIV‐TMA is associated with advanced HIV infection.

The disorder carries a significant risk of mortality despite treatment with therapeutic plasma exchange.

Further prospective studies are needed to delineate the theoretical benefit of therapeutic plasma exchange over plasma infusion in the treatment of HIV‐TMA.