Toronto general hospital controlled trial data plasma exchange therapy in guillain‐barre' syndrome

The mechanism by which plasma exchange (PE) may benefit patients with acute Gillain‐Barre' syndrome (AGBS) is unclear. It is possible, therefore, that the response of patients with AGBS is influenced by the choice of replacement solution (whole plasma vs. albumin or similar protein‐containing solution). This report compares the outcome in 57 patients with AGBS treated at the Toronto General Hospital (TGH) using conventional therapy (27), PE with plasma replacement (15) and PE with albumin replacement (15). Fifteen patients (5 treated conventionally, 8 by PE with plasma replacement, 2 by PE with albumin replacement) were treated before the Baltimore coordinated multicenter trial. Forty‐two patients (22 treated conventionally, 7 by PE with plasma replacement and 13 by PE with albumin replacement) were then entered at the TGH into the multicenter trial. The best outcome was observed in those patients (9) in whom PE was started within 14 days of the first neuropathic symptoms and plasma was used as replacement. The mean improvements in clinical grade in this subgroup of patients of 1.11 at four weeks after starting treatment and 1.71 at six weeks were significantly better than the corresponding improvements in the conventionally treated group of 0.35 (p<0.01) and 0.94 (p<0.05). The response of patients (9) exchanged within 14 days of onset, but replaced with albumin (grade change of 0.67 at four weeks and 0.86 at six weeks), was not significantly different from that of the conventionally treated patients. These data support the need for a randomized trial to compare PE using plasma replacement and PE using albumin replacement in patients with AGBS. The rationale for the use of plasma exchange (PE) in acute Guillain‐Barre 1 syndrome (AGBS) is the evidence that the serum of affected patients may contain demyelinating factors [1], antibodies to peripheral nerve tissue [2] or immune complexes [3,4]. However, the role of these serum factors in causing AGBS is unknown and any beneficial effect of PE in AGBS might be through mechanisms other than removal of these substances. A multicenter controlled trial has demonstrated that, despite our lack of understanding of the pathogenesis of AGBS, plasma exchange is of benefit in this disorder [5]. A similar conclusion has been reached to the contrary [8], most likely because the response to PE is not consistent and because the improvement, compared with conventional treatment, may not be dramatic. In most studies of PE in AGBS, solutions other than whole plasma have been used for fluid replacement. Yet, there is a report that a patient with chronic Guillain‐Barre 1 Syndrome responded to plasma infusion, as well as to PE with plasma replacement [9]. Even though simple removal of plasma factors by PE appears to be of some benefit to patients with AGBS [5], it is possible that the effect of PE would be enhanced if plasma were used for replacement. For example, patients with AGBS might be deficient in a normal plasma component required to remove myelinotoxic factors from their plasma. PE with plasma replacement would then be superior to PE with albumin replacement since the former would not only physically remove the toxic factors but would also promote their clearance by the patient. This paper compares the outcomes of 27 patients with AGBS at the Toronto General Hospital (TGH) treated conventionally, 15 treated with plasma exchange using plasma replacement and 15 treated with plasma exchange using albumin replacement. Forty‐two of the 57 patients were randomly assigned to their therapy as part of the multicenter trial reported by Griffin et al. [5] The other 15 patients were treated at the TGH in 1980 and 1981 before the trial started.