PMC6595396_01
Trends in (A) hemoglobin and (B) platelet count in case 1.
CNCS-7-035-01.jpg
PMC6595396_01_CNCS-7-035-01.jpg
Figure1
However, his hemoglobin and platelet count continued to remain low with this therapy, and the patient subsequently received 6 treatments of therapeutic plasma exchange (TPE), over the course of which his hemoglobin and platelet count stabilized and slowly recovered to normal (Figure 1). 
Thrombotic microangiopathy with glomerular capillary thrombi and fragmented red blood cells as noted on renal biopsy in case 1.
CNCS-7-035-02.jpg
PMC6595396_01_CNCS-7-035-02.jpg
Figure2
The biopsy revealed fibrin deposition and fragmented red blood cells within capillary loops and acute tubular injury consistent with thrombotic microangiopathy (Figure 2).
PMC6595396_02
Trends in platelet count and serum creatinine in case 2, both during initial disease presentation (A) and during relapse (B).
CNCS-7-035-03.jpg
PMC6595396_02_CNCS-7-035-03.jpg
Figure3
TPE treatments with fresh frozen plasma (FFP), followed by 3 additional TPE treatments with FFP on alternate days. The patient experienced an anaphylactic reaction during his 4th TPE treatment, but tolerated subsequent treatments without incident. The patient's thrombocytopenia (Figure 3A) and elevated LDH gradually improved and ultimately normalized by the 9th day of his TPE treatment course. Interestingly, his serum creatinine continued to rise after initiation of TPE (Figure 3A), peaking at 2.7 mg/dL on the 3rd day of TPE treatment, then gradually improved, with renal function normalizing by the 9th day of treatment.  He received 8 consecutive daily treatments with TPE, followed by 3 additional TPE treatments on alternate days, with gradual improvement and ultimately normalization of his thrombocytopenia by the 5th day of his TPE treatment course (Figure 3B), and his LDH by the 9th day of his course. With this occurrence of his relapsed thrombotic microangiopathy, his renal dysfunction worsened quickly despite initiation of TPE, with creatinine peaking at 3.6 mg/dL (Figure 3B) and BUN peaking at 82 mg/dL and the development of oliguria on the second day of TPE treatment, necessitating a single hemodialysis treatment, then gradually improved, with renal function normalizing by the 6th day of treatment.
PMC6595396_03