European Journal of Cardiovascular Medicine

Guillain-Barré syndrome (GBS) is an acute polyradiculoneuropathy typically triggered by infections such as Campylobacter jejuni or viruses including cytomegalovirus and Zika [1,2]. Standard therapies—intravenous immunoglobulin (IVIg) and therapeutic plasma exchange (PLEX)—have proven efficacy [3], but cost and infrastructure limit access, especially in low- and middle-income countries (LMICs) [4].Small volume plasma exchange (SVPE), a modified PLEX approach using lower exchange volumes, has shown promise in preliminary studies [5,6]. It requires less technical support and is more affordable, yet its clinical utility remains under-investigated. This study assesses the effectiveness and safety of SVPE in adult patients with moderate to severe GBS in a tertiary care center.

Study Design and Participants

This prospective cohort study was conducted at Government General Hospital, Gandhi medical college, Secunderabad, Telangana. A total of 50 patients who were diagnosed of Guillain Barre Syndrome fulfilling the Brighton criteria were taken from the pool of inpatients from various medical wards and Neurology wards. Institutional Ethics Committee approved the study protocol and written informed consent was taken from all relatives of participant.

Inclusion criteria were:

• Adults (≥18 years)
• GBS diagnosed by Brighton criteria level 1 or 2 [7]
• GBS disability score ≥3 on admission

Patients with prior immunotherapy, severe cardiac instability, or contraindications to central venous access were excluded.

Procedure

Technique of small volume plasma exchange:[8,9]

1. Collection of blood: blood is collected by the usual venesection and phlebotomy, from the antecubital vein as used for blood donation. A double blood bag system is used and about 350ml blood is collected per session.
2. Separation of plasma: Double-blood bag is centrifuged in a refrigerated centrifuge at a speed of 1500-2500G (fast spin) for 10 minutes. The double blood bag is kept in a plasma extractor, which separates out the plasma in one bag while the packed cells are left behind the original bag.
3. Transfusion of packed cells: Bag with plasma is discarded in blood bank and the bag with packed red cells is sent to ward, where it is transfused back into the patient.
4. Transfusion of plasma: After every two sessions of manual plasmapheresis, the patient is transfused about 200ml of plasma to make up for the lost plasma. About 200 ml of plasma is thus removed per session of manual plasmapheresis. An individual patient may require 10-15 sessions for treatment. Around 50 ml of plasma per kg body weight was removed.

Replacement fluid included 5% albumin or isotonic saline. Antibiotic prophylaxis and thromboprophylaxis were administered as per institutional protocol.

Outcome Measures

Primary outcome:

• Improvement of ≥1 grade on GBS disability score at 4 weeks

Secondary outcomes:

• Requirement of invasive mechanical ventilation
• Hospital stay duration
• Adverse events (e.g., hypotension, catheter-related infections)

Statistical Analysis

Data were analyzed using SPSS v26.0. Categorical variables were reported as frequencies and percentages; continuous variables as means ± standard deviation. 

Baseline Characteristics

42 patients were included (mean age 39.8 ± 14.2 years; 64% male). Antecedent infections were reported in 76%, mostly upper respiratory. GBS variants included AIDP (71%), AMAN (21%), and AMSAN (8%).(Table1)

Primary Outcome (Table 2)

At 4 weeks, 76.2% (32/42) improved by ≥1 grade in disability score, 19% (8/42) required mechanical ventilation and No mortality was recorded during hospitalization. Time to walking unaided (among responders) was 19.3 ± 6.2 days.Mean hospital stay was 14.3 ± 5.7 days.

Secondary Outcomes (Table 3)

Minor complications observed were hypotension (7%), catheter-related infection (5%). No serious bleeding or thrombotic events

Table 1: Baseline Characteristics of Study Participants (n = 42)

Table 2: Clinical Outcomes after Small Volume Plasma Exchange

Table 3: Adverse Events During SVPE Therapy

Guillain-Barré syndrome (GBS) is an acute immune-mediated polyneuropathy characterized by ascending muscle weakness and areflexia, often following a viral or bacterial infection. It remains a significant cause of acute flaccid paralysis worldwide and frequently requires intensive care, particularly in cases involving respiratory muscle involvement. Intravenous immunoglobulin (IVIg) and plasma exchange (PLEX) are established treatments shown to reduce disease severity and improve outcomes when administered early in the disease course [3,10]. However, both treatments are expensive and resource-intensive.

Our findings suggest SVPE is a viable, safe, and cost-effective alternative to conventional PLEX in managing moderate to severe GBS. The response rate (76.2%) is consistent with prior studies involving standard PLEX or IVIg [3,5].In resource-limited environments, SVPE provides an accessible treatment that retains therapeutic benefit while reducing the financial burden.

This study aimed to assess the effectiveness and safety of small volume plasma exchange (SVPE) as a low-cost, logistically feasible alternative to conventional PLEX in GBS management. Our results show that SVPE is associated with a substantial rate of functional improvement at 4 weeks, with 76.2% of patients showing ≥1 grade improvement in GBS disability score. These findings are promising and comparable to outcomes from previous trials on conventional PLEX and IVIg, which typically report 4-week improvement rates between 65% and 85% [1,11].This result is consistent with recent studies, such as one conducted by Singh et al. (2023), where SVPE was found to significantly shorten the time to recovery and improve the overall disability scores in GBS patients, similar to the results seen with conventional plasma exchange.[12]

Moreover, our study aligns with findings from Bedi et al. (2023), who reported that SVPE achieved rapid improvements in motor function and overall clinical scores, which are critical for reducing long-term disability in GBS patients. The improvement in recovery time is particularly significant as earlier intervention has been linked to better outcomes in GBS, such as a lower risk of respiratory failure and a quicker return to independent mobility.[13]

SVPE is predicated on the concept that repeated low-volume plasma exchanges can achieve immunomodulatory effects similar to standard PLEX by gradually reducing circulating autoantibodies and immune complexes. GBS pathophysiology—particularly in the axonal forms (AMAN, AMSAN)—involves immune-mediated injury to peripheral nerves by antibodies directed against gangliosides, which activate complement and promote demyelination or axonal damage [14]. Even limited removal of these antibodies through serial low-volume exchanges may attenuate this process, supporting the biological plausibility of SVPE.

In our cohort, the majority of patients had the AIDP variant, consistent with the distribution observed in South Asian populations [6]. The mean time to treatment was 5.3 days, falling within the critical window for effective immunotherapy. Previous studies have emphasized the importance of early intervention in reducing progression to severe disability and respiratory failure [15], which may explain the favorable outcomes in our cohort. Moreover, only 19% of patients required mechanical ventilation—lower than the typically reported 25–30% in untreated or late-treated GBS cases [16].

SVPE was well-tolerated by the majority of patients in our study, with only 12% of patients had mild adverse events such as hypotension and minor bruising at the catheter insertion site. This is consistent with the findings of Ray.et al.(2022), who reported a low incidence of complications associated with SVPE, emphasizing that it is a safer alternative compared to traditional PE.The safety profile of SVPE was also favorable. Hypotension occurred in 7% of patients, and catheter-related infections in 5%. These rates are lower than those seen with standard PLEX, where hypotension can occur in up to 15–20% of sessions and infection risk increases with central venous catheter duration [18,19]. No major complications such as anaphylaxis, thrombosis, or bleeding were observed, reinforcing SVPE's tolerability.

Another key finding of our study is the economic benefit of SVPE. The cost of SVPE was significantly lower than that of standard PE or IVIg treatments, with a reduction in the treatment cost by approximately 40%. This finding is consistent with research by Iqbal et al. (2023), which concluded that SVPE is a highly cost-effective treatment.The reduced use of plasma and the less complex equipment required for SVPE contribute to its lower cost, making it a viable option for healthcare systems in low-income regions[20].Conventional PLEX requires large volumes of 5% albumin or fresh frozen plasma (FFP), specialized apheresis machines, and round-the-clock trained staff. In contrast, SVPE can be performed with simpler setups and uses less replacement fluid, reducing both direct and indirect costs. A cost-effectiveness study in India estimated that SVPE reduces treatment costs by over 60% compared to IVIg [5].

Nonetheless, this study has several limitations. Most importantly, it was an observational, single-arm study without a control group. While the clinical outcomes are encouraging, the lack of a comparator group prevents definitive conclusions about efficacy relative to standard treatments. Furthermore, the sample size was relatively small and derived from a single center, which may limit generalizability. Future studies should include longer follow-up durations to capture sustained recovery, relapse rates and late complications. Another consideration is patient selection. SVPE may not be suitable for rapidly progressive GBS or those with fulminant presentations where high-volume immunomodulation is critical.

In conclusion, SVPE appears to be a safe, effective, and low-cost treatment modality for patients with moderate to severe GBS in resource-constrained settings. The majority of patients in our study experienced clinically significant improvement with minimal adverse effects. Given its affordability and feasibility, SVPE holds great potential for broader implementation, particularly in regions where access to IVIg and conventional PLEX is limited. As GBS continues to be a significant health challenge globally, particularly in resource-limited settings, SVPE offers a promising option that can improve access to effective treatment and reduce healthcare costs.However, randomized controlled trials comparing SVPE with standard therapies are urgently needed to confirm these findings and guide treatment guidelines.

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