Introduction:
The use of plasma exchange (PLEX) to treat liver failure has become more commonplace in view of observational data in favour of the same . The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure (ACLF) is mediated by systemic inflammation triggered by both microbial and non-microbial factors. Therapeutic plasma exchange (TPE) has been proven to be an efficacious therapy in autoimmune conditions and altered immunity, with more recent data supporting its use in the management of liver failure. Our experience of treating patients with acute-(ALF) or acute-on-chronic (ACLF) liver failure with PLEX is shared here.
Methods:
Patients with ALF or ACLF, encephalopathy, model for end-stage liver disease (MELD- Na) score ≥ 20 were included. PLEX cycles were repeated every 24 h or 48 h, each of 2.5–4.0 h duration with 50 ml/kg body weight of plasma being removed per session. PLEX cycle was repeated till either of the end-points were achieved (i) MELD Na < 20 for 48 h or reaches below the baseline, whichever is lower, (ii) hemodynamic instability (iii) sepsis or (iv) or outcome achieved. Outcome of interest was categorized as favorable (discharged in stable condition) or unfavorable (death or discharge in moribund condition). Data are expressed as median (interquartile range).
Results:
Thiry three patients (age 40.5 [1 – 62] years; male 25; ALF 14 (yellow phosphorous poisoning- 9, viral hepatitis- 4, paracetamol overdose- 1) , ACLF 14; MELD- Na 32 [24–37] were included. Participants received 4 (1-8) cycles of PLEX during 15 (11–31) days of hospitalization. Overall, serum bilirubin, INR, creatinine, MELD Na scores were significantly improved after PLEX. Twelve patients (36%) had a favourable outcome. Those with favorable outcome had significant improvement in serum bilirubin, INR, and MELD Na scores as compared to those with unfavourable outcome. 4 patients were lost to follow up as they were discharged against medical advice. 17 patients expired.
Conclusions:
PLEX may be effective in patients with ALF or ACLF. Newer therapies aimed at improving survival in liver failure rely on the removal of toxins and inflammatory mediators and simultaneously supporting the synthetic and metabolic function of the liver while awaiting either Liver Transplantation or spontaneous hepatic regeneration. No ideal extracorporeal liver replacement therapy yet exists. TPE remains a safe, reliable, and feasible treatment. While high volume plasmaphereses has been approved as a treatment of ALF, low volume PLEX appears to be as effective and safer with better utilisations of blood products. Future studies should identify which etiologies of ALF and ACLF are best served by TPE, and confirm the optimal exchange volume, frequency, and duration of treatment.
I have no potential conflict of interest to disclose.
I did not use generative AI and AI-assisted technologies in the writing process.