Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial

Maiwall, Rakhi; Bajpai, Meenu; Singh, Akanksha; Agarwal, Tanvi; Kumar, Guresh; Bharadwaj, Ankit; Nautiyal, Nidhi; Tevethia, Harsh Vardhan; Jagdish, Rakesh Kumar; Rangachari, Vijayaraghavan; Choudhury, Ashok; Mathur, Rajendra Prasad; Hidam, Ashini; Pati, Nirupma; Sharma, Manoj Kumar; Kumar, Anupam; Sarin, Shiv Kumar

doi:10.1016/j.cgh.2021.01.036

Cited by 57 publications

(42 citation statements)

References 24 publications

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“…In our experience, standardvolume TPE effectively improves survival in patients with ALF. 40 In another retrospective study, a low-volume strategy of TPE improved mean arterial pressure, vasopressor dose, and multiorgan dysfunction in patients with ALF compared with SMT. 99 In patients with ACLF, most of the reported literature favors SVP (►Table 2) Trials comparing SVP to HVP are required in patients with ALF and ACLF to understand the appropriate strategy of PE in liver failure.…”

Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 97%

“…The majority of these patients achieved spontaneous clinical recovery. 40 Patients who were nonresponders required more intense therapy and these patients had higher sequential organ failure assessment (SOFA) scores and renal involvement. The adverse effects were more frequent in patients who require more prolonged treatment.…”

Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 99%

“…Metabolic abnormalities, loss of platelets, and coagulation factors were the most typical adverse effects. Repeated TPE can be associated with loss of beneficial growth factors 40 and coagulation factors, such as factor XIII and fibrinogen, predisposing to bleeding. [101][102][103][104] In patients requiring repeated TPE or those with hypofibrinogenemia or ACLF, whether performing selective plasma exchange alternately with TPE would be better needs to be explored.…”

Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 99%

“…The two randomized controlled trials performed in ALF have shown FFP as the most appropriate replacement fluid for patients with ALF. 26,40 In patients with ACLF, while most studies have used FFPs as the replacement fluid, some have reported a combination of FFP and albumin (►Tables 1 and 2).…”

Section: Plasma Exchange In Liver Failure Maiwall and Sarinmentioning

confidence: 99%

“…Also, PE improves bilirubin, arterial lactate, and organ failure scores in these patients. 26,40 There is currently a need for dynamic prognostic models in patients subjected to PE for deciding the need for an emergency liver transplant versus continuation of therapy. We consider a rebound increase in the parameters after two to three sessions of PE as markers of nonresponse and consideration of emergency liver transplant in patients with ALF and ACLF.…”

Section: Decision Making For Liver Transplant In Patients On Plasma Exchangementioning

confidence: 99%

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Plasma Exchange in Acute and Acute on Chronic Liver Failure

Maiwall

Sarin

2021

Semin Liver Dis

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Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.

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Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 97%

Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 99%

Section: Prescription For Therapeutic Plasma Exchange: Deciding the Exchange Volume And Intensitymentioning

confidence: 99%

Section: Plasma Exchange In Liver Failure Maiwall and Sarinmentioning

confidence: 99%

Section: Decision Making For Liver Transplant In Patients On Plasma Exchangementioning

confidence: 99%

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Plasma Exchange in Acute and Acute on Chronic Liver Failure

Maiwall

Sarin

2021

Semin Liver Dis

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Acute Liver Failure: Indian Perspective

Acharya

2021

Clinical Liver Disease

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Acute liver failure (ALF) is an infrequent, unpredictable clinical sequela of acute liver injury (ALI) in an individual without any previous history of liver disease and is associated with a mortality rate of 50% to 75%. 1 Encephalopathy subsequent to ALI (icterus) is the usual presentation in ALF, and coagulopathy (international normalized ratio [INR] >1.5) is frequent. 1 The etiology of ALF is geographically distinct with varying icterus-encephalopathy interval (IEI), from 4 weeks in India to 26 weeks in the United States. 2 In the United Kingdom, United States, and Europe, ALF etiology is heterogenous (paracetamol, nonsteroidal anti-inflammatory drugs [NSAIDs], autoimmune hepatitis [AIH], and metabolic diseases). 2 In India, ALF has a homogeneous etiology (hepatitis virus in 90%). 1,2 Etiology influences phenotypic presentation.In the United Kingdom, Japan, and France, ALF with IEI of 1 week or 10 days had significantly higher survival than with IEI of longer than 1 week or 10 days, leading to subclassification in ALF as hyperacute (IEI ≤ 7 days), acute (IEI > 7 days to ≤4 weeks), and subacute (IEI of 5 to ≤12 weeks). 3 In India, as a result of homogenous etiology, rapidity of encephalopathy does not influence survival, and all ALF cases have IEI of ≤4 weeks. Therefore, the Indian National Association for the Study of Liver (INASL) consensus in ALF defines it "as a clinical syndrome characterized by encephalopathy, jaundice, and prolonged prothrombin time

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Therapeutic plasma‐exchange improves short‐term, but not long‐term, outcomes in patients with acute‐on‐chronic liver failure: A propensity score‐matched analysis

Swaroop

Arora

Biswas

et al. 2022

J of Clinical Apheresis

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Background Acute‐on‐chronic liver failure (ACLF) is associated with a high short‐term mortality rate in the absence of liver transplantation. The role of therapeutic plasma exchange (TPE) in improving the outcomes of ACLF and acute decompensation (AD) is unclear. In this retrospective analysis, we aimed to determine the impact of TPE on mortality in patients with ACLF. Methods ACLF patients receiving TPE with standard medical treatment (SMT) were propensity score matched (PSM) with those receiving SMT alone (1:1) for sex, grades of ACLF, CLIF C ACLF scores, and the presence of hepatic encephalopathy. The primary outcomes assessed were mortality at 30 and 90 days. Survival analysis was performed using Kaplan Meier survival curves. Results A total of 1151 patients (ACLF n = 864 [75%], AD [without organ failure] n = 287 [25%]) were included. Of the patients with ACLF (n = 864), grade 1, 2, and 3 ACLF was present in 167 (19.3%), 325 (37.6%), and 372 (43.0%) patients, respectively. Thirty‐nine patients received TPE and SMT, and 1112 patients received only SMT. On PSM analysis, there were 38 patients in each group (SMT plus TPE vs SMT alone). In the matched cohort, the 30‐days mortality was lower in the TPE arm compared to SMT (21% vs 50%, P = .008), however, the 90‐day mortality was not significantly different between the two groups (36.8% vs 52.6%, P = .166); HR, 0.82 (0.44‐1.52), P = .549. Conclusion TPE improves short‐term survival in patients with ACLF, but has no significant impact on long‐term outcomes. Randomized control trials are needed to obtain a robust conclusion in this regard.

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Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial

Cited by 57 publications

References 24 publications

Plasma Exchange in Acute and Acute on Chronic Liver Failure

Plasma Exchange in Acute and Acute on Chronic Liver Failure

Acute Liver Failure: Indian Perspective

Therapeutic plasma‐exchange improves short‐term, but not long‐term, outcomes in patients with acute‐on‐chronic liver failure: A propensity score‐matched analysis

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