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

Abstract

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.

Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis

“…Eventually, 24 11–15,31–49 studies met inclusion criteria and were included in the meta-analysis. Nineteen 12–15,33,36–38,40–49 studies assessed PE in ACLF, 4 11,31,32,35 studies assessed PE in ALF, and 1 34 study assessed PE in both ALF and ACLF. The selection process is summarized in the PRISMA diagram in Figure 1.…”

“…A total of 20 12–15,33,34,36–49 studies that assessed PE in ACLF were included (involving a total of 5705 patients: 2856 received PE and 2849 received SMT). Twelve 13–15,34,36,37,40,43,45,47–49 studies were retrospective cohorts, 4 38,40,44,46 were prospective cohorts, 2 33,42 were RCTs, 1 12 was case-control, and 1 41 was a nonrandomized trial. All the included studies were published between December 2005 and December 2022.…”

“…Males represented most of the patients (81.1% of the total patients). Fourteen 33,34,36,38,40–44,46–49 studies were conducted in China, 4 12,14,15,45 in India, 1 37 in Bangladesh, and 1 13 in Germany. Twelve 33,36,38,40–44,47–49 studies included only ACLF patients due to HBV, 2 12,14 studies included alcohol-associated ACLF patients, and 6 13,15,34,37,45,46 studies included ACLF patients with mixed etiology.…”

“…Fourteen 33,34,36,38,40–44,46–49 studies were conducted in China, 4 12,14,15,45 in India, 1 37 in Bangladesh, and 1 13 in Germany. Twelve 33,36,38,40–44,47–49 studies included only ACLF patients due to HBV, 2 12,14 studies included alcohol-associated ACLF patients, and 6 13,15,34,37,45,46 studies included ACLF patients with mixed etiology. Of the 20 included studies, 7 12,14,41,43,45,47,48 studies used APASL guidelines and 3 13,15,44 studies used EASL guidelines to define ACLF.…”

“…Among the 20 studies, 5 13,33,34,42,46 studies included patients bridged to LT; and overall, only 2.1% underwent LT (122/5,705). Across the 20 studies, 10 12,13,15,36–38,41–43,45 studies used PE alone, 9 33,34,39,40,44,46–49 studies included combined modality of PE with other ALSS modalities, and 1 14 study included a combined modality of PE with steroid therapy.…”