Therapeutic plasma exchange in acute liver failure

Abstract

Background: Multi-organ dysfunction in acute liver failure (ALF) has been attributed to a systemic inflammatory response directly triggered by the injured liver.High-volume therapeutic plasma exchange (HV-TPE) has been demonstrated in a large randomized controlled trial to improve survival. Here, we investigated if a more cost-/ resource effective low-volume (LV) TPE strategy might have comparable beneficial effects. Methods: This retrospective study evaluated the effect of LV-TPE on remote organ failure, hemodynamical and biochemical parameters as well as on survival in patients with ALF. Twenty patients treated with LV-TPE in addition to standard medical therapy (SMT) were identified and 1:1 matched to a historical ALF cohort treated with SMT only. Clinical and biochemical parameters were recorded at admission to the intensive care unit and the following 7 days after LV-TPE. Results: Mean arterial pressure increased following first LV-TPE treatments (d0: 68 [61-75] mm Hg vs d7: 88 [79-98] mm Hg, P = .003) and norepinephrine dose was reduced (d0: 0.264 [0.051-0.906] μg/kg/min vs d3: 0 [0-0.024] μg/kg/min, P = .016). Multi-organ dysfunction was significantly diminished following LV-TPE (CLIF-SOFA d0: 17 [13-20] vs d7: 7 [3-11], P = .001). Thirty-day in-hospital survival was 65% in the LV-TPE cohort and 50% in the SMT cohort (Hazard-ratio for TPE: 0.637; 95% CI: 0.238-1.706, P = .369).Abbreviations: ACLF, acute on chronic liver failure; ALF, acute liver failure; CLIF-OF, chronic liver failure-organ failure score; CLIF-SOFA, chronic liver failure-sequential organ failure assessment score; DAMPs, damage associated molecular patterns; FFP, fresh frozen plasma; HE, hepatic encephalopathy; HV-TPE, high-volume therapeutic plasma exchange; IBW, ideal body weight; INR, international normalized ratio; LV-TPE, low-volume therapeutic plasma exchange; MAP, mean arterial pressure; NE, norepinephrine; PCM, paracetamol; PDMS, patient data monitoring system; RRT, renal replacement therapy; SMT, standard medical therapy; SOFA, sequential organ failure assessment; TPE, therapeutic plasma exchange; TRALI, transfusion-related acute lung injury.Markus Busch and Sascha David contributed equally to this study.

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Therapeutic Plasma Exchange in Parvovirus B19-induced Acute Hepatic Failure

“…Stahl et al compared performance of high-volume TPE vs low-volume TPE and found comparable results. 11 It has also been found to be safe and well-tolerated, and it improves the coagulation profile and liver function tests in critically ill liver disease patients. 12 …”

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