Growing Evidence for Survival Benefit with Plasma Exchange to Treat Liver Failure

Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score‐matched analysis

“…In recent years, TPE has emerged as one of the most commonly used ELSS in patients with PALF. 8,24,25 Various mechanisms have been described for the action of TPE in PALF, including the modulation of pro-and antiinflammatory cytokines, removal of toxins, and replacement of coagulation factors. Larsen et al demonstrated a significant reduction in phenotypic markers of monocyte activation (CD163, CD64, and CCR7) and neutrophil adhesion (L-selectin), as well as a decrease in circulating levels of pro-inflammatory mediators such as TNF-α, IL-6, and IL-8 in patients with ALF undergoing TPE.…”

“…9 Recently, TPE has been shown to clear acute inflammatory macromolecules such as Von Willebrand factor (VWF), which can accumulate in the sinusoids, leading to a functional sinusoidal obstruction and compromised microcirculation. 24,25 Interestingly, increased levels of VWF predict poor outcomes in rodenticide-induced hepatotoxicity, an etiology in which TPE has been found to be particularly beneficial. 23,26 Other postulated mechanisms for the role of TPE in ALF include removal of ammonia, improved cerebral blood flow velocity, decreased coma scores, increased hepatic blood flow, and replacement of coagulation factors.…”

“…31 Pre-LT TPE may also improve post-LT outcomes in PALF, as suggested in a recent study in children where patients receiving TPE could be extubated earlier and had a shorter intensive care unit (ICU) stay post-living donor LT. 32 Although TPE appears to be well tolerated in patients with ALF, 9,13 there are several concerns, including local complications such as port-related infection, bleeding, inadvertent arterial puncture, and transfusion-related complications such as transfusion-associated circulatory overload, transfusion-related acute lung injury, sepsis, and citrate (anti-coagulant) toxicity. 24 Jorgensen et al demonstrated the safety and tolerability of TPE in children with PALF. 16 There is no consensus regarding the ideal volume of plasma that needs to be exchanged, and benefits have been shown with high-, standard-, and lowvolume TPE.…”

“…9,13,23 The higher the volume of plasma exchanged, the greater the strain on blood bank resources, the risk of transfusion-associated complications, and the risk of transfusion-transmitted infections. 24 Future studies should assess the various TPE protocols (high vs standard volume) to define the optimal amount of plasma to be exchanged to obtain a survival benefit without unnecessarily burdening blood bank resources. In contrast to previous studies without a control group, [16][17][18] this study provides a comparative analysis of TPE and matched controls derived from PSM in a relatively homogenous PALF group.…”

Management of Yellow Phosphorus-Induced Acute Liver Failure: A Case Report and Review of Literature

“…No For most patients with ALF secondary to yellow phosphorus poisoning, a liver transplant is the definitive treatment [13]. The American College for Apheresis recommends high-volume PLEX, or plasmapheresis, as the first-choice therapy for ALF of any etiology [14]. Various studies have shown the benefit of PLEX in ALF secondary to different etiologies, including paracetamol poisoning [15], viral hepatitis [16], Wilson's disease [17], and rodenticide poisoning among children [18].…”