Plasma Exchange in Acute and Acute on Chronic Liver Failure

Maiwall, Rakhi; Sarin, Shiv Kumar

doi:10.1055/s-0041-1730971

Cited by 23 publications

(34 citation statements)

References 166 publications

(212 reference statements)

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“…In contrast, other artificial support systems did not reach statistical significance in this meta-analysis (51). Overall, several studies have indicated that PE might be a feasible treatment strategy in ACLF (52,53). However, due to the low quality of evidence, larger RCTs are required, which are currently undertaken, for example by the APACHE trial.…”

Section: Management Of Aclf Before Ltmentioning

confidence: 79%

Liver Transplantation as a Cornerstone Treatment for Acute-On-Chronic Liver Failure

Schulz¹,

Gu²,

Schnitzbauer³

et al. 2022

Transpl Int

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Acute-on-chronic liver failure (ACLF) is a distinct clinical syndrome, characterized by acute decompensation (AD) of liver cirrhosis, severe systemic inflammation, intra- and extrahepatic organ failures, and a high short-term mortality. Liver transplantation (LT) is a potentially life-saving treatment for patients with decompensated liver cirrhosis and, due to the high mortality rates, particularly for ACLF patients. In the last decade, a plethora of studies has produced compelling evidence in favor of LT in ACLF, demonstrating high post-LT survival rates and excessive waitlist mortality. The importance of LT in these patients is underscored by the fact that no specific therapy for ACLF is available yet, rendering expeditious life-saving LT to be the only feasible treatment option for some ACLF patients. This review aims to provide an overview on pathophysiology, clinical trajectory, and clinical management of ACLF and to delineate the current literature regarding perspectives and limitations of LT as a life-saving treatment option for ACLF patients.

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Section: Management Of Aclf Before Ltmentioning

confidence: 79%

Liver Transplantation as a Cornerstone Treatment for Acute-On-Chronic Liver Failure

Schulz¹,

Gu²,

Schnitzbauer³

et al. 2022

Transpl Int

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“… 91 Therapeutic plasma exchange would allow recovery of native liver function by facilitating liver regeneration through reducing systemic inflammatory mediators and removing toxic substances. Studies related to therapeutic plasma exchange have shown improvement in systemic hemodynamics and encephalopathy in patients with ACLF, 92 but none of these studies have assessed renal function improvement specifically in patents with HRS-AKI.…”

Section: Treatment Of Hrsmentioning

confidence: 99%

“… Source: Adapted and modified from Maiwall and Sarin. 92 AKI: acute kidney injury; CKD, chronic kidney disease; Cr Cl, creatinine clearance; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; HUS, hemolytic uremic syndrome; OPTN, Organ Procurement and Transplantation Network; SLK, simultaneous liver–kidney; SLKT, simultaneous liver–kidney transplant. …”

Section: Treatment Of Hrsmentioning

confidence: 99%

“…Any patient who is registered on the kidney waitlist between 60 and 365 days after transplantation and is either on chronic hemodialysis or has an eGFR ⩽20 ml/min will qualify for increased priority after (a) Liver transplantation alone, or (b) SLK recipient who experienced immediate and permanent non-function of the transplanted kidney. After confirmation of the eligibility criteria by the transplant candidate's transplant nephrologist, the transplant program must document continued eligibility in the candidate's medical records at least weekly Source: Adapted and modified from Maiwall and Sarin 92. AKI: acute kidney injury; CKD, chronic kidney disease; Cr Cl, creatinine clearance; eGFR, estimated glomerular filtration rate; ESRD, end-stage renal disease; HUS, hemolytic uremic syndrome; OPTN, Organ Procurement and Transplantation Network; SLK, simultaneous liver-kidney; SLKT, simultaneous liver-kidney transplant.…”

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confidence: 99%

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Management of hepatorenal syndrome in liver cirrhosis: a recent update

Bera

2022

Therap Adv Gastroenterol

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Hepatorenal syndrome (HRS) is a serious form of renal dysfunction in patients with cirrhosis and ascites. It is an important component of the acute-on-chronic liver failure (ACLF) syndrome. Significant recent changes in the understanding of the pathophysiology of renal dysfunction in cirrhosis include the role of inflammation in addition to hemodynamic changes. The term acute kidney injury (AKI) is now adopted to include all functional and structural forms of acute renal dysfunction in cirrhosis, with various stages describing the severity of the condition. Type 1 hepatorenal syndrome (HRS1) is renamed HRS-AKI, which is stage 2 AKI [doubling of baseline serum creatinine (sCr)] while fulfilling all other criteria of HRS1. Albumin is used for its volume expanding and anti-inflammatory properties to confirm the diagnosis of HRS-AKI. Vasoconstrictors are added to albumin as pharmacotherapy to improve the hemodynamics. Terlipressin, although not yet available in North America, is the most common vasoconstrictor used worldwide. Patients with high grade of ACLF treated with terlipressin are at risk for respiratory failure if there is pretreatment respiratory compromise. Norepinephrine is equally effective as terlipressin in reversing HRS1. Recent data show that norepinephrine may be administered outside the intensive care setting, but close monitoring is still required. There has been no improvement in overall or transplant-free survival shown with vasoconstrictor use, but response to vasoconstrictors with reduction in sCr is associated with improvement in survival. Non-responders to vasoconstrictor plus albumin will need liver transplantation as definite treatment with renal replacement therapy as a bridge therapy. Combined liver and kidney transplantation is recommended for patients with prolonged history of AKI, underlying chronic kidney disease or with hereditary renal conditions. Future developments, such as the use of biomarkers and metabolomics, may help to identify at risk patients with earlier diagnosis to allow for earlier treatment with improved outcomes.

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“…Plasma exchange can be performed either by membrane separation or centrifugal separation. Systemic heparin anticoagulation membrane TPE is a common TPE treatment method in patients with liver failure [2]. In recent years, regional citrate anticoagulation (RCA) has become a favorable alternative to heparin in patients at risk from excessive bleeding.…”

mentioning

confidence: 99%

The efficacy and safety of regional citrate anticoagulation centrifugal plasma exchange is equivalent to those of systemic heparin anticoagulation membrane plasma exchange in patients with liver failure: a single center retrospective cohort study

Zhu

Liu

et al. 2022

Preprint

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Background: The purpose of this study is to compare with the efficacy and safety of regional citrate anticoagulation centrifugal plasma exchange and systemic heparin anticoagulation membrane plasma exchange in patients with liver failure.Methods: This study was a single center and retrospective study. All enrolled liver failure patients were treated with therapeutic plasma exchange. The patients treated by regional citrate anticoagulation centrifugal plasma exchange were defined as RCA group and those treated by systemic heparin anticoagulation membrane plasma exchange were defined as heparin group, respectively. Survival and clinical characteristics, including patients’ age, gender, total bilirubin, serum creatinine, international normalized ratio, platelet count, types of liver failure, arterial blood gas analysis, the model for end-stage liver disease (MELD) score, and occurrence of complications were compared between the two groups. Survival analyses of two groups and subgroups classified by MELD score were performed by Kaplan-Meier method and were compared by the log-rank test.Results: There were 69 patients enrolled in this study, 51 patients in RCA group and 18 patients in heparin group respectively. In overall patients, the 28-day mortality rate was 41% in RCA group and 39% in heparin group (P > 0.05). The 90-day mortality rate was 59% in RCA group and 50% in heparin group (P > 0.05). MELD best-fit value is 30, and area under the ROC curve is 0.7208 in the transplantation free patients with liver failure in both RCA group and heparin group. There was no significant difference in the occurrence of complications between the two groups.Conclusions: In conclusion, our study demonstrates that the efficacy and safety of regional citrate anticoagulation centrifugal plasma exchange is equivalent to those of systemic heparin anticoagulation membrane plasma exchange in patients with liver failure. RCA plasma exchange at an interval of 48 hours in patients with acute or acute-on-chronic liver failure may be an effective in reducing the occurrence of the complication of citrate accumulation. RCA centrifugal plasma exchange treatment can achieve a good prognosis and well tolerance, especially in MELD<30 patients with liver failure.

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Plasma Exchange in Acute and Acute on Chronic Liver Failure

Cited by 23 publications

References 166 publications

Liver Transplantation as a Cornerstone Treatment for Acute-On-Chronic Liver Failure

Liver Transplantation as a Cornerstone Treatment for Acute-On-Chronic Liver Failure

Management of hepatorenal syndrome in liver cirrhosis: a recent update

The efficacy and safety of regional citrate anticoagulation centrifugal plasma exchange is equivalent to those of systemic heparin anticoagulation membrane plasma exchange in patients with liver failure: a single center retrospective cohort study

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