Therapeutic plasma exchange does not reduce vasopressor requirement in severe acute liver failure: a retrospective case series

Abstract

BackgroundIn acute liver failure (ALF) therapeutic plasma exchange (TPE) improves laboratory measures of liver function. In patients with ALF requiring minimal vasoactive support TPE has also been shown to provide haemodynamic benefits including an increase in systemic blood pressure. However the haemodynamic effects of TPE in patients with severe ALF requiring moderate or high dose vasopressor therapy has not been reported. We retrospectively examined the haemodynamic effects of TPE in a cohort of patients with severe ALF requiring vasopressor therapy.MethodsPhysiological, laboratory and treatment data were collected on all patients with ALF who received TPE between January 2000 and December 2012. All patients were managed in the intensive care unit of a tertiary referral centre for ALF and liver transplantation.The primary outcome measures were changes in mean arterial pressure (MAP), vasopressor score and the ratio of vasopressor score to MAP (vasopressor dependency index (VDI)) from baseline prior to TPE through to 12 hours after completion of TPE. Secondary outcome measures were changes in other routinely collected physiological variables and laboratory results. Results are presented as median (interquartile range (IQR)). Outcome measures were evaluated using a mixed effect model.ResultsThirty nine TPE were performed in 17 patients with ALF (13 paracetamol poisoning). All TPE were performed with a centrifugal apheresis system (duration 130 minutes (IQR 115 – 147.5), plasma volume removed 5.1% body weight (IQR 4.6 – 5.5). Baseline values for primary outcome measures were: MAP 82 mmHg (IQR 72 – 92.5), vasopressor score 8.35 (IQR 3.62 – 24.6) and VDI 0.10 (IQR 0.05 – 0.31).MAP was significantly higher immediately after TPE compared to baseline (p = 0.039), however when corrected for change in vasopressor requirement there was no significant change in VDI with TPE (p = 0.953). Twelve hours after TPE the MAP, vasopressor score and VDI were not significantly different from baseline (p = 0.563, p = 0.317 and p = 0.214 respectively).ConclusionIn this cohort of patients with severe ALF centrifugal TPE did not significantly affect vasopressor requirements.Electronic supplementary materialThe online version of this article (doi:10.1186/s12871-015-0017-9) contains supplementary material, which is available to authorized users.

Hemodynamic stability in liver failure patients undergoing therapeutic plasma exchange

“…Larsen and colleagues postulated that filtration method of TPE removed a circulating substance or “humoral factor,” perhaps an endotoxin with a high molecular weight, responsible for the hyperdynamic circulation in ALF. While Wiersema et al postulated that, if the mechanism of clearance is adsorption rather than filtration, hemodynamic changes may not occur with centrifugal TPE . Contrary to this, we found significant changes in hemodynamic parameters with centrifugal TPE.…”

“…In our study, the volume of plasma removed was almost half that used by Larsen and colleagues even then we found a significant effect on hemodynamic parameters. Contrary to our finding, Wiersema et al did not find any significant effect on hemodynamic parameters with similar volumes of plasma removal …”

“…The management strategy for ALF patients is to restore and preserve vital organ function and mitigate or limit the progression of MOF until either spontaneous liver regeneration occurs or a suitable donor liver becomes available for liver transplantation (LT) . A central component of supportive care is vasopressor therapy for distributive shock …”

Prevalent metabolic derangement and severe thrombocytopenia in ABO-incompatible liver recipients with pre-transplant plasma exchange

“…Currently, ABO-I LDLT comprises approximately 20% of the total annual number of LDLT cases in Asian institutions 10 . In addition, recent studies are actively investigating the efficacy of TPE as a rescue and bridging treatment to LT for acute liver failure 11 , 12 .…”

Why do we need extracorporeal blood purification for sepsis and septic shock?

“…For many years, plasma exchange has been suggested as an adjunctive therapy for patients with sepsis or septic shock but still remains an unproven therapy due to conflicting data from uncontrolled human case reports and limited human trials …”