Therapeutic plasma exchange is a safe and effective bridge therapy in patients with alcohol‐associated ACLF not having immediate prospects for liver transplantation—A case‐control, pilot study

Abstract

Background: Therapeutic plasma exchange (TPE) is a well-established treatment modality in acute liver failure patients, but its efficacy in treating acute on chronic liver failure (ACLF) patients is yet to be established. Aim: To assess the efficacy and safety of TPE in patients with alcoholassociated ACLF who were nonresponders to standard medical treatment (SMT) and without immediate prospects for liver transplantation.Methods: Twenty-eight alcohol-related ACLF (grade II) patients (14 cases and 14 controls) were enrolled in the study. Cases underwent standard volume TPE along with SMT while the controls were on SMT alone. The change (baseline to day 10) in laboratory parameters, cytokine concentrations, clinical severity scores along with 30 and 90 day mortality rates were noted and compared between the two groups. The adverse events (AEs) were noted in the groups and analyzed.Results: A total of 51 TPE procedures were performed in 14 patients (average of 3.62 procedures/patient). TPE was effective in reduction of serum bilirubin, ammonia, activated partial thromboplastin time, prothrombin time, international normalized ratio, and severity scores (ACLF Research Consortium, Maddrey's discriminant function, and model for end-stage liver disease) (P < .05).There was no significant difference in the reduction of serum interleukin-6 (IL-6), IL-10, and tumor necrosis factor-α concentrations among cases. Among the cases who received the complete TPE interventions, 30-and 90-day mortality rates were lower in the cases as compared to controls albeit only the 90-day mortality was significantly different. Procedure-related AEs was observed in 2% of procedures. Conclusion: TPE is an effective and well-tolerated bridge therapy in patients with alcohol-associated ACLF of moderate severity not improving on SMT and without immediate prospects for liver transplantation.

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.…”

“…Characteristics of ACLF studies are summarized in Table 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.…”

“…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.…”