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A Novel Anticoagulation Strategy for High-Volume Plasma Exchange in Pediatric Patients With Acute Liver Failure

Amanda M Walker1,2, Kevin D Smith3,4, Joella L Slowik1

  • 1Division of Pediatric Critical Care, Nemours Children's Hospital, Delaware, Wilmington, Delaware, USA.

Pediatric Transplantation
|October 22, 2025
PubMed

Insights

High-volume plasma exchange (HVPE) is safe for pediatric acute liver failure. Combining citrate and heparin anticoagulation reduces citrate lock complications without increasing bleeding risk, aiding recovery or transplantation.

Area of Science:

  • Pediatrics
  • Hepatology
  • Critical Care Medicine

Background:

  • Pediatric acute liver failure (PALF) presents significant morbidity and mortality.
  • High-volume plasma exchange (HVPE) is a vital blood purification technique for PALF patients, enabling survival for liver transplantation or recovery.
  • Current HVPE protocols require optimized anticoagulation strategies.

Purpose of the Study:

  • To describe a novel anticoagulation protocol using citrate and heparin for HVPE in pediatric acute liver failure patients.
  • To evaluate the safety and efficacy of this combined anticoagulation strategy during HVPE.

Main Methods:

  • Retrospective review of pediatric patients (<18 years) with acute liver failure undergoing HVPE.
  • Analysis of anticoagulation protocols, focusing on citrate-only versus citrate-plus-heparin.
  • Assessment of adverse events, including bleeding, citrate lock, hypotension, and hypothermia.

Main Results:

  • Twelve HVPE encounters in 11 pediatric patients were analyzed.
  • Switching to citrate plus heparin significantly reduced citrate lock incidence from 80% to 25% (OR 0.083).
  • No bleeding complications or life-threatening adverse events were observed; non-severe events occurred in 44% of treatments.

Conclusions:

  • HVPE is a safe and well-tolerated treatment for pediatric acute liver failure, serving as a bridge to transplantation or recovery.
  • Adding heparin to citrate anticoagulation during HVPE effectively decreases citrate lock frequency.
  • The combined anticoagulation strategy enhances HVPE safety in pediatric acute liver failure without increasing bleeding risk.
Abstract

Keywords:
anticoagulationchildrencitrate lockcritical careheparinshocktransplant

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