Comparative Efficacy of Standard-Volume Plasma Exchange Versus High-Volume Plasma Exchange in Patients With...

High-volume therapeutic plasma exchange (HV-TPE) is an established treatment modality in acute liver failure; however, its role in acute-on-chronic liver failure (ACLF) and its comparative efficacy versus standard-volume TPE (SV-TPE) remain unclear. This single-center, prospective, randomized pilot study conducted over 2 years (2021-2023) compared the efficacy of HV-TPE and SV-TPE in patients with ACLF. Twenty-two consecutive patients with ACLF Grade I and II without prospects for liver transplantation were enrolled; 11 patients underwent HV-TPE, and 11 underwent SV-TPE. In addition to tolerability, the effects of both TPE modalities on coagulation parameters, biochemical indices, cytokine levels (IL-6, IL-10, and TNF-α), and clinical severity scores-including the Asia Pacific Association for the Study of the Liver ACLF Research Consortium (AARC) score, Maddrey discriminant function (MDF), Model for End-Stage Liver Disease (MELD), and Child-Turcotte-Pugh (CTP) score-were assessed before and after therapy. Length of hospital stay and 30-day and 90-day mortality were also compared. Both HV-TPE and SV-TPE resulted in significant improvement in coagulation parameters, including prothrombin time (PT), activated partial thromboplastin time (aPTT), and international normalized ratio (INR), along with significant reductions in serum total and conjugated bilirubin, alkaline phosphatase, total protein, and serum ammonia (p < 0.05). Significant improvement in serum urea (p = 0.004), serum creatinine (p = 0.004), and serum lactate (p = 0.007) was observed only in the HV-TPE group. Clinical severity scores (AARC, MDF, MELD, and CTP) improved significantly in both groups (p < 0.05). There were no significant differences between the groups in 30-day mortality (27% vs. 27%, p = 1.00), 90-day mortality (36% vs. 45%, p = 0.40), or changes in cytokine levels. Procedure-related adverse events were infrequent and comparable between HV-TPE (6.8%) and SV-TPE (5.7%). In conclusion, both HV-TPE and SV-TPE effectively improved clinical severity scores in patients with ACLF; however, a definitive difference in mortality benefit could not be demonstrated in this study. Trial Registration: CTRI/2019/06/019660 (dated 14 June 2019).