Title: Symptomatic hypocalcemia is uncommon in patients with liver disease undergoing low-volume plasma exchange by...

Citrate-based anticoagulants and blood product replacement during centrifugal plasma exchange (PLEX) can cause hypocalcemia, especially in liver disease where citrate clearance is impaired. This study aimed to determine the incidence and predictors of hypocalcemia in patients undergoing low-volume PLEX (PLEX-LV) for liver failure syndromes.

Consecutive adult patients who underwent centrifugal PLEX-LV (50 % of calculated plasma volume) between 2020 and 2024 were included. Acid citrate dextrose-A was used as the anticoagulant, and all patients received 20 mL of 10 % calcium gluconate intravenously during each session. Serum corrected calcium levels were measured before and 12 h after each session. Hypocalcemia was defined as corrected calcium < 8.4 mg/dl.

A total of 276 patients (75.4 % male; mean age 38.5 years) underwent 924 PLEX-LV sessions for acute-on-chronic liver failure (56.5 %), acute liver injury (13.8 %), acute liver failure (20.3 %), and cholestasis (9.4 %). Alcohol-related liver disease predominated in ACLF (78.2 %), while rodenticide hepatotoxicity was common in ALI/ALF (59.6 %). Post-PLEX hypocalcemia occurred in 39 patients (14.1 %) across 54 sessions (5.8 %), including 29 patients with ALI/ALF (74.4 %), of whom 27/29 had rodenticide toxicity (p < 0.001). Two patients (0.7 %) developed symptomatic hypocalcemia and recovered with calcium supplementation. On univariate analysis, young age (p = 0.01), female gender (p = 0.02), and syndrome type (ACLF v/s ALI/ALF p < 0.001) were significant. On multivariable analysis, the presence of ALI/ALF remained the only independent predictor of hypocalcemia (OR 6.85, p < 0.001).

Symptomatic hypocalcemia is uncommon in liver disease patients undergoing low-volume centrifugal plasma exchange with protocol calcium supplementation. Serial calcium monitoring is advisable in these patients.