Plasma exchange in acute liver failure

Acute liver failure is a life-threatening condition that requires intensive medical management or liver transplant for survival. Plasma exchange has been investigated as a supportive intervention to provide a bridge to hepatic recovery or to liver transplant. This review aims to explain the physiologic rationale, provide historical context, and review recent evidence on the use of plasma exchange in acute liver failure.

Recent studies paint a mixed picture of plasma exchange's role in the current armamentarium for the management of acute liver failure. Although multiple meta-analyses have shown a survival benefit from plasma exchange, the results from original studies published in the interim are less consistent, with some showing a survival benefit and others not. Further, the literature on this topic is quite heterogeneous with respect to baseline patient characteristics, etiologies of acute liver failure, the dose of plasma exchange administered, and the outcomes assessed. The takeaways and limitations of recent evidence will be discussed.

Plasma exchange has a clear physiologic basis for use in acute liver failure, and multiple prospective studies have shown its ability to improve survival. The effectiveness of plasma exchange, however, depends on appropriate patient selection and timely initiation.