Therapeutic Plasma Exchange for Acute and Acute-on-Chronic Liver Failure: A Randomized Pilot Study Comparing...

Area of Science:

• Hepatology
• Critical Care Medicine
• Transplantation Immunology

Background:

• Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are associated with high short-term mortality.
• Liver transplantation is the primary treatment, but access is limited in regions relying on living-donor transplantation.
• Therapeutic plasma exchange (TPE) is a potential bridge therapy, yet data from resource-limited systems are scarce.

Purpose of the Study:

• To evaluate the feasibility and effectiveness of TPE as a bridging strategy for ALF and ACLF in a resource-limited tertiary care setting.
• To compare standard medical therapy (SMT) with standard-volume TPE (SVPE) and high-volume TPE (HVPE).

Main Methods:

• A prospective randomized pilot study involving 46 adults with ALF or ACLF.
• Patients were assigned to SMT (n=15), SVPE (n=16; 1.5-2.0 plasma volumes), or HVPE (n=15; 8-12 L/day for 3 days).
• Outcomes assessed included changes in ALT, bilirubin, INR, MELD-Na score, complications, and 90-day mortality.

Main Results:

• Both TPE groups showed greater improvements in liver function markers (ALT, bilirubin, INR) and MELD-Na score compared to SMT alone.
• HVPE led to the most significant MELD-Na reduction but had higher complication rates (infections, neurological).
• SVPE demonstrated a favorable safety-effectiveness profile, and both TPE groups had lower 90-day mortality than SMT.

Conclusions:

• Protocolized TPE is feasible and can improve short-term outcomes for ALF and ACLF patients in resource-limited settings.
• SVPE emerges as a potentially safer and more scalable bridging strategy for patients awaiting liver transplantation.