Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review

Table 3 Studies included in for study of plasmapheresis in acute liver failure in pediatric cohort

Ref.	Type of study / No. of patients recruited	Study group(s)	Plasma exchange regime	Etiology; Age	Results
Pham et al[19]	Case series	PE, No comparative arm	Plasma volume: Targeted 1-1.25 plasma volumes	Wilsons Disease	Post TPE 9 patients underwent liver transplantation and all 10 patients had at least 6 mo survival
	n = 10
				Age 6-61 yr
					Median days from first to OLT was 1-53 d
			Plasma exchange fluid: 77% of procedures were performed with plasma as sole replacement fluid while 23% used the combination of plasma and 5% albumin
			Median number of TPE: 3.5
Chien et al[22]	Retrospective case series	PE, No comparative arm	Plasma exchange volume: Plasma exchange was usually performed daily for the first 3 d, and then shifted to every other day or every 3 d according to the patient's condition	60% idiopathic, 17% infection, 8% metabolic and immunologic, 4% toxin	11 (48%) had native liver recovery (NLR), 9 (39.1%) died without liver transplant, and 3 (12.9%) received liver transplantation
					The no liver recovery group showed a lower proportion of idiopathic cases, lower peak ammonia level, higher peak alpha fetoprotein (AFP) level, and they had plasma exchange fewer times than the other groups
	n = 23
				Age 0.29-9.25 yr
			Plasma exchange volume: 2–4 times the patient’s estimated plasma volume
			Plasma exchange fluid: FFP
Ide et al[47]	Retrospective case series	PE/CVVHDF, No comparative arm	CVVHDF and PE were applied in all ALF patients	2/17 viral	All laboratory results relating to liver dysfunction decreased significantly after CVVHDF + PE
				1/17 mitochondrial
			PE using 100 mL/kg of FFP per treatment course was implemented once daily for 6 to 8 h until the recovery of coagulopathy		Overall survival rate 88% with median follow up period of 28 mo
				14/17 indeterminate
	n = 17
				Age 1-11 mo [Median Weight 8.0 (2.7-10 kg)]
Verma et al[23]	Case report	PE, No comparative arm	Plasma exchange volume: 1.5-2 h, 1.2 L plasma exchange in each session, in addition to oral D penicillamine and Zinc	Wilson’s disease	Patient improved initially but subsequently deteriorated fter developing renal failure and shock, and died from acute pulmonary hemorrhage.
				Age 5 yr (Weight: 15 kg)
Morgan et al[25]	Case report	PE, No comparative arm	Plasma exchange volume: 1500 mL TPE, 5 single plasma volume over 11 d in addition to trientine	Wilson’s disease	Patient had worsening bilirubin, coagulopathy despite treatment and underwent OLT 12 d after beginning TPE
			Plasma exchange fluid: Plasma	Age 6 years
Zhang et al[24]	Case report	PE, No comparative arm	Plasma exchange volume: 1200 mL each time, with blood flow velocity of 45–50 mL/min, plasma separation speed of 650–750 mL/h, and a replacement time of approximately 2 h. Total 9 exchanges	Wilson’s disease	CPFA started after PE. The patient had rapid recovery of consciousness, removal of copper and stabilization of serum bilirubin and hemoglobin. 9 d after last PE patient underwent liver transplant.
			Plasma exchange fluid: FFP	Age 7 yr (Weight 21 kg)
Yukselmis et al[26]	Case report	PE, No comparative arm	Plasma exchange volume: 1.5 times total blood volume then 1 time for the subsequent courses	Viral (Influenza)	Patient did not require transplantation in light of clinical improvement and PE resulted in complete recovery
			Total 3 sessions PE on top of ostelmavir	Age 4 yr (Weight 16 kg)
			Plasma exchange fluid: FFP
Ponikvar et al[27]	Case report	PE+HD, No comparative arm	Plasma exchange volume: 3 volumes of plasma (12% of body weight of 16 kg) per procedure were exchanged (1972 ± 85 mL; range, 1800–2150 mL). FFP was used as the replacement solution. An equal volume of plasma was removed and replaced	Unknown Excluded viruses and metabolic cause	Patient did not improve after 1 mo and was referred to a liver transplant center and successfully transplanted. Patient also had hyperbaric oxygen (HBO) during treatment
				Age 3 yr (Weight 16 kg)
			A total of 13 PEs, 13 HD sessions, and 9 HBO treatments over a period of 1mo. The initial 4 PEs were followed by HD sessions while the other 8 PE treatments were given simultaneously with HD. There was no renal failure; HD was instituted to improve ammonia elimination
Harmanci et al[48]	Case report / Letter to editor	PE, No comparative arm	Plasma exchange volume: 2.5 L per session	Wilson’s Disease	Patients mental status improved and was extubated and weaned from mechanical ventilation on the fifth day of hospitalization. The patient did not require liver transplantation. The patient was treated continously with zinc and D-penicillamine
				Age 17 yr
			Started daily and continued for 7 consecutive days

CPFA: Continuous plasma filtration adsorption; HBO: Hyperbaric oxygen; PE: Plasma exchange; SMT: Standard medical treatment; ALF: Acute liver failure; HLH: Hemophagocytic lymphohistiocytosis; FFP: Fresh frozen plasma; INR: International normalised ratio; ALT: Alanine aminotransferase; CVVHDF: Continuous venous-venous hemodiafiltration; CHDF: Continuous hemodiafiltration; HBV: Hepatitis B virus; HSV: Herpes simplex virus; LDH: Lactate dehydrogenase; DILI: Drug induced liver injury; AFLP: Acute fatty liver of pregnancy; DILI: Drug induced liver injury; TPE: Therapeutic plasma exchange; AFP: Alphafetoprotein.