Navigating the therapeutic tightrope: Precision use of plasmapheresis and continuous renal replacement therapy in liver failure

Table 5 Key studies on continuous renal replacement therapy in acute-on-chronic liver failure

Ref.	Design	GRADE	Sample size	Etiology	CRRT regimen used	Key findings (detailed)	Effect estimates
Saraiva et al[8], 2020	Retrospective cohort	Moderate	120	ACLF with AKI (mixed, predominantly alcohol and viral)	CVVHDF (dose 25-35 mL/kg/hour, RCA preferred, early vs late initiation)	CRRT in ACLF-AKI; early initiation improved renal recovery, reduced sepsis, and provided a survival benefit	90-day survival 45% vs 25% (early vs late, P < 0.01) AKI recovery 55%
Zhang et al[21], 2019	Meta-analysis	High	500 (10 studies)	Liver failure (cirrhosis/ACLF with AKI)	Varied CRRT modes (mostly CVVHDF/CVVH, RCA vs heparin)	RCA is safer than heparin in liver failure CRRT; lower bleeding, effective clearance	Complication RR: 0.80 (95%CI: 0.65-0.99) I2 = 12%
Pourcine et al[71], 2021	Prospective cohort	Moderate	40	Severe liver impairment (cirrhosis/ACLF)	RCA-CRRT (CVVHDF, citrate 3-4 mmol/L, dose approximately 30 mL/kg/hour)	RCA in liver impairment: Low toxicity, stable hemodynamics, prolonged filter lifespan	Citrate toxicity 5%. Filter lifespan increasing 20% (P < 0.05)
Ma et al[72], 2025	Retrospective cohort	Low	198	ACLF-AKI (mixed, HBV predominant)	CRRT alone vs CRRT + TPE (CVVHDF, dose 30-40 mL/kg/hour)	No added benefit of TPE combo vs CRRT alone for MELD reduction or survival	MELD reduction similar (P > 0.05), 28-day survival approximately 50% (no difference)
Maiwall and Sharma[73], 2025	Prospective cohort	High	236 (AKI-3: 78)	ACLF with stage 3 AKI (mixed, alcohol/HBV predominant)	CRRT (mostly CVVHDF, dose not specified, initiated in 59%)	Rapid AKI-3 progression; CRRT modest AKI resolution benefit, but no significant TFS improvement; high mortality	CRRT use 59% AKI resolution 28% vs 9% (P = 0.04), 28-day TFS 23% vs 16% (P = 0.31), 90-day TFS 18% 90-day mortality 82%
Staufer et al[74], 2017	Retrospective cohort	Moderate	78	Cirrhosis with ACLF (68% ACLF, mostly grade 2-3)	RRT (continuous and intermittent, predominantly CRRT in ICU)	High mortality independent of LT; low renal recovery; CLIF-C ACLF score best predictor	ICU mortality 82% 90-day mortality 91% 1-year mortality 92%. Renal recovery 13% bridged to LT 14% CLIF-C ACLF AUC: 0.866

GRADE: Grading of recommendations assessment, development and evaluation; CRRT: Continuous renal replacement therapy; ACLF: Acute-on-chronic liver failure; AKI: Acute kidney injury; CVVHD: Continuous veno-venous hemodialysis; RCA: Regional citrate anticoagulation; CVVH: Continuous veno-venous hemofiltration; RR: Relative risk; CI: Confidence interval; TPE: Therapeutic plasma exchange; HBV: Hepatitis B virus; MELD: Model for end-stage liver disease; TFS: Transplant-free survival; ICU: Intensive care unit; LT: Liver transplantation; CLIF-C ACLF: Chronic Liver Failure Consortium Acute-on-Chronic Liver Failure; AUC: Area under the curve.