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

Table 6 Key studies on therapeutic plasma exchange and continuous renal replacement therapy in acute liver failure (both combined and sequential)

Ref.	Design	GRADE	Sample size	Etiology	TPE/CRRT regimen	Key findings (detailed)	Effect estimates
Thanh et al[62], 2023	Case series	Low	10	Pediatric dengue-induced ALF	Combined TPE + CRRT (SV-TPE 1-1.5 volumes + CVVHDF 30-40 mL/kg/hour)	Vietnamese pediatric dengue-ALF; combined improved outcomes, rapid toxin/ammonia clearance	Survival 80%. Ammonia decreasing 50% in 24 hours (P < 0.05)
Jackson et al[75], 2024	Retrospective cohort	Moderate	50	Pediatric ALF (mixed)	Combined TPE + CRRT (SV-TPE + CVVHDF, dose 35-50 mL/kg/hour)	United States pediatric; combined as a bridge to LT/recovery; improved neuro/renal function	Transplant-free survival 44% HE resolution 70%
Colak and Ocak[76], 2024	Retrospective cohort	Low	30	Pediatric ALF (mixed, viral/toxin)	Combined TPE + CRRT (SV-TPE + CVVHDF)	Turkish pediatric; combined effective for stabilisation; low complications	The improvement 70%, survival 67%
Vo et al[77], 2023	Prospective cohort	Moderate	15	Pediatric dengue-shock ALF	Combined TPE + CRRT (SV-TPE + high-volume CVVH)	Vietnamese; combined reduced shock duration and ammonia levels	Ammonia decreasing 50%, ICU stay decreasing 3 days (P = 0.04)
Trepatchayakorn et al[78], 2021	Case series	Low	5	Pediatric ALF (dengue/toxin)	Combined TPE + CRRT	Thai pediatric; combined bridged to recovery; effective toxin clearance	Survival 60%, bilirubin decreasing 35%
Ruhatiya et al[79], 2025	Retrospective observational (propensity-matched)	Low	99 (after matching; original 222, exclusions 34)	ALF, excluding yellow phosphorus poisoning and Wilson’s disease	CRRT alone vs sequential CRRT + PLEX (plasma exchange, details not specified)	Indian adult ALF; no benefit from adding PLEX to CRRT; potential harm in transplanted patients; similar ICU/hospital stay	Non-transplant survival: 30.6% (CRRT) vs 16.1% (CRRT + PLEX), P = 0.251. Transplant survival: 100% (CRRT) vs 70.6% (CRRT + PLEX), P = 0.046. Overall, no benefit, possible harm

GRADE: Grading of recommendations assessment, development and evaluation; TPE: Therapeutic plasma exchange; CRRT: Continuous renal replacement therapy; ALF: Acute liver failure; SV-TPE: Standard-volume therapeutic plasma exchange; CVVHD: Continuous veno-venous hemodialysis; LT: Liver transplantation; HE: Hepatic encephalopathy; CVVH: Continuous veno-venous hemofiltration; ICU: Intensive care unit; PLEX: Plasma exchange.