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

Figure 3 Proposed flowchart designed to guide clinicians in the precise use of therapeutic plasma exchange and continuous renal replacement therapy for managing acute liver failure and acute-on-chronic liver failure. The flowchart outlines decision-making pathways for patient selection, therapy initiation, sequencing (sequential or combined therapeutic plasma exchange-continuous renal replacement therapy), regimen selection, and monitoring, based on evidence from 2016-2025 (PubMed, EMBASE, Cochrane) and standardised guidelines (e.g., American Society for Apheresis, Asian Pacific Association for the Study of the Liver). ALF: Acute liver failure; ACLF: Acute-on-chronic liver failure; TPE: Therapeutic plasma exchange; CRRT: Continuous renal replacement therapy; HE: Hepatic encephalopathy; INR: International normalised ratio; AIH: Autoimmune hepatitis; HV: High volume; SV: Standard volume; AKI: Acute kidney injury; CVVH: Continuous veno-venous hemofiltration; CVVHDF: Continuous veno-venous hemodiafiltration; RCA: Regional citrate anticoagulation; MELD: Model for end-stage liver disease; HBV: Hepatitis B virus; FFP: Fresh frozen plasma.