Systematic Review
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jan 14, 2020; 26(2): 219-245
Published online Jan 14, 2020. doi: 10.3748/wjg.v26.i2.219
Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review
Eunice Xiang-Xuan Tan, Min-Xian Wang, Junxiong Pang, Guan-Huei Lee
Eunice Xiang-Xuan Tan, Guan-Huei Lee, National University Health System, Singapore 119228, Singapore
Min-Xian Wang, Junxiong Pang, Centre for Infectious Disease Epidemiology and Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore
Guan-Huei Lee, National University of Singapore, Singapore 119077, Singapore
Author contributions: Lee GH conceptualized and designed the review; Tan EXX and Lee GH carried out the analysis; Tan EXX drafted the initial manuscript; Wang MX and Pang VJX provided statistical support; all authors reviewed and approved the final manuscript as submitted.
Conflict-of-interest statement: All authors have no conflict(s) of interest to declare in relation to this manuscript.
PRISMA 2009 Checklist statement: A PRISMA checklist was used to guide the development of the systematic review.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Guan-Huei Lee, FRCP, MBBS, MRCP, PhD, Assistant Professor, Attending Doctor, Doctor, Senior Consultant, Division of Gastroenterology and Hepatology, National University Hospital, 1E Kent Ridge Rd, Singapore 119228, Singapore.
Received: October 6, 2019
Peer-review started: October 6, 2019
First decision: November 4, 2019
Revised: December 21, 2019
Accepted: January 1, 2020
Article in press: January 1, 2020
Published online: January 14, 2020

Acute liver failure (ALF) and acute-on-chronic liver (ACLF) carry high short-term mortality rate, and may result from a wide variety of causes. Plasma exchange has been shown in a randomized control trial to improve survival in ALF especially in patients who did not receive a liver transplant. Other cohort studies demonstrated potential improvement in survival in patients with ACLF.


To assess utility of plasma exchange in liver failure and its effect on mortality in patients who do not undergo liver transplantation.


Databases MEDLINE via PubMed, and EMBASE were searched and relevant publications up to 30 March, 2019 were assessed. Studies were included if they involved human participants diagnosed with liver failure who underwent plasma exchange, with or without another alternative non-bioartificial liver assist device.


Three hundred twenty four records were reviewed, of which 62 studies were found to be duplicates. Of the 262 records screened, 211 studies were excluded. Fifty-one articles were assessed for eligibility, for which 7 were excluded. Twenty-nine studies were included for ALF only, and 9 studies for ACLF only. Six studies included both ALF and ACLF patients. A total of 44 publications were included. Of the included publications, 2 were randomized controlled trials, 14 cohort studies, 12 case series, 16 case reports. All of three ALF studies which looked at survival rate or survival days reported improvement in outcome with plasma exchange. In two out of four studies where plasma exchange-based liver support systems were compared to standard medical treatment (SMT) for ACLF, a biochemical improvement was seen. Survival in the non-transplanted patients was improved in all four studies in patients with ACLF comparing plasma exchange vs SMT. Using the aforementioned studies, plasma exchange based therapy in ACLF compared to SMT improved survival in non-transplanted patients at 30 and 90-d with a pooled OR of 0.60 (95%CI 0.46-0.77, P < 0.01).


The level of evidence for use of high volume plasma exchange in selected ALF cases is high. Plasma exchange in ACLF improves survival at 30-and 90-d in non-transplanted patients. Further well-designed randomized control trials will need to be carried out to ascertain the optimal duration and amount of plasma exchange required and assess if the use of high volume plasma exchange can be extrapolated to patients with ACLF.

Keywords: Acute-on-chronic liver failure, Acute liver failure, Plasmapheresis, Plasma exchange, Liver failure

Core tip: High volume plasmapheresis has been shown to improve survival in non-transplanted patients with acute liver failure. However, there has not been, to date, a review article that summarizes the different plasmapheresis regimens and its effect on mortality and improvement of liver biochemistry. This review article serves as a summary and appraisal of available literature on plasma exchange in liver failure taking into account the volume of plasma exchange, duration of plasmapheresis, and etiology of liver failure in conjunction with the study outcomes of interest and highlights potential areas which might be essential to include in future good quality randomized controlled trials.