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World J Hepatol. Aug 27, 2021; 13(8): 904-915
Published online Aug 27, 2021. doi: 10.4254/wjh.v13.i8.904
Therapeutic plasma exchange in liver failure
Abimbola Chris-Olaiya, Aanchal Kapoor, Kristin S Ricci, Christina C Lindenmeyer
Abimbola Chris-Olaiya, Aanchal Kapoor, Department of Critical Care, Cleveland Clinic, Cleveland, OH 44195, United States
Kristin S Ricci, Department of Hematology and Medical Oncology, Cleveland Clinic, Cleveland, OH 44195, United States
Christina C Lindenmeyer, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, OH 44195, United States
Author contributions: Chris-Olaiya A designed the outline and drafted the article; Ricci K made critical revisions related to intellectual content and approved the final version; Kapoor A provided input in the writing and made critical revisions; Lindenmeyer C coordinated the writing of the paper, made critical revisions, and approved the final version.
Conflict-of-interest statement: The authors have none to disclose.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (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: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Christina C Lindenmeyer, MD, Assistant Professor, Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, 9500 Euclid Avenue A51, Cleveland, OH 44195, United States. lindenc@ccf.org
Received: March 7, 2021
Peer-review started: March 7, 2021
First decision: March 29, 2021
Revised: April 2, 2021
Accepted: July 20, 2021
Article in press: July 20, 2021
Published online: August 27, 2021
Abstract

The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure (ACLF) is thought to be mediated by overwhelming systemic inflammation triggered by both microbial and non-microbial factors. Therapeutic plasma exchange (TPE) has been proven to be an efficacious therapy in autoimmune conditions and altered immunity, with more recent data supporting its use in the management of liver failure. Few therapies have been shown to improve survival in critically ill patients with liver failure who are not expected to survive until liver transplantation (LT), who are ineligible for LT or who have no access to LT. TPE has been shown to reduce the levels of inflammatory cytokines, modulate adaptive immunity with the potential to lessen the susceptibility to infections, and reduce the levels of albumin-bound and water-bound toxins in liver failure. In patients with acute liver failure, high volume TPE has been shown to reduce the vasopressor requirement and improve survival, particularly in patients not eligible for LT. Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF. TPE may be most favorably employed as a bridge to LT in patients with ACLF. In this review, we discuss the efficacy and technical considerations of TPE in both acute and acute-on-chronic liver failure.

Keywords: Therapeutic plasma exchange, High volume plasma exchange, Acute liver failure, Acute-on-chronic liver failure, Cirrhosis, Liver transplantation, Cytokines

Core Tip: Multi-organ failure accompanying liver failure is mediated by overwhelming systemic inflammation and altered host immunity. Therapeutic plasma exchange has been proven to be an efficacious therapy in autoimmune conditions and altered immunity. We review the efficacy and technical considerations of therapeutic plasma exchange in both acute and acute-on-chronic liver failure.