Plasma exchange does not improve overall survival in patients with acute liver failure in a real-world cohort

Abstract

Background & aims: Therapeutic plasma exchange (PEX) has emerged as a potential treatment option for patients with acute liver failure (ALF). The effect of PEX on survival outcomes outside of clinical trials is not yet well established. In this study we aimed to evaluate the real-world use and outcomes of PEX for the treatment of ALF.

Methods: This multicentre retrospective cohort study included consecutive patients with ALF admitted to all seven tertiary liver transplant centres in the UK between June 2013 and December 2021. Changes in clinical variables following PEX treatment were assessed, while overall survival and transplant-free survival up to hospital discharge in patients receiving PEX were compared to those receiving standard medical therapy Propensity score matching was performed to control for intergroup covariates and selection bias.

Results: We included 378 patients with ALF (median [IQR] age 36 (28-48), 64% [n = 242] female) of whom 120 received PEX. There was a significant improvement in most clinical variables following PEX, including median dose of noradrenaline (reduction from 0.35 μg/kg/min [0.19-0.70 μg/kg/min] to 0.16 μg/kg/min [0.08-0.49], p = 0.001). There was no significant difference between PEX and standard medical therapy groups in overall survival (51.4% vs. 62.6%, respectively, p = 0.12) or transplant-free survival (42.6% vs. 53.1%, p = 0.24).

Conclusion: PEX is now frequently used in the management of patients with ALF in the UK. It is associated with significant improvement in haemodynamic parameters but not survival benefit.

Impact and implications: Therapeutic plasma exchange is frequently used in the management of patients with acute liver failure in the UK. This real-world study demonstrates significant improvement in haemodynamic status but has not confirmed the survival benefit seen in previous published literature. These results should help guide the future use of plasma exchange in this patient population.