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

Laura Burke; William Bernal; Tasneem Pirani; Banwari Agarwal; Rajiv Jalan; Jennifer Ryan; Mansoor Nawaz Bangash; Phillip El-Dalil; Nick Murphy; Mhairi Donnelly; Janice Davidson; Ken Simpson; Hannah Giles; Phyo Set Mone; Steven Masson; Andrew Davenport; Ian Rowe; Joanna Moore

doi:10.1016/j.jhep.2024.09.034

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

J Hepatol. 2024 Oct 1:S0168-8278(24)02574-1. doi: 10.1016/j.jhep.2024.09.034. Online ahead of print.

Authors

Laura Burke¹, William Bernal², Tasneem Pirani², Banwari Agarwal³, Rajiv Jalan⁴, Jennifer Ryan⁵, Mansoor Nawaz Bangash⁶, Phillip El-Dalil⁷, Nick Murphy⁷, Mhairi Donnelly⁸, Janice Davidson⁸, Ken Simpson⁸, Hannah Giles⁹, Phyo Set Mone¹⁰, Steven Masson¹¹, Andrew Davenport¹², Ian Rowe¹, Joanna Moore¹³

Affiliations

¹ Leeds Liver Unit, Leeds NHS Teaching Hospitals Trust, Leeds, UK; Leeds Institute for Medical Research, University of Leeds, Leeds, UK.
² Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK.
³ Department of Critical Care, Royal Free Hospital, London, UK.
⁴ Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus; London, UK and Department of Hepatology, Royal Free Hospital, Pond Street, London, UK; European Foundation for the Study of Chronic Liver Failure; Barcelona, Spain.
⁵ Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus; London, UK and Department of Hepatology, Royal Free Hospital, Pond Street, London, UK.
⁶ Department of Critical Care, Queen Elizabeth Hospital Birmingham, UK; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, UK.
⁷ Department of Critical Care, Queen Elizabeth Hospital Birmingham, UK.
⁸ Department of Hepatology and Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, UK.
⁹ Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; New Zealand Liver Transplant Unit, Auckland City Hospital, Auckland, New Zealand.
¹⁰ Cambridge Liver Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
¹¹ Newcastle NIHR Biomedical Research Centre, Newcastle upon Tyne Hospitals NHS Foundation Trust, UK; Translational and Clinical Research Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.
¹² UCL Department of Renal Medicine, Royal Free Hospital, University College London, UK.
¹³ Leeds Liver Unit, Leeds NHS Teaching Hospitals Trust, Leeds, UK; Leeds Institute for Medical Research, University of Leeds, Leeds, UK. Electronic address: [email protected].

PMID: 39362282
DOI: 10.1016/j.jhep.2024.09.034

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.

Keywords: Acute; Liver Failure; Liver Transplantation; Plasma Exchange.