Therapeutic Plasma Exchange in Patients With Acute-On-Chronic Liver Failure Improves Survival-An Updated Meta-Analysis.

Santhosh E Kumar, Ashish Goel, C E Eapen, Juan Pablo Arab, Jonel Trebicka, Constantine J Karvellas, Ashok Kumar Choudhury, Kausala Sithamparapillai, P Krishna Bharadwaj, Prasanna Samuel Premkumar

Journal: Liver international : official journal of the International Association for the Study of the Liver 2025;45(5):e70018

PMID: 40265656

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Abstract

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a syndrome that develops after an acute insult and is associated with organ failures and high short-term mortality. Plasma exchange (PLEX) is an emerging modality for treating ACLF patients. We aimed to evaluate the efficacy of PLEX in treating ACLF.

METHODS

We conducted a systematic review and meta-analysis of studies comparing PLEX versus standard medical therapy (SMT) to treat patients with ACLF across different definitions and etiologies. Pooled risk ratios were determined by the Mantel-Haenszel method within a random effect model. The primary outcome studied was survival at 30 days in PLEX group compared to SMT.

RESULTS

Twenty-three studies (5336 ACLF patients with 2724 in PLEX arm, including 4 RCTs) were included. PLEX was associated with a significant reduction in mortality at 30 days (RR 0.70; 95% CI, 0.60-0.81; p < 0.001) and at 90 days (RR 0.81;0.77-0.86; p < 0.001). Six studies (1495 patients; 2 RCTs) with data for 1-year survival showed better outcomes in the PLEX group (RR 0.85; 0.79-0.92; p < 0.0001) compared to SMT. Among HBV-related ACLF and alcohol-related ACLF, there was a significant reduction in mortality among PLEX treated group at 90 days; RR 0.79 (0.74-0.85), p < 0.001 and RR 0.69 (0.52-0.92), p = 0.01 respectively. PLEX was associated with improved 3-month survival across definitions for ACLF. The most common adverse effects were skin rash and allergic reactions (14%).

CONCLUSIONS

In this up-to-date meta-analysis, significant 1, 3-month and up to 1-year survival benefit was noted among patients with ACLF treated with PLEX compared to SMT.

Address: Department of Hepatology, Christian Medical College, Vellore, India.; Department of Physiology, University of Jaffna, Jaffna, Sri Lanka.; Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.; Department of Internal Medicine B, University of Münster, Münster, Germany; European Foundation for the Study of Chronic Liver Failure, EF CLIF, Barcelona, Spain.; Division of Gastroenterology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.; Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, Virginia, USA.; Department of Biostatistics, Christian Medical College, Vellore, India.

DOI: 10.1111/liv.70018

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MeSH Terms: Humans, Acute-On-Chronic Liver Failure, Plasma Exchange, Treatment Outcome