Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis

Author:

Beran Azizullah1,Mohamed Mouhand F.H.2,Shaear Mohammad3,Nayfeh Tarek4,Mhanna Mohammed5,Srour Omar6,Nawras Mohamad7,Mentrose Jonathan A.8,Assaly Ragheb9,Kubal Chandrashekhar A.10ORCID,Ghabril Marwan S.1ORCID,Hernaez Ruben111213ORCID,Patidar Kavish R.1112ORCID

Affiliation:

1. Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA

2. Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA

3. Department of General Surgery, College of Medicine, Central Michigan University, Saginaw, Michigan, USA

4. Evidence-based practice research program, Mayo Clinic, Rochester, USA

5. Department of Cardiology, University of Iowa, Iowa City, Iowa, USA

6. Department of Critical Care and Pulmonary Medicine, Henry Ford Health System, Detroit, Michigan, USA

7. College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA

8. Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA

9. Divison of Critical Care and Pulmonary Medicine, University of Toledo, Toledo, Ohio, USA

10. Division of Transplantation, Department of Surgery, Indiana University, Indianapolis, Indiana, USA

11. Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA

12. Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

13. Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA

Abstract

Plasma exchange (PE) is a promising therapeutic option in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). However, the impact of PE on patient survival in these syndromes is unclear. We aimed to systematically investigate the use of PE in patients with ALF and ACLF compared with standard medical therapy (SMT). We searched PubMed/Embase/Cochrane databases to include all studies comparing PE versus SMT for patients ≥ 18 years of age with ALF and ACLF. Pooled risk ratios (RR) with corresponding 95% CIs were calculated by the Mantel-Haenszel method within a random-effect model. The primary outcome was 30-day survival for ACLF and ALF. Secondary outcomes were overall and 90-day survival for ALF and ACLF, respectively. Five studies, including 343 ALF patients (n = 174 PE vs. n = 169 SMT), and 20 studies, including 5,705 ACLF patients (n = 2,856 PE vs. n = 2,849 SMT), were analyzed. Compared with SMT, PE was significantly associated with higher 30-day (RR 1.41, 95% CI 1.06–1.87, p = 0.02) and overall (RR 1.35, 95% CI 1.12–1.63, p = 0.002) survival in ALF patients. In ACLF, PE was also significantly associated with higher 30-day (RR 1.36, 95% CI 1.22–1.52, p < 0.001) and 90-day (RR 1.21, 95% CI 1.10–1.34, p < 0.001) survival. On subgroup analysis of randomized controlled trials, results remained unchanged in ALF, but no differences in survival were found between PE and SMT in ACLF. In conclusion, PE is associated with improved survival in ALF and could improve survival in ACLF. PE may be considered in managing ALF and ACLF patients who are not liver transplant (LT) candidates or as a bridge to LT in otherwise eligible patients. Further randomized controlled trials are needed to confirm the survival benefit of PE in ACLF.

Publisher

Ovid Technologies (Wolters Kluwer Health)

Subject

Transplantation,Hepatology,Surgery

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