Role of Therapeutic Plasma Exchange on Survival in Pediatric Acute Liver Failure and Acute-on Chronic Liver Failure: A Systematic Review and Meta-analysis

Overview

Journal Indian J Gastroenterol

Specialty Gastroenterology

Date 2025 Mar 4

PMID 40035795

Authors

Kalpana Panda

Devi Prasad Dash

Prateek Kumar Panda

Mrutunjay Dash

Prasant Kumar Saboth

Girish Kumar Pati

Affiliations

Soon will be listed here.

Abstract

Background: Therapeutic plasma exchange (TPE) has emerged as a promising treatment option for pediatric liver failure (PLF) either as a standalone therapy or as a bridge to liver transplant; however, its precise impact on survival outcomes has not been investigated systematically to date. This meta-analysis aims to evaluate the effect of TPE on survival of pediatric patients with liver failure. METHODS: PubMed, Scopus and Embase databases were searched to include all studies till August 2024 reporting the effect of TPE on survival of acute and acute-on-chronic liver failure patients of age < 18 years. Primary outcome measures were overall survival (OS) and transplant-free survival (TFS) at Day ≥ 28 in pediatric acute liver failure (PALF) and pediatric acute-on-chronic liver failure (pACLF) patients undergoing TPE. The secondary outcome measure was to determine changes in biochemical parameters (international nrmalized ratio [INR], bilirubin and ammonia) pre and post-TPE in them.

Results: Twelve studies (8 = exclusive PALF cohorts and 4 = combined PALF + pACLF cohorts) comprising 310 patients (273 = PALF and 37 = pACLF) who received TPE were included. Pooled OS at Day ≥ 28 for PLF after TPE is 61% (95% CI: 55-66%, p = 0.03, I = 49%). The estimated pooled TFS in them was 35% (95% CI: 29-41%, p = < 0.01, I = 84%). On sub-group analysis, the standard-volume TPE group had both higher OS and TFS in comparison to the high-volume sub-group. There was a significant improvement in all three biochemical parameters post-TPE compared to pre-TPE values. None of the included studies reported any TPE-related mortality or potentially fatal side effects.

Conclusion: TPE shows the potential to improve overall survival in pediatric liver failure, mostly acting as a bridge to liver transplant or native liver recovery. Further, well-designed, adequately powered, randomized-controlled trials are needed to confirm TPE's survival benefit in PLF.

References

Squires Jr R, Shneider B, Bucuvalas J, Alonso E, Sokol R, Narkewicz M . Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr. 2006; 148(5):652-658. PMC: 2662127. DOI: 10.1016/j.jpeds.2005.12.051. View

Alam S, Khanna R, Sood V, Lal B, Rawat D . Profile and outcome of first 109 cases of paediatric acute liver failure at a specialized paediatric liver unit in India. Liver Int. 2017; 37(10):1508-1514. DOI: 10.1111/liv.13370. View

Alam S, Lal B, Sood V, Rawat D . Pediatric Acute-on-Chronic Liver Failure in a Specialized Liver Unit: Prevalence, Profile, Outcome, and Predictive Factors. J Pediatr Gastroenterol Nutr. 2016; 63(4):400-5. DOI: 10.1097/MPG.0000000000001179. View

Squires J, Alonso E, Ibrahim S, Kasper V, Kehar M, Martinez M . North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2021; 74(1):138-158. DOI: 10.1097/MPG.0000000000003268. View

Alam S, Lal B . Pediatric Acute-on-Chronic Liver Failure. Indian J Pediatr. 2023; 91(4):374-382. DOI: 10.1007/s12098-023-04717-3. View

Larsen F . Artificial liver support in acute and acute-on-chronic liver failure. Curr Opin Crit Care. 2019; 25(2):187-191. DOI: 10.1097/MCC.0000000000000584. View

Padmanabhan A, Connelly-Smith L, Aqui N, Balogun R, Klingel R, Meyer E . Guidelines on the Use of Therapeutic Apheresis in Clinical Practice - Evidence-Based Approach from the Writing Committee of the American Society for Apheresis: The Eighth Special Issue. J Clin Apher. 2019; 34(3):171-354. DOI: 10.1002/jca.21705. View

Larsen F, Schmidt L, Bernsmeier C, Rasmussen A, Isoniemi H, Patel V . High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial. J Hepatol. 2015; 64(1):69-78. DOI: 10.1016/j.jhep.2015.08.018. View

Maiwall R, Bajpai M, Singh A, Agarwal T, Kumar G, Bharadwaj A . Standard-Volume Plasma Exchange Improves Outcomes in Patients With Acute Liver Failure: A Randomized Controlled Trial. Clin Gastroenterol Hepatol. 2021; 20(4):e831-e854. DOI: 10.1016/j.cgh.2021.01.036. View

10.

Tan E, Wang M, Pang J, Lee G . Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review. World J Gastroenterol. 2020; 26(2):219-245. PMC: 6962432. DOI: 10.3748/wjg.v26.i2.219. View

11.

Sithamparapillai K, Zachariah U, Eapen C, Goel A . Plasma exchange improves survival in acute liver failure - An updated systematic review and meta-analysis focussed on comparing within single etiology. Indian J Gastroenterol. 2024; 43(2):397-406. DOI: 10.1007/s12664-024-01557-7. View

12.

Beran A, Mohamed M, Shaear M, Nayfeh T, Mhanna M, Srour O . Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis. Liver Transpl. 2023; 30(2):127-141. DOI: 10.1097/LVT.0000000000000231. View

13.

Grazioli S, Deep A . High-volume Plasmapheresis in Children With Acute Liver Failure: Another Brick in the Wall in the Current Management?. J Pediatr Gastroenterol Nutr. 2021; 72(6):786-787. DOI: 10.1097/MPG.0000000000003134. View

14.

Alexander E, Deep A . Therapeutic plasma exchange in children with acute liver failure (ALF): is it time for incorporation into the ALF armamentarium?. Pediatr Nephrol. 2021; 37(8):1775-1788. PMC: 9239959. DOI: 10.1007/s00467-021-05289-0. View

15.

Lal B, Khanna R, Sood V, Alam S, Nagral A, Ravindranath A . Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN). Hepatol Int. 2024; 18(5):1343-1381. DOI: 10.1007/s12072-024-10720-3. View

16.

Munn Z, Barker T, Moola S, Tufanaru C, Stern C, McArthur A . Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth. 2020; 18(10):2127-2133. DOI: 10.11124/JBISRIR-D-19-00099. View

17.

Balshem H, Helfand M, Schunemann H, Oxman A, Kunz R, Brozek J . GRADE guidelines: 3. Rating the quality of evidence. J Clin Epidemiol. 2011; 64(4):401-6. DOI: 10.1016/j.jclinepi.2010.07.015. View

18.

Jorgensen M, Rasmussen A, Christensen V, Jensen A, Fonsmark L, Andreassen B . Safety of High-Volume Plasmapheresis in Children With Acute Liver Failure. J Pediatr Gastroenterol Nutr. 2021; 72(6):815-819. DOI: 10.1097/MPG.0000000000003108. View

19.

Pawaria A, Sood V, Lal B, Khanna R, Bajpai M, Alam S . Ninety days transplant free survival with high volume plasma exchange in Wilson disease presenting as acute liver failure. J Clin Apher. 2020; 36(1):109-117. DOI: 10.1002/jca.21848. View

20.

Hu J, Wang C, Bai K, Liu C . Clinical application of regional citrate anticoagulation for membrane-based therapeutic plasma exchange in children with liver failure. Front Pediatr. 2023; 11:1206999. PMC: 10621744. DOI: 10.3389/fped.2023.1206999. View