High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial

Fin Stolze Larsen, Lars Ebbe Schmidt, Christine Bernsmeier, Allan Rasmussen, Helena Isoniemi, Vishal C Patel, Evangelos Triantafyllou, William Bernal, Georg Auzinger, Debbie Shawcross, Martin Eefsen, Peter Nissen Bjerring, Jens Otto Clemmesen, Krister Hockerstedt, Hans-Jørgen Frederiksen, Bent Adel Hansen, Charalambos G Antoniades, Julia Wendon

    433 Citationer (Scopus)

    Abstract

    BACKGROUND & AIMS: Acute liver failure (ALF) often results in cardiovascular instability, renal failure, brain oedema and death either due to irreversible shock, cerebral herniation or development of multiple organ failure. High-volume plasma exchange (HVP), defined as exchange of 8-12 or 15% of ideal body weight with fresh frozen plasma in case series improves systemic, cerebral and splanchnic parameters.

    METHODS: In this prospective, randomised, controlled, multicentre trial we randomly assigned 182 patients with ALF to receive either standard medical therapy (SMT; 90 patients) or SMT plus HVP for three days (92 patients). The baseline characteristics of the groups were similar. The primary endpoint was liver transplantation-free survival during hospital stay. Secondary-endpoints included survival after liver transplantation with or without HVP with intention-to-treat analysis. A proof-of-principle study evaluating the effect of HVP on the immune cell function was also undertaken.

    RESULTS: For the entire patient population, overall hospital survival was 58.7% for patients treated with HVP vs. 47.8% for the control group (hazard ratio (HR), with stratification for liver transplantation: 0.56; 95% confidence interval (CI), 0.36-0.86; p=0.0083). HVP prior to transplantation did not improve survival compared with patients who received SMT alone (CI 0.37 to 3.98; p=0.75). The incidence of severe adverse events was similar in the two groups. Systemic inflammatory response syndrome (SIRS) and sequential organ failure assessment (SOFA) scores fell in the treated group compared to control group, over the study period (p<0.001).

    CONCLUSIONS: Treatment with HVP improves outcome in patients with ALF by increasing liver transplant-free survival. This is attributable to attenuation of innate immune activation and amelioration of multi-organ dysfunction.

    OriginalsprogEngelsk
    TidsskriftJournal of Hepatology
    Vol/bind64
    Udgave nummer1
    Sider (fra-til)69-78
    Antal sider10
    ISSN0168-8278
    DOI
    StatusUdgivet - jan. 2016

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