Départment of Hepatology Institute of Liver and Biliary Science, New Delhi, India.
Department of Transfusion Medicine, ILBS, New Delhi, India.
Liver Int. 2021 May;41(5):1083-1096. doi: 10.1111/liv.14806. Epub 2021 Feb 24.
Plasma-exchange (PE) has improved survival in acute liver failure by ameliorating systemic inflammatory response syndrome (SIRS). We evaluated PE and compared it to Fractional Plasma Separation and Adsorption (FPSA) and standard medical treatment (SMT) in a large multinational cohort of ACLF patients.
Data were prospectively collected from the AARC database and analysed. Matching by propensity risk score (PRS) was performed. Competing risk survival analysis was done to identify deaths because of multiorgan failure (MOF). In a subset of 10 patients, we also evaluated the mechanistic basis of response to PE.
ACLF patients (n = 1866, mean age 44.3 ± 12.3 yrs, 93% males, 65% alcoholics) received either artificial liver support (ALS) (n = 162); [PE (n = 131), FPSA (n = 31)] or were continued on standard medical therapy (SMT) (n = 1704). In the PRS-matched cohort (n = 208, [ALS-119; PE-94, FPSA-25)], SMT-89). ALS therapies were associated with a significantly higher resolution of SIRS (Odd's ratio 9.23,3.42-24.8), lower and delayed development of MOF (Hazard ratio 7.1, 4.5-11.1), and lower liver-failure-related deaths as compared to FPSA and SMT (P < .05). PE cleared inflammatory cytokines, damage-associated molecular patterns, and endotoxin in all patients. Responders improved monocyte phagocytic function and mitochondrial respiration and increased the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1RA) compared to non-responders. PE was associated with lesser adverse effects as compared to FPSA.
PE improves systemic inflammation and lowers the development of MOF in patients with ACLF. Plasma-exchange provides significant survival benefit over FPSA and could be a preferred modality of liver support for ACLF patients.
血浆置换（PE）通过改善全身炎症反应综合征（SIRS）改善了急性肝衰竭的存活率。我们评估了 PE，并在急性肝衰竭患者的大型多中心队列中与部分血浆分离和吸附（FPSA）和标准治疗（SMT）进行了比较。
前瞻性地从 AARC 数据库中收集数据并进行分析。通过倾向风险评分（PRS）进行匹配。采用竞争风险生存分析确定多器官衰竭（MOF）导致的死亡。在 10 名患者的亚组中，我们还评估了对 PE 反应的机制基础。
急性肝衰竭患者（n=1866，平均年龄 44.3±12.3 岁，93%为男性，65%为酒精性）接受人工肝支持（ALS）（n=162）；[PE（n=131），FPSA（n=31）]或继续标准治疗（SMT）（n=1704）。在 PRS 匹配队列（n=208，[ALS-119；PE-94，FPSA-25]）中，SMT-89）。与 FPSA 和 SMT 相比，ALS 治疗与 SIRS 明显更高的缓解率（优势比 9.23，3.42-24.8），MOF 的发生和延迟发展（风险比 7.1，4.5-11.1），以及较低的肝衰竭相关死亡率相关（P<.05）。PE 清除了所有患者的炎症细胞因子、损伤相关分子模式和内毒素。与非反应者相比，反应者改善了单核细胞吞噬功能和线粒体呼吸，并增加了抗炎细胞因子白细胞介素 1 受体拮抗剂（IL-1RA）。PE 与 FPSA 相比，不良反应较少。
PE 可改善急性肝衰竭患者的全身炎症反应，降低 MOF 的发生。与 FPSA 相比，PE 可显著提高急性肝衰竭患者的生存率，可能是急性肝衰竭患者肝支持的首选方式。
