Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA.
Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA.
Liver Transpl. 2024 Feb 1;30(2):127-141. doi: 10.1097/LVT.0000000000000231. Epub 2023 Aug 3.
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.
血浆置换（PE）是急性肝衰竭（ALF）和慢加急性肝衰竭（ACLF）患者有前途的治疗选择。然而，PE 对这些综合征患者生存的影响尚不清楚。我们旨在系统地研究与标准药物治疗（SMT）相比，PE 在 ALF 和 ACLF 患者中的应用。我们检索了 PubMed/Embase/Cochrane 数据库，纳入了所有比较年龄≥18 岁的 ALF 和 ACLF 患者中 PE 与 SMT 的研究。采用 Mantel-Haenszel 法在随机效应模型中计算合并风险比（RR）及其相应的 95%置信区间（CI）。主要结局为 ACLF 和 ALF 的 30 天生存率。次要结局分别为 ALF 和 ACLF 的总生存率和 90 天生存率。分析了 5 项研究，共纳入 343 例 ALF 患者（n=174 例 PE 与 n=169 例 SMT），以及 20 项研究，共纳入 5705 例 ACLF 患者（n=2856 例 PE 与 n=2849 例 SMT）。与 SMT 相比，PE 显著提高了 ALF 患者的 30 天（RR 1.41，95%CI 1.06-1.87，p=0.02）和总生存率（RR 1.35，95%CI 1.12-1.63，p=0.002）。在 ACLF 中，PE 也显著提高了 30 天（RR 1.36，95%CI 1.22-1.52，p<0.001）和 90 天（RR 1.21，95%CI 1.10-1.34，p<0.001）生存率。在随机对照试验的亚组分析中，ALF 中的结果保持不变，但在 ACLF 中，PE 与 SMT 之间的生存率无差异。总之，PE 可改善 ALF 患者的生存率，并可能改善 ACLF 患者的生存率。PE 可用于管理不符合肝移植（LT）条件或作为 LT 桥接的 ALF 和 ACLF 患者。需要进一步的随机对照试验来证实 PE 在 ACLF 中的生存获益。
