Panda Kalpana, Dash Devi Prasad, Panda Prateek Kumar, Dash Mrutunjay, Saboth Prasant Kumar, Pati Girish Kumar
Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Institute of Medical Sciences and SUM Hospital, Bhubaneswar, 751 003, India.
Department of Critical Care Medicine, Kalinga Institute of Medical Sciences, Bhubaneswar, 751 024, India.
Indian J Gastroenterol. 2025 Mar 4. doi: 10.1007/s12664-025-01742-2.
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.
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.
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.
治疗性血浆置换（TPE）已成为治疗小儿肝衰竭（PLF）的一种有前景的治疗选择，可作为单一疗法或作为肝移植的桥梁；然而，迄今为止，其对生存结局的确切影响尚未得到系统研究。本荟萃分析旨在评估TPE对小儿肝衰竭患者生存的影响。
检索了PubMed、Scopus和Embase数据库，纳入截至2024年8月所有报告TPE对年龄<18岁的急性和慢性急性肝衰竭患者生存影响的研究。主要结局指标是接受TPE的小儿急性肝衰竭（PALF）和小儿慢性急性肝衰竭（pACLF）患者在≥28天时的总生存（OS）和无移植生存（TFS）。次要结局指标是确定他们在TPE前后生化参数（国际标准化比值[INR]、胆红素和氨）的变化。
纳入了12项研究（8项为单纯PALF队列，4项为PALF + pACLF联合队列），共310例接受TPE的患者（273例为PALF，37例为pACLF）。TPE后PLF患者在≥28天时的合并OS为61%（95%CI：55 - 66%，p = 0.03，I = 49%）。估计他们的合并TFS为35%（95%CI：29 - 41%，p = <0.01，I = 84%）。亚组分析显示，标准容量TPE组的OS和TFS均高于高容量亚组。与TPE前的值相比，TPE后所有三项生化参数均有显著改善。纳入的研究均未报告任何与TPE相关的死亡率或潜在致命副作用。
TPE显示出改善小儿肝衰竭总体生存的潜力，主要作为肝移植或自体肝恢复的桥梁。此外，需要设计良好、样本量充足的随机对照试验来证实TPE对PLF患者生存的益处。
