From the Guidelines
Plasma therapy has a limited but promising role in liver transplantation, particularly for patients with acute liver failure awaiting transplant, as supported by strong evidence from recent guidelines. The use of plasma exchange in liver transplantation is backed by level A evidence, suggesting its potential benefits for patients with acute-on-chronic liver failure (ACLF) awaiting liver transplants or experiencing spontaneous regeneration 1. However, the European Association for the Study of the Liver (EASL) guideline advises against the routine use of plasma exchange for ACLF outside of research trials, also supported by level A evidence 1. Some studies suggest that plasma exchange may benefit patients with HBV-related ACLF, but further research is needed to confirm its clinical utility 1. Key points to consider when using plasma therapy in liver transplantation include:
- Plasma exchange may be beneficial for patients with ACLF awaiting liver transplants or experiencing spontaneous regeneration
- The EASL guideline advises against routine use of plasma exchange for ACLF outside of research trials
- Plasma exchange may benefit patients with HBV-related ACLF, but further research is needed
- Plasma therapy carries risks, including allergic reactions, hypocalcemia, and fluid overload, and must be administered under close medical supervision. In real-life clinical practice, plasma therapy should be considered on a case-by-case basis, taking into account the individual patient's condition and the potential benefits and risks of treatment, as supported by the most recent and highest quality study available 1.
From the Research
Role of Plasma Therapy in Liver Transplantation
- Plasma therapy, including therapeutic plasma exchange (TPE), has been shown to be an efficacious therapy in the management of liver failure, particularly in patients with acute and acute-on-chronic liver failure (ACLF) 2.
- TPE has been proven to reduce the levels of inflammatory cytokines, modulate adaptive immunity, and reduce the levels of albumin-bound and water-bound toxins in liver failure 2.
- In patients with acute liver failure, high-volume TPE has been shown to reduce the vasopressor requirement and improve survival, particularly in patients not eligible for liver transplantation (LT) 2, 3.
- Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF 2.
Plasma Therapy as a Bridge to Liver Transplantation
- TPE may be most favorably employed as a bridge to LT in patients with ACLF, allowing for the removal of toxic substances and facilitating liver regeneration 2, 3.
- The use of solvent/detergent plasma (S/D Plasma) has been proposed as an alternative to fresh frozen plasma (FFP) to reduce the risk of massive bleeding and its related complications during LT 4.
- Prothrombin complex concentrates (PCCs) may offer several advantages over FFP, including reduced risk of transfusion-associated circulatory overload (TACO) and transfusion-related immunomodulation (TRIM) 5.
Clinical Applications and Outcomes
- Therapeutic plasma exchange has been reported to be useful in the management of early allograft dysfunction after living donor liver transplant, although the evidence is limited and further studies are needed to confirm its efficacy 6.
- The use of PCCs to correct coagulation abnormalities during LT is an increasingly widespread practice, although the level of evidence supporting this practice and the associated risks are not yet fully understood 5.