Is plasma exchange helpful in sepsis-induced liver dysfunction with hyperbilirubinemia?

Plasma Exchange in Sepsis-Induced Liver Dysfunction with Hyperbilirubinemia

Plasma exchange is not recommended for routine use in sepsis-induced liver dysfunction with hyperbilirubinemia, except in specific cases of acute liver failure with hyperammonemia. 1

Current Guideline Recommendations

• The 2023 Critical Care Medicine guidelines suggest using plasma exchange in critically ill acute liver failure (ALF) patients who develop hyperammonemia, but this is a conditional recommendation with low-quality evidence 1
• The Surviving Sepsis Campaign guidelines (2016-2017) make no specific recommendation regarding the use of blood purification techniques in adult sepsis patients 1
• For pediatric patients, the 2020 Surviving Sepsis Campaign guidelines specifically suggest against using plasma exchange in children with septic shock or sepsis-associated organ dysfunction without thrombocytopenia-associated multiple organ failure (TAMOF) 1

Evidence for Plasma Exchange in Liver Dysfunction

Potential Benefits

• Plasma exchange may help reduce bilirubin levels in patients with severe hyperbilirubinemia, with studies showing approximately 40% reduction in bilirubin levels per treatment session 2, 3
• In acute liver failure, plasma exchange might improve outcomes by removing accumulated toxins, including bilirubin and inflammatory mediators 4
• Some case reports suggest clinical improvement in patients with severe hyperbilirubinemia after plasma exchange treatment 3, 5

Limitations and Concerns

• The evidence supporting plasma exchange in sepsis-induced liver dysfunction is primarily from small case series and retrospective studies 4, 2, 3
• Alternative methods such as cytokine adsorption systems may be considered for lowering bilirubin levels in liver failure, though they have limitations in ammonia removal 6
• Plasma exchange carries risks including allergic reactions, hypotension, electrolyte disturbances, and potential infectious complications 3

Clinical Decision Algorithm

1. Initial assessment:

   • Confirm sepsis-induced liver dysfunction with hyperbilirubinemia (jaundice is defined as plasma total bilirubin ≥ 4 mg/dL or ≥ 70 µmol/L) 1
   • Evaluate for presence of hyperammonemia and encephalopathy 1

2. Standard management approach:

   • Focus on treating the underlying sepsis according to Surviving Sepsis Campaign guidelines 1
   • Provide supportive care for liver dysfunction 1

3. Consider plasma exchange only if:

   • Patient has acute liver failure with hyperammonemia 1
   • Patient has failed standard medical therapy 3
   • Patient has severe complications from hyperbilirubinemia (e.g., cardiac arrhythmias, neurological complications) 5

4. If plasma exchange is performed:

   • Monitor bilirubin levels before and after each session 3
   • Evaluate clinical response after each treatment 2
   • Consider discontinuation if no improvement after 2-3 sessions 3

Important Caveats

• Plasma exchange should not be used as a routine intervention for all patients with sepsis-induced liver dysfunction and hyperbilirubinemia 1
• The decision to use plasma exchange should be made in centers with expertise in extracorporeal therapies 1
• Other extracorporeal liver support techniques such as double plasma molecular adsorption systems may be alternatives to consider in specific cases 4
• The primary focus should remain on treating the underlying sepsis and providing appropriate supportive care 1

In conclusion, while plasma exchange may reduce bilirubin levels in sepsis-induced liver dysfunction with hyperbilirubinemia, current guidelines do not support its routine use except in specific cases of acute liver failure with hyperammonemia. The evidence for its efficacy remains limited, and treatment decisions should be individualized based on the severity of liver dysfunction and the presence of complications.