Is plasma exchange (PLEX) indicated in a patient with hepatitis A, elevated International Normalized Ratio (INR), hyperbilirubinemia, impaired renal function, and hepatic encephalopathy?

Plasma Exchange (PLEX) is NOT Indicated for This Patient

Based on current guidelines, this patient does not meet criteria for plasma exchange because he lacks the critical requirement of severe hepatic encephalopathy (grade III-IV). 1

Critical Assessment of Disease Severity

This 40-year-old male with hepatitis A presents with:

• INR 2.9 (moderate coagulopathy)
• Bilirubin 17 mg/dL (severe hyperbilirubinemia)
• Creatinine 1.3 mg/dL (mild renal impairment)
• Hepatic encephalopathy present (grade unspecified)

MELD Score Calculation

Using these values, the estimated MELD score is approximately 28-30, indicating high mortality risk and severe disease. 1 This level warrants intensive monitoring and consideration for liver transplant evaluation, but does not automatically trigger PLEX. 1

Why PLEX is NOT Indicated

The primary and essentially only indication for plasma exchange in acute hepatitis is fulminant hepatic failure with hepatic encephalopathy grade III-IV combined with severe coagulopathy. 1 The guidelines are explicit that:

• Absence of severe (grade III-IV) hepatic encephalopathy is a major contraindication to plasma exchange 1
• PLEX is reserved specifically for patients with impending or established hepatic coma 1
• The procedure does not improve outcomes in patients without advanced encephalopathy 2

Since your patient has "hepatic encephalopathy" without specification of grade III-IV severity, PLEX should not be initiated. 1

Hepatitis A-Specific Considerations

Hepatitis A typically follows a self-limited course with >95% spontaneous recovery in adults, even with severe biochemical abnormalities like those present in this patient. 1 Key points:

• Fulminant hepatic failure from hepatitis A is rare 1
• Most patients recover with supportive care alone, despite alarming laboratory values 1
• The presence of severe jaundice and elevated INR does not automatically indicate fulminant failure requiring PLEX 1

Recommended Management Approach

Immediate Actions

Monitor intensively for progression to grade III-IV hepatic encephalopathy, as this would fundamentally change management. 2, 1 Specifically:

• Assess encephalopathy grade every 4-6 hours using standardized criteria (West Haven criteria) 2
• Serial laboratory monitoring every 12-24 hours: INR, bilirubin, creatinine, arterial ammonia, lactate, arterial blood gas 2, 1
• Calculate daily MELD score to track disease trajectory 1
• Monitor for metabolic complications: hypoglycemia (check glucose every 2 hours), hyponatremia, hypophosphatemia 2

Supportive Care Priorities

• Maintain serum sodium 140-145 mmol/L to prevent cerebral edema 2
• N-acetylcysteine administration should be considered regardless of etiology (though evidence strongest for acetaminophen toxicity) 2
• Avoid prophylactic correction of coagulopathy unless active bleeding or high-risk procedures, as INR monitoring guides prognosis 2
• Standard ICU supportive care if clinical deterioration occurs 2

Escalation Triggers for Liver Transplant Evaluation

Contact a liver transplant center urgently if any of the following develop: 2, 1

• Progression to hepatic encephalopathy grade III-IV (Glasgow Coma Scale <8, stupor, or coma) 2
• Rising INR despite supportive care (particularly if INR continues increasing beyond 3.0) 2, 3
• MELD score exceeds 30-35 with clinical deterioration 1
• Development of metabolic acidosis (pH <7.30) or lactate >3.5 mmol/L 2
• Worsening renal function (creatinine rising or oliguria developing) 2

Critical Pitfall to Avoid

Do not initiate PLEX based solely on laboratory abnormalities (elevated INR and bilirubin) without grade III-IV encephalopathy. 1 This is a common error that:

• Exposes patients to unnecessary procedural risks (bleeding, line complications, citrate toxicity) 2
• Has no proven benefit in patients without severe encephalopathy 1
• May obscure prognostic markers (INR) needed for transplant decision-making 2

When PLEX Would Be Indicated

PLEX should only be considered if this patient progresses to: 1

• Hepatic encephalopathy grade III (stupor, marked confusion, incomprehensible speech) OR
• Hepatic encephalopathy grade IV (coma, unresponsive to painful stimuli)

AND continues to have severe coagulopathy (INR >2.5-3.0). 1

At that point, the patient would meet criteria for fulminant hepatic failure, and both PLEX and urgent liver transplant evaluation would be appropriate. 2, 1