Plasmapheresis in Acute Liver Failure
Plasmapheresis is recommended as a bridging therapy to liver transplantation in acute liver failure, particularly for Wilson disease-related cases, where it can acutely lower serum copper and limit hemolysis while awaiting definitive transplantation. 1
Primary Indication: Wilson Disease-Related ALF
The American Association for the Study of Liver Diseases specifically recommends plasmapheresis (or plasma exchange) as part of the treatment strategy for Wilson disease-related acute liver failure, where it serves to acutely lower serum copper and limit further hemolysis. 2, 1 This is critical because Wilson disease-related ALF is considered uniformly fatal without transplantation, and plasmapheresis can protect the kidneys from copper-mediated tubular damage while awaiting transplant. 1
Alternative liver support systems including albumin dialysis and continuous hemofiltration are equally acceptable options for copper reduction in Wilson disease. 2, 1
Role as Bridging Therapy
Plasmapheresis functions primarily as a temporizing measure rather than definitive treatment:
- It can stabilize patients and delay (though not eliminate) the need for transplantation. 1
- High-volume plasmapheresis (HVP), defined as exchange of 8-12 L or 15% of ideal body weight with fresh-frozen plasma, increases the time window to obtain a donor liver and optimizes conditions for the surgical procedure. 3
- In patients awaiting emergency liver transplantation, daily plasmapheresis prevented irreversible neurological complications for 48-144 hours until transplantation could be performed. 3
Evidence for Broader ALF Applications
While guidelines specifically endorse plasmapheresis for Wilson disease, emerging research suggests potential benefits in other ALF contexts:
- High-volume plasmapheresis improves biochemical parameters, volume status, and hemodynamics in ALF patients. 4, 5
- The procedure clears inflammatory cytokines, damage-associated molecular patterns, and endotoxin. 6
- Early initiation of HVP may provide benefit in ALF patients who do not qualify for liver transplant. 4
- In acute-on-chronic liver failure (ACLF), plasma exchange improved systemic inflammation, reduced multiorgan failure development, and provided survival benefit over other modalities. 6
Practical Implementation
When using plasmapheresis in ALF:
- Perform high-volume exchanges (8-12 L) with fresh-frozen plasma replacement. 3
- Continue daily treatments until transplantation or clinical improvement. 3
- The procedure is readily available in most hospitals, making it accessible when specialized liver support systems are unavailable. 4, 5
- Monitor for improvement in hepatic encephalopathy grade, coagulation parameters (Factor VII, prothrombin), and bilirubin levels. 7
Critical Caveats
Plasmapheresis should be used very cautiously in patients with severe HCV liver disease, and HCV/HBV infection evolution should be carefully monitored, particularly when combined with immunosuppressants. 2 This warning comes from cryoglobulinemia management guidelines but applies to any apheresis use in viral hepatitis contexts.
The procedure does not replace liver transplantation as definitive therapy—it only extends the window for obtaining a donor organ. 3 All patients receiving plasmapheresis for ALF should be simultaneously listed for transplantation unless contraindications exist. 1
Comparison to Other Liver Support Systems
The Molecular Adsorbents Recirculating System (MARS) and other sorbent-based systems have been tested but show only transient improvement in hepatic encephalopathy without clear long-term benefit. 2 Plasmapheresis appears superior to Fractional Plasma Separation and Adsorption (FPSA) with fewer adverse effects and better survival outcomes in ACLF. 6