What are the exact High-Volume Plasma Exchange (HVPE) and Therapeutic Plasma Exchange (TPE) doses per session for a 60 kg female patient with Acute Liver Failure?

HVPE and TPE Dosing for Acute Liver Failure

For a 60 kg female with acute liver failure, High-Volume Plasma Exchange (HVPE) should be performed at 9 liters per session (15% of ideal body weight), and standard Therapeutic Plasma Exchange (TPE) at 3.6 liters per session (1-1.5 plasma volumes), with "per session" meaning one complete exchange procedure performed over several hours on a given day, not per 24-hour period. 1, 2

Understanding "Per Session" Terminology

• "Per session" refers to one complete plasma exchange procedure, not a 24-hour period 1, 3, 4
• HVPE protocols typically involve daily sessions for 3 consecutive days, with each session being a distinct treatment performed over 2-4 hours 3, 2
• Multiple sessions may be performed on consecutive days, but each session is counted separately 4, 2

Exact HVPE Dose Calculation for 60 kg Female

• HVPE volume = 15% of ideal body weight = 0.15 × 60 kg = 9 liters per session 1, 2
• This 9-liter volume should be exchanged with fresh frozen plasma during a single treatment session 1, 4
• The exchange is typically performed using centrifugation technique 1
• Standard protocol: 9 liters exchanged daily for 3 consecutive days (total of 3 sessions over 3 days) 2

Exact TPE Dose Calculation for 60 kg Female

• Standard TPE volume = 1-1.5 plasma volumes 5
• For a 60 kg female, plasma volume ≈ 40 mL/kg = 2.4 liters
• TPE dose = 2.4-3.6 liters per session (1-1.5 plasma volumes) 5
• TPE uses lower volumes than HVPE and is primarily indicated for Wilson disease-related ALF to reduce copper levels 5

Critical Distinctions Between HVPE and TPE

• HVPE exchanges 8-12 liters or 15% of ideal body weight - this is the defining characteristic 1, 6, 4, 2
• Standard TPE exchanges 1-1.5 plasma volumes (approximately 3-4 liters for a 60 kg patient) 5
• HVPE is specifically used for general ALF management to improve transplant-free survival 2
• TPE at lower volumes is primarily used for Wilson disease to acutely lower serum copper 5

Treatment Protocol and Monitoring

• Perform HVPE daily for 3 consecutive days as the standard protocol 2
• Each session takes several hours to complete the full volume exchange 1, 4
• Monitor for severe adverse events during each session, particularly severe alkalosis (most common), hypotension, and hypocalcemia 1
• Severe adverse events occur in approximately 27% of sessions, with alkalosis being most frequent 1

Expected Biochemical Changes Per Session

• Hemoglobin, platelets, transaminases, ammonia, and bilirubin decrease during the session 1, 4
• Coagulation factors increase (INR improves from median 4.46 to 1.48) 4
• Creatinine and lactate remain relatively unchanged 1
• SIRS and SOFA scores improve over the treatment course 2

Clinical Outcomes and Indications

• HVPE improves transplant-free survival to 58.7% compared to 47.8% with standard medical therapy alone 2
• Particularly beneficial in patients with high CLIF-SOFA scores (≥13), improving 30-day survival to 91% vs 29% without HVPE 4
• Post-HVPE arterial pH ≤7.43 is negatively associated with day-21 transplant-free survival 1
• Acetaminophen etiology is positively associated with better outcomes 1, 3

Important Caveats

• Severe alkalosis is the most common complication (occurring in 24/117 sessions), requiring careful pH monitoring and correction 1
• Hypotension occurs in approximately 3% of sessions and hypocalcemia in 3% 1
• HVPE requires ICU-level monitoring with dedicated staff for adverse event management 1, 2
• The procedure does not improve survival if performed before liver transplantation compared to standard therapy alone (HR 0.37-3.98, p=0.75) 2
• For Wilson disease specifically, albumin dialysis and continuous hemofiltration are equally acceptable alternatives to plasma exchange 5