DPMAS Use in Decompensated Liver Cirrhosis
Direct Answer
DPMAS is not recommended as standard therapy for decompensated cirrhosis based on current guideline evidence, as extracorporeal liver support systems including albumin dialysis (MARS) and fractionated plasma separation (Prometheus) have failed to demonstrate survival benefit in randomized controlled trials of ACLF. 1
Guideline-Based Position on Extracorporeal Liver Support
Current Evidence Against Routine Use
Extracorporeal liver support systems do not improve survival in patients with ACLF and should not be recommended in this indication, according to the European Association for the Study of the Liver. 1
Large randomized controlled trials evaluating both MARS and Prometheus systems showed no significant effects on survival in ACLF patients. 1
The definition of ACLF in these trials differed from current CANONIC study-based definitions, which limits direct applicability but does not change the negative survival findings. 1
Potential Exception Requiring Further Study
A sub-analysis of the Prometheus study demonstrated a beneficial effect on survival specifically in patients with MELD score >30, though this finding requires further investigation before clinical implementation. 1
Two controlled studies showed promising beneficial effects in patients with type 1 hepatorenal syndrome using MARS or Prometheus systems, but these require additional validation. 1
Priority Management Instead of DPMAS
First-Line Approach: Treat the Underlying Cause
Etiological treatment must be initiated immediately, as this is the single most important intervention associated with decreased risk of further decompensation and increased survival in decompensated cirrhosis. 2
For HBV reactivation causing ACLF, antiviral therapy with lamivudine, tenofovir, or entecavir is associated with inhibition of HBV replication, improvement of liver function, and higher survival. 1
All patients with decompensated cirrhosis from HBV should receive treatment regardless of HBV DNA level, with tenofovir plus lamivudine combination, or entecavir or tenofovir monotherapy as preferred first-line treatment. 3
Organ Support and Complication Management
Treatment should be based on organ support and management of precipitants rather than extracorporeal liver support systems. 1
Patients should be treated in intermediate care or intensive care settings with frequent monitoring of liver, kidney, brain, lung, coagulation, and circulation. 1
For hepatic encephalopathy, lactulose is first-line therapy, reducing mortality and recurrent overt hepatic encephalopathy. 2
For refractory hyperbilirubinemia with ascites, first-line treatment consists of sodium restriction plus spironolactone with or without furosemide. 2
Liver Transplantation Pathway
Referral Criteria
Patients with clinically decompensated cirrhosis should be referred for consideration of liver transplantation, as this is the treatment of choice. 1
Early referral to a transplant center is crucial in ACLF, as late referral may make transplantation impossible due to rapid evolution. 1
Patients suitable for liver transplantation should be referred early in the course of ACLF, as the condition progresses rapidly in most patients. 1
Contraindications
Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation. 2
For patients with organ failures ≥4 or CLIF-C ACLFs >64 at days 3-7 after diagnosis of ACLF-3, intensive organ support should be discontinued owing to futility if liver transplantation is contraindicated or unavailable. 1
Research Context on DPMAS (Not Guideline-Recommended)
While guidelines do not support DPMAS use, recent research provides context on its technical application:
Bilirubin Reduction Capacity
DPMAS demonstrates dose-dependent reduction in total bilirubin, with processed plasma volumes up to 4500 mL showing progressive benefit. 4
In acute severe cholestatic hepatitis, DPMAS significantly reduced requirements for liver transplantation and achieved significant declines in total bilirubin, direct bilirubin, total bile acid, and cholesterol. 5
Comparative Efficacy Studies
Sequential DPMAS with plasma exchange achieved higher removal of total bilirubin, ALT, AST, and alkaline phosphatase than mono DPMAS, but provided no survival benefit (50% vs 47.5% at 90 days). 6
DPMAS combined with half-dose plasma exchange showed higher 28-day survival rates than full-dose plasma exchange alone in intermediate-advanced stage HBV-ACLF patients (72.2% vs 62.3%). 7
Compared to DPMAS, therapeutic plasma exchange was more efficient in eliminating total bilirubin and direct bilirubin but associated with higher albumin loss, with similar 12-week survival rates. 8
Critical Caveats
The research showing DPMAS efficacy conflicts directly with guideline-level evidence from large RCTs showing no survival benefit for extracorporeal liver support systems. 1
Research studies on DPMAS are predominantly observational or small comparative studies from single centers, lacking the methodological rigor of the guideline-cited randomized controlled trials. 4, 5, 6, 7, 8
Monitoring and management should be individualized according to patients' age and comorbidities, but the fundamental recommendation against routine DPMAS use remains unchanged. 1
Growth factors can be used for treatment-associated anemia (epoetin) and leukopenia (G-CSF, GM-CSF) in patients with decompensated cirrhosis receiving antiviral therapy, but this does not apply to DPMAS indication. 1