8. Efficacy of high volume plasma exchange in transplant free survival in pediatric ALF with advanced hepatic encephalopathy

Abstract

Background and Aims: Prompt management with supportive care and liver support strategies, largely determine the outcome of acute liver failure (ALF). The aim of this work was to analyze the effect of high volume plasma exchange (HVPE) on the outcome of children with ALF. Methods: In this single centre prospective interventional trial done between May 2015 to April 2018, all children with ALF (diagnosed as per the Paediatric Acute Liver Failure study group definition) with Hepatic Encephalopathy (HE) Grade III and IV weighing more than 10 kg were offered to receive HVPE. Twenty-three ALF patients agreed to receive HVPE with standard medical therapy (SMT) and another 23 age and gender matched children who received SMT alone were included as controls. Endpoint of the study was survival with native liver/liver transplantation (LT) or death by 30 days hospital stay. The primary outcome measures were transplant free survival in days and proportions of transplant free survival at day 7 and at day 30. The HVPE procedure was undertaken on three consecutive days at the interval of 24 h. For each HVPE 1.5-2 times the plasma volume was exchanged. Results: The baseline characteristics of the groups were similar. In the HVPE group, 12 received 3 or more sessions of HVPE whereas 11 patients received 1 or 2 sessions of HVPE. In the HVPE group 12 died, 5 (21.7%) were transplanted and 6 (26.1%) survived with native liver (SNL). In the SMT alone group, 11 (47.8%) died, 4 (17.4%) were transplanted and 8 (34.7%) SNL. Median Transplant free survival in HVPE group was 8.2 (IQR 3.2–20.2) days versus 5 (IQR 2–11) days in the SMT alone group (Mean Difference 4.37, 95% CI 2–10.7, p = 0.172). Transplant free survival on day 7 was 13/23 (56.5%) and 9/23 (39.1%) (OR 2.02, 95%CI 0.62–6.5, p = 0.38) while on day 30 was 6/23 (26.1%) and 8/23 (34.7%) (OR 0.66, 95%CI 0.18–2.34, p = 0.75) in the HVPE and SMT group respectively. Overall survival on day 7 was 17/23 (73.9%) and 12/23 (52.2%) (OR 2.59, 95%CI 0.75–8.9, p = 0.22) while on day 30 was 11/23 and 12/23 (OR 0.84, 95%CI 0.26–2.7, p = 1) in the HVPE and SMT group respectively. Conclusions: Although half of the sample size did not receive the 3 sessions of HVPE, yet compared with the SMT alone group, HVPE did prolong the transplant free survival in days and improve the proportions of patients surviving on day 7 but these comparisons did not reach the level of statistical significance. HVPE may have a potential role as a bridging therapy for LT. The authors have none to declare.