Plasma exchange and the arterial blood ketone body ratio in patients with acute hepatic failure

Abstract

Hepatocyte regeneration in acute hepatic failure is essential for recovery, but requires a large amount of energy. One problem with plasma exchange as supportive therapy in these cases is that massive citrate infusion has an adverse effect on the hepatic energy charge, which may be a serious risk in these patients. The ratio of acetoacetate to beta-hydroxybutyrate in arterial blood has been reported to reflect the cellular energy charge of hepatocytes. In this study, this ratio was assessed before and after plasma exchange in 19 patients with acute hepatic failure. Eight patients recovered and 11 died. The arterial blood ketone body ratio was below 0.6 in all 11 nonsurvivors. It fell to below 0.4 in 10 of them during the first plasma exchange session, and remained below 0.4 for over 12 h in seven of them. On the other hand, the arterial blood ketone body ratio returned to above 0.6 in four of eight surviving patients within 12 h after the first plasma exchange and remained below 0.4 for over 12 h only in two of eight patients. These data indicate that plasma exchange may cause suppression of the arterial ketone body ratio in patients with severe acute hepatic failure. These metabolic changes impair liver metabolism and may make effective hepatocyte regeneration impossible.