Plasma Exchange Is an Effective Adjunct in the Management of Hyperbilirubinemia in Early Allograft Dysfunction and Small for Size Syndrome after Liver Transplant

Abstract

Background: Management of early allograft dysfunction (EAD) and small for size syndrome (SFSS) after liver transplant remains challenging and care is largely based around supportive treatment. The role of plasmapheresis/plasma exchange in SFSS is not well established. However, it can potentially serve an important role as a salvage option by reducing the metabolic load of toxins including bilirubin and supplying important coagulation proteins to maintain coagulation homeostasis. Methods: We present three cases. A 19-year-old female underwent living-donor liver transplant (LDLT) and received a healthy right lobe graft. Graft-to-recipient weight ratio (GRWR) was 0.85. She developed SFSS and underwent one cycle of plasma exchange on post-operative day (POD) 8 (peak bilirubin 414umol/l) that was prematurely terminated as she developed an allergic response. A 58-year-old female underwent deceased-donor liver transplant and developed acute worsening hyperbilirubinemia on POD8-10 (from 116umol/l to 858 umol/l). She underwent one cycle of plasma exchange that was sufficient to serve as a bridge to treat the hyperbilirubinemia until liver biopsy diagnosis of acute cellular rejection was obtained and definitive steroid treatment was initiated. A 42-year-old female underwent LDLT and received a left lobe graft (GRWR 0.75). She developed SFSS despite portal inflow modulation performed during transplant. She underwent three sessions of plasma exchange (POD25,27,30). Results: In the three cases bilirubin levels improved significantly following plasma exchange, and graft recovery was evident. Conclusion: Our cases suggest the efficacy of plasma exchange as a potential adjunct for the supportive treatment of hyperbilirubinemia in EAD and SFSS to avoid re-transplantation.