Low Volume Plasma Exchange and Low Dose Steroid Improve Survival in Patients With Alcohol-Related Acute on Chronic Liver Failure and Severe Alcoholic Hepatitis - Preliminary Experience

Santhosh E Kumar; Ashish Goel; Uday Zachariah; Sukesh C Nair; Vinoi G David; Santosh Varughese; Prashanth B Gandhi; Amit Barpha; Anand Sharma; Balakrishnan Vijayalekshmi; Kunissery A Balasubramanian; Elwyn Elias; Chundamannil Eapen Eapen

doi:10.1016/j.jceh.2021.07.010

Low Volume Plasma Exchange and Low Dose Steroid Improve Survival in Patients With Alcohol-Related Acute on Chronic Liver Failure and Severe Alcoholic Hepatitis - Preliminary Experience

J Clin Exp Hepatol. 2022 Mar-Apr;12(2):372-378. doi: 10.1016/j.jceh.2021.07.010. Epub 2021 Jul 21.

Affiliations

¹ Departments of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India.
² Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India.
³ Nephrology, Christian Medical College, Vellore, Tamil Nadu, India.
⁴ Wellcome Trust Research Laboratory (GI Sciences), Christian Medical College, Vellore, Tamil Nadu, India.
⁵ Liver Unit, University Hospitals Birmingham, Birmingham, UK.

Abstract

Background: Alcohol-related acute on chronic liver failure (A-ACLF) patients have high short-term mortality and are poor candidates for steroid therapy. Plasma exchange (PLEX) improves survival in ACLF patients. We analyzed our experience with low volume PLEX (50% of plasma volume exchanged per session) and low dose steroids to treat A-ACLF patients.

Methods: We retrospectively compared the efficacy of low volume PLEX and low-dose steroids with standard medical treatment (SMT) in A-ACLF patients treated at our center between November 2017 to June 2019. The primary study outcome was one-year survival.

Results: Twenty-one A-ACLF patients in PLEX group [age 40 (29-56) years, median (range); MELD score 31 (29-46)] and 29 A-ACLF patients in SMT group [age 41.5 (28-63) years, MELD score 37 (21-48)] were studied. All 50 study patients had severe alcoholic hepatitis [mDF 84.7 (50-389)]. PLEX group patients had 3 (1-7) PLEX sessions with 1.5 (1.4-1.6) liters of plasma exchanged per session and oral Prednisolone 20 mg daily, tapered over 1 month. Kaplan Meier analysis showed better survival over 1 year in the PLEX group compared to the SMT group (P = 0.03). There was renal dysfunction in 10 patients in the PLEX group, which normalized in six patients after PLEX.

Conclusion: In this preliminary report, compared to SMT, low volume PLEX and low dose steroid improved survival over one year in A-ACLF patients with severe alcoholic hepatitis. In patients with renal dysfunction, 60% showed improvement in renal function with PLEX. Studies with a larger number of patients are needed to validate these results.

Keywords: A-ACLF, Alcohol-related acute on chronic liver failure; AARC score, APASL ACLF Research Consortium score; ADAMTS13, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13; APASL, Asia pacific association for the study of the liver; INR, International normalized ratio; MELD, Model for end-stage liver disease; PLEX, Plasma exchange; SMT, standard medical treatment; VWF, von Willebrand factor; acute on chronic liver failure; alcohol; mDF, modified discriminant function; plasma exchange; steroid.