Single-Centre Experience With Low-Volume Plasma Exchange and Low-Dose Steroid to Treat Patients With Idiosyncratic Drug-Induced Acute Liver Failure

Kunwar A Singh; Santhosh E Kumar; Uday G Zachariah; Dolly Daniel; Vinoi David; Kandasamy Subramani; Kishore Pichamuthu; Ebor Jacob; Thomas A Kodiatte; Chundamannil E Eapen; Ashish Goel

doi:10.1016/j.jceh.2023.11.003

Single-Centre Experience With Low-Volume Plasma Exchange and Low-Dose Steroid to Treat Patients With Idiosyncratic Drug-Induced Acute Liver Failure

J Clin Exp Hepatol. 2024 Mar-Apr;14(2):101303. doi: 10.1016/j.jceh.2023.11.003. Epub 2023 Nov 7.

Authors

Affiliations

¹ Department of Hepatology, Christian Medical College, Vellore, Tamil Nadu, India.
² Department of Transfusion Medicine, and Immunohematology, Christian Medical College, Vellore, Tamil Nadu, India.
³ Department of Nephrology, Christian Medical College, Vellore, Tamil Nadu, India.
⁴ Department of Critical Care, Christian Medical College, Vellore, Tamil Nadu, India.
⁵ Department of General Pathology, Christian Medical College, Vellore, Tamil Nadu, India.

PMID: 38076447
PMCID: PMC10698001 (available on 2025-03-01)
DOI: 10.1016/j.jceh.2023.11.003

Abstract

Background: Idiosyncratic drug-induced liver injury (iDILI) causing acute liver failure (ALF) carries high short-term mortality and patients who meet King's College criteria for liver transplantation have 1-month survival of 34% without liver transplantation (PMID: 20949552). We present our experience with low-volume plasma exchange (PLEX-LV, 50% of estimated plasma volume exchanged per session) and low-dose steroid to treat iDILI ALF.

Methods: We retrospectively analysed data of patients with iDILI (diagnosed as per RUCAM score), treated with PLEX-LV and low-dose steroid (prednisolone: 10 mg OD, with rapid taper) in our department from 2016 to 2022. Baseline and dynamic parameters (post-PLEX) were assessed as predictors of 1-month liver transplantation-free survival.

Results: Twenty-two iDILI patients [probable: possible iDILI: 20:2, males: 9, age: 30 (14-84) years, median (range); MELD score: 30.5 (19-43)] underwent PLEX-LV for ALF during the study period. Causative agents were complementary and alternative medications (36%), antiepileptics (18%) antimicrobials (14%), antitubercular drugs (14%), antifungal drugs (9%) and others (9%). All patients had jaundice and encephalopathy; 9 patients also had ascites. None of the patients underwent liver transplantation. Study patients underwent 3 (1-7) PLEX sessions and 1.4 (0.6-1.6) litres of plasma was exchanged per session. One-month transplant-free survival was 59% (13/22) in the study population and 63% (12/19) among patients who fulfilled Kings College criteria for liver transplantation. Reduction of ≥25% in plasma von Willebrand factor (VWF) levels after PLEX-LV predicted improved survival (HR: 0.09, 95% CI: 0.01-0.65; AUROC: 0.81; 95% CI: 0.6-1.0).

Conclusion: Low-volume PLEX and low-dose steroid appears a promising treatment option in patients with iDILI-induced ALF not opting for liver transplantation. Dynamic changes in VWF level after PLEX predict 1-month survival in these patients.

Keywords: acute liver failure; idiosyncratic drug-induced injury; plasma exchange; von Willebrand factor.