Exploring the Impact of Therapeutic Plasma Exchange on Organ Function in Patients With ACLF: A Retrospective, Single-center Propensity Score-matched Cohort Study.

Background and aims: Acute on chronic liver failure (ACLF) represents the most severe outcome of acute decompensation in patients with liver cirrhosis, with ACLF-grade 3 carrying a nearly 80% mortality rate within 28 days. Prognosis is especially dire within the first 3-7 days with full organ support. Currently, effective treatments are limited to transplantation, but therapeutic plasma exchange (TPE) may contribute by removing harmful inflammatory mediators and replenishing essential proteins, thus offering promise for patients unresponsive to standard medical treatments (SMT). Material and methods: This retrospective study analyzed patients with ACLF receiving SMT with or without TPE at a tertiary care transplant center. Patients were monitored for at least 90 days postdiagnosis. The primary endpoint was 28-day transplant-free survival, with secondary endpoints including 90-day transplant-free survival, organ dysfunction parameters, and chronic liver failure consortium (CLIF-C) scores. A cohort of 25 patients treated with SMT + TPE and 65 with SMT alone was identified. Propensity scores enabled 1:1 matching, resulting in a final analysis of 40 patients (20 TPE group and 20 SMT group). Results: Patients underwent a median of three (IQR 2.25-5) TPE sessions, starting a median of 14 (IQR 7.25-17) days after ACLF diagnosis. Significant improvements were observed in ACLF grade, CLIF-C-ACLF score, hepatic encephalopathy and prothrombin time 24-48 h postfinal TPE session. The 28-day transplant-free survival rates were 70% in the TPE group versus 45% in the SMT group (P = 0.083) and at 90 days, survival rates were 30% in bothgroups (P = 0.426). Patients unresponsive to SMT who received TPE had significantly higher 28-day transplant-free survival rates compared to those treated with SMT alone (70.6% vs 26.7%, P = 0.008). Conclusion: TPE may demonstrate potential efficacy in ameliorating organ dysfunction in patients with ACLF and could contribute to enhanced short-term survival in selected cases. However, clear criteria for initiating TPE have yet to be established. Unresponsiveness to standard medical treatment may serve as a potential surrogate parameter to guide clinical decision-making on an individual basis.