P0998 - Plasma Exchange for Acute and Acute-On-Chronic Liver Failure: A Systematic Review and Meta-Analysis

Azizullah Beran, MD¹, Mouhand FH. Mohamed, MD², Mohammad Shaear, MD³, Mohammed Mhanna, MD⁴, Omar Srour, MD⁵, Mohamad Nawras, BS⁶, Jonathan Montrose, DO⁷, Ragheb Assaly, MD⁸, Chandrashekhar Kubal, MD¹, Marwan Ghabril, MD¹, Ruben Hernaez, MD, MPH, PhD⁹, Kavish Patidar, MD^9
1Indiana University, Indianapolis, IN; ²Brown University, Providence, RI; ³Central Michigan University, Mount Pleasant, MI; ⁴University of Iowa, Iowa City, IA; ⁵Henry Ford Health System, Detroit, MI; ⁶University of Toledo College Medicine and Life Sciences, Toledo, OH; ⁷Indiana University School of Medicine, Indianapolis, IN; ⁸University of Toledo, Toledo, OH; ⁹Baylor College of Medicine, Houston, TX

Introduction: Liver transplantation (LT) is a lifesaving and curative treatment for patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). However, LT is limited by organ supply and patient selectivity. Plasma exchange (PE) has shown immunological and biochemical benefits in ALF and ACLF. The survival benefit for PE in ALF and ACLF remains unclear and limited by conflicting results of previous studies. In this meta-analysis, we aimed to compare PE vs. standard medical therapy (SMT) in ALF and ACLF patients.

Methods: We searched PubMed/Embase/Cochrane databases for studies comparing PE versus SMT for ALF and ACLF patients >18 years old. Pooled risk ratios (RR) with the corresponding 95% confidence intervals (CIs) were calculated by the Mantel-Haenszel method within a random-effect model. A RR >1 indicated survival benefit for PE, and P-values < 0.05 were considered statistically significant. Subgroup analyses were performed based on the study design and type of PE protocols. Primary outcome was 30-day survival for ACLF and ALF. Secondary outcomes were overall survival and 90-day survival for ALF and ACLF, respectively.

Results: Five studies, including 343 ALF patients (n=174 PE vs. n=169 SMT), and 19 studies, including 5,522 ACLF patients (n=2,762 PE vs. n=2,760 SMT), were analyzed. Compared to SMT, PE was significantly associated with higher 30-day (RR 1.41, 95% CI 1.06-1.87, P=0.02, Figure 1A) and overall (RR 1.35, 95% CI 1.12-1.63, P=0.002, Figure 1B) survival in ALF patients. In ACLF, PE was also significantly associated with higher 30-day (RR 1.33, 95% CI 1.19-1.50, P< 0.00001, Figure 1C) and 90-day (RR 1.23, 95% CI 1.10-1.37, P=0.0002, Figure 1D) survival. In the subgroup analysis of randomized controlled trials (RCT), overall survival benefit remained consistent favoring PE over SMT in ALF (RR 1.31, 95% CI 1.02-1.67, P=0.03, Figure 1E), but there was no difference in 90-day survival between PE and SMT in ACLF, despite trends towards higher survival with PE (44.3% vs. 27%, respectively; RR 2.14, 95% CI 0.67-6.85, P=0.20, Figure 1F). The survival benefit for both ALF and ACLF remained significant regardless of PE protocols.

Discussion: PE was associated with a survival benefit in ALF and could improve survival in ACLF. PE may be considered in managing ALF and ACLF patients who are not LT candidates or as a bridge to LT in otherwise eligible patients. Further RCTs are needed to confirm the survival benefit of PE in ACLF.



Disclosures:


Azizullah Beran, MD¹, Mouhand FH. Mohamed, MD², Mohammad Shaear, MD³, Mohammed Mhanna, MD⁴, Omar Srour, MD⁵, Mohamad Nawras, BS⁶, Jonathan Montrose, DO⁷, Ragheb Assaly, MD⁸, Chandrashekhar Kubal, MD¹, Marwan Ghabril, MD¹, Ruben Hernaez, MD, MPH, PhD⁹, Kavish Patidar, MD⁹. P0998 - Plasma Exchange for Acute and Acute-On-Chronic Liver Failure: A Systematic Review and Meta-Analysis, ACG 2023 Annual Scientific Meeting Abstracts. Vancouver, BC, Canada: American College of Gastroenterology.