Semin Liver Dis 2021; 41(04): 476-494
DOI: 10.1055/s-0041-1730971
Review Article

Plasma Exchange in Acute and Acute on Chronic Liver Failure

Rakhi Maiwall
1  Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
Shiv K. Sarin
1  Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
› Author Affiliations


Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.


ALF, acute liver failure; ACLF, acute on chronic liver failure; APASL, Asian pacific association for liver study; CAM, complementary and alternative medicines; CARS, compensatory inflammatory response syndrome; CHDF, continuous hemodiafiltration; CLIF, chronic liver failure acute-on-chronic liver failure in cirrhosis (CANONIC); CN, cholemic nephrosis; CRRT, continuous renal replacement therapy; cTPE, centrifugation therapeutic plasma exchange; DAMPs, damage-associated molecular patterns; EASL, European study of liver; EPV, estimated plasma volume; FFP, fresh-frozen plasma; FXR, farnesoid-X-receptor; HVP, high-volume plasma exchange; IFN-γ, interferon-gamma; IL, interleukin; IL-1RA-IL-1, receptor antagonist; INR, international normalized ratio; LPS, lipopolysaccharide; MELD, model for end-stage liver disease; MERTK, monocytes expressing the tyrosine-protein kinase Mer; MARS, molecular adsorption recirculation system; mTPE, membrane therapeutic plasma-exchange; PAMPs, pathogen-associated molecular patterns; RCA, regional citrate anticoagulation; SIRS, systemic inflammatory response syndrome; SMT, standard medical treatment; SOFA, sequential organ failure assessment; TIMP-1, tissue-inhibitor of metalloproteinase-1; TIPS, transjugular intrahepatic portosystemic shunt; TNF-α, tumor necrosis factor-α; TMP, transmembrane pressure; TPE, therapeutic plasma-exchange.

Financial Disclosures


Publication History

Publication Date:
14 July 2021 (online)

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