Plasma Exchange in Acute-on-Chronic Liver Failure

Guideline Recommendations

The European Association for the Study of the Liver (EASL) explicitly recommends against routine use of plasma exchange for ACLF outside of research trials, citing insufficient high-quality evidence despite emerging data showing potential survival benefit 2, 3
The American Association for the Study of Liver Diseases (AASLD) suggests plasma exchange only for acute liver failure with hyperammonemia, not for ACLF, with a conditional recommendation based on low-quality evidence 1, 4, 3
The Critical Care Medicine guidelines state that plasma exchange should be used in critically ill acute liver failure patients who develop hyperammonemia, but this recommendation does not extend to ACLF 1, 5

Plasma exchange might be considered in ACLF patients who are listed for liver transplantation, deteriorating despite standard medical therapy, at a center with plasma exchange expertise, and ideally enrolled in a research protocol 3, 1
The Asian Pacific Association for the Study of the Liver (APASL) and Chinese guidelines are more supportive of plasma exchange as a promising treatment for ACLF patients awaiting transplants, but this conflicts with Western guidelines 3

The standard management of ACLF includes lactulose or polyethylene glycol for hepatic encephalopathy, rifaximin as adjunctive therapy, early identification and treatment of precipitating factors, organ support, and early referral to a transplant center 4, 2, 7
The European Association for the Study of the Liver (EASL) and the American Association for the Study of Liver Diseases (AASLD) recommend against routine use of plasma exchange in ACLF, except in highly selected cases 2, 1

The clinical algorithm for decision-making in ACLF involves confirming the diagnosis and severity, initiating standard medical therapy, assessing transplant candidacy, and considering plasma exchange only if all criteria are met 7, 2, 3

Plasma exchange is generally safe, but procedure-related adverse events can occur, and the presence of 4 or more organ failures or a high CLIF-C ACLF score should prompt re-evaluation of continuing organ support in the absence of transplant options 2