Plasma Exchange for Acute-on-Chronic Liver Failure

Guideline-Based Recommendations

The European Association for the Study of the Liver (EASL) recommends against the routine use of plasma exchange (PLEX) for acute-on-chronic liver failure (ACLF) outside of research trials, except in highly selected critically ill patients as a bridge to transplantation when standard therapies fail 1
The American Association for the Study of Liver Diseases (AASLD) suggests PLEX only for acute liver failure (ALF) with hyperammonemia (ammonia >150 μmol/L), not for ACLF, with a conditional recommendation based on low-quality evidence 2

The EASL guidelines explicitly reject routine PLEX use despite emerging data showing potential survival benefit with PLEX in ACLF, citing insufficient high-quality evidence and the need for controlled trials 1

The AASLD guidelines recommend PLEX for ALF with hyperammonemia, but not for ACLF, highlighting the critical distinction between ALF and ACLF 2
PLEX might be considered for a critically ill ACLF patient who is listed for transplant, deteriorating while awaiting organ availability, failing standard therapies, and at a center with PLEX expertise, ideally within a research protocol 1

Acute-on-Chronic Liver Failure (ACLF) is characterized by acute onset with rapid deterioration in clinical condition, presence of liver failure in patients with chronic liver disease, and at least one extrahepatic organ failure 3

The Asian Pacific Association for the Study of the Liver (APASL) and Chinese guidelines support PLEX as a promising treatment for ACLF patients awaiting liver transplants or experiencing spontaneous regeneration 4
The European Association for the Study of the Liver (EASL) advises against routine use of PLEX for ACLF outside of research trials 4
The American Association for the Study of Liver Diseases (AASLD) suggests using plasma exchange in critically ill ALF patients who develop hyperammonemia (conditional recommendation, low quality evidence) 5

Early identification and treatment of precipitating factors, such as bacterial infections, is crucial in ACLF management 6
Organ support is essential in the management of ACLF 7
Consideration for liver transplantation in eligible patients is important in ACLF management 6, 8

The American College of Critical Care Medicine provides a conditional recommendation (low quality evidence) for plasma exchange in critically ill ALF patients with hyperammonemia, but this does not extend to ACLF 9

Centers with plasma exchange expertise and resources available should consider plasma exchange for ACLF patients listed for liver transplantation and awaiting organ availability, deteriorating despite standard medical therapy, according to the American College of Critical Care Medicine 9