On-treatment decline in MELD score predicts outcome in rodenticidal hepatotoxicity patients treated with plasma exchange

Background and Aim: Plasma exchange (PLEX) improves survival in patients with rodenticidal hepatotoxicity. However, predictors of treatment response are unknown. We aimed to assess predictors of response to PLEX treatment in these patients. Methods: Patients with rodenticide ingestion from 2014 to 2022 managed in our department were included in this study. Kochi criteria (MELD score or INR with hepatic encephalopathy) was used to assess the need for liver transplantation. We analyzed predictors of in-hospital survival. Bilirubin, MELD score and INR were calculated as percentage change of the parameter after third PLEX session (or value after last PLEX if < 3 PLEX session done) from baseline pre-PLEX value. Results: During the study period, low volume PLEX treatment was instituted in patients with rodenticidal hepatotoxicity(n=186) in 34/86 for acute liver injury (ALI) (male 25; age median, range: 22, 12-63), and 56/77 for acute liver failure (ALF) (male 11; age: 20, 3 - 70). No patient had liver transplantation. Of the 69 patients (43 had PLEX) who fulfilled Kochi criteria, 29(42%) survived. In PLEX treated patients, survival was 67.8% (ALI: 34/34 patients; ALF: 27/56, Kochi criteria fulfilled: 21/43). Predictors of survival were analyzed in patients who had either ALF or fulfilled Kochi criteria. Age (p=0.007) and MELD (p<0.001) were significant on univariate analysis. On multivariate, MELD significantly predicted in-hospital survival (OR = 0.948, p=0.002), (AUROC:0.84; 95 % CI:0.74-0.95). Decrease of 10% in MELD score while on PLEX had 87% sensitivity and 64% specificity in predicting survival. Conclusion: Delta decline in MELD while on PLEX treatment independently predicted survival in rodenticidal hepatotoxicity patients. This may help guide decision on stopping PLEX in patients predicted to respond to treatment and to consider alternate treatment options in non-responders.