Standard Volume Plasma Exchange Is Safe and Effective For Patients With Severe Alcohol-Related Hepatitis

Background and Aim: Several patients with SAH are unsuitable for corticosteroid therapy because of kidney injury, infection, and gastrointestinal bleeding. Early liver transplantation (LT) is not readily accepted in our settings. Therefore, we aimed to assess the efficacy and safety of Therapeutic plasma exchange (PLEX) in patients with SAH. Methods: In this prospective study, we included patients with SAH (NIAAA definition) who were ineligible for corticosteroid therapy and/or unwilling for LT. The primary objective was to assess the survival at days 30 and 90, and secondary outcomes were to determine the adverse events related to PLEX and predictors of 30- and 90-day mortality. Results: 54 patients (age-40.67 ± 8.04 years; males-100%; mDF score-119.75 ± 65.72, MELD-32.08 ± 5.43) with SAH without active infection underwent standard volume PLEX during the study period. Survival at one and three months was 76% (41/54) and 57.41% (31/54), respectively.10% of patients developed adverse events due to PLEX. 22% percent of patients(n=12) developed infection within three weeks of PLEX. Patients who died at 3 months had significantly higher severity scores at baseline (MELD: 34.9 =/-5.7 vs. 30+/-4.2 in alive; mDF- 152.4+/-86 vs. 95.5+/-28.1 in alive patients). Baseline procalcitonin was considerably higher in patients who died (0.96+/-0.82 ng/ml) compared to those who survived (0.52+/-0.38:P=0.05). On multivariate logistic regression analysis, MELD and MELD NA were found to be a significant predictor of mortality at 1 month (OR, 0.72 [0.6-0.88]; P<0.001) and 3 months (OR, 0.78 [0.61-0.91]; P=0.002), respectively. On ROC curve analysis, baseline MELD>=33.5, MELD NA>=35.5, and mDF>=130.8 predicted mortality at 1 month despite PLEX. While baseline MELD>=32.5, MELD NA>=34.5, and mDF>=108.5 predicted mortality at 3 months, indicating the futility of PLEX in high severity scores (Figure) Conclusions: Plasma exchange is safe and effective for patients with SAH providing survival of 76% and 57.4% at 1 and 3 months. MELD remains the best predictor of mortality. MELD between 21-33 and mDF between 60-109 are ideal candidates to benefit from PLEX.