Effects Of Plasma Exchange On Survival In Patients With Acute-on-Chronic Liver Failure

ObjectiveAcute-on-chronic liver failure(ACLF)is a series of clinical syndrome characterized by progressive jaundice,blood coagulation dysfuntion,ascites,electrolyte disorder and hepatic encephalopathy,which is caused by an acute deterioration of pre-existing chronic liver disease usually related to a precipitating event and associated with increased mortality.At present,clinical symptomatic supportive treatment is mainly used in clinical practice,with long treatment cycles,high costs,and low survival rates.Liver transplantation is the most effective treatment for acute-on-chronic liver failure,but only a few patients can benefit from it because of the lack of donor organs,the high cost,and the postoperative care.The artificial liver support system(ALSS)came into being in such an environment.It temporarily replaces part of the function of the failed liver,creating conditions for hepatocyte regeneration and liver function recovery or waiting for opportunities for liver transplantation.In the past decades,plasma exchange(PE)has become the mainstream of the artificial liver support system in China,which owns to its accurate curative effect,convenient operation,and simple equipment requirements.In this study,we retrospectively analyzed the clinical efficacy of PE in the treatment of ACLF,and compared the patients who received standard medical therapy in the same period,to determine the therapeutic characteristics,and to explore the relevant factors affecting the prognosis of ACLF.Providing basis for its clinical application in the treatment of ACLF.MethodsA total of 208 hospitalized patients who were diagnosed with ACLF and underwent PE or standard medical therapy were retrospectively analyzed.According to the treatment methods used,they were divided into PE group(n=94)and standard medical therapy group(n=114),and followed up for 90 days.By comparing the changes of serum biochemical indexes and model for end-stage liver disease score between the two groups of patients at the time of admission and before discharge,the clinical efficacy of PE in the treatment of ACLF was clarified.Meanwhile,by analyzing the adverse reactions during PE,the safety of PE for ACLF was clarified.Furthermore,by comparing the median time to death at day 90 and mortality probalities at days 28 and 90,irrespective of liver transplantation,and analyzing the relevant factors that affect the prognosis,the treatment characteristics of plasma exchange and its impact on survival outcomes were clarified.In this study,SPSS22.0 software is used for data analysis.The measurement data obeying normal distribution were expressed by mean ±standard deviation((?)),paired t-test was used for intra-group comparison before and after treatment,and two independent sample t-test was used for inter-group comparison,median and quartile interval[M(Q3-Q1)]were used for non-normal distribution,Wilcoxon rank sum test was used for intra-group comparison before and after treatment,and Mann-Whitney U test was used for inter-group comparison.The counting data are expressed in terms of rates(%),and the comparison is made by the Pearson ?2 test or the Fisher exact probability method.The independent risk factors influencing the prognosis of ACLF were determined by logistic regression analysis and P<0.05 was considered as statistical defference.Results1.Effects of Laboratory IndicatorsAfter PE treatment,serum total bilirubin,alanine aminotransferase,hematocrit,platelet count,and model for end-stage liver disease score decreased(P<0.05);prothrombin time activity,albumin,and serum sodium ameliorated significantly(P<0.05).2.Adverse EventsA total of thirty-four adverse events occurred during plasma exchange treatment,including allergic reactions,chills,hypotension,limb numbness and convulsion.3.Effects on SurvivalThere were no significant differences in survival between the PE and the standard medical therapy group.Twenty eight-day mortality probability for the PE and standard medical therapy groups was 31.9%and 33.3%(P>0.05)and 90-day mortality probability was 45.7%and 44.7%,respectively(P>0.05).The corresponding Kaplan-Meier estimates of median time to death were 18.7 and 15.9 days in the PE and standard medical therapy groups(P>0.05).The main cause of death was multiorgan failure,followed by uncontrolled bacterial infection and uncontrolled bleeding.There were no differences between groups regarding the cause of death(67.4%vs56.8%;20.9%vs29.4%;11.6%vs13.7%;P>0.05).Following the study protocol,subgroup analyses were performed according to the severity of prothrombin time activity,severe hepatic encephalopathy?grade ?,or age.There were no differences in 90-day transplant-free survival in any of the subgroups.4.Early Predictors of DeathUnivariate analyses identified hepatic encephalopathy equal or higher than grade?,hypoproteinemia,hepatorenal syndrome as predictors of death.Conclusions1.Treatment with PE was associated with a significant amelioration with Liver function and coagulation function and reduction with model for end-stage liver disease.2.Plasma exchange is a safe and effective artificial liver support system.The patient is generally well tolerated.The main adverse events include allergy,hypotension,limb numbness and convulsions.3.Treatment with PE was not improve the short-term survival.4.Independent baseline risk factors in an univariate analyses were as follows:hypoproteinemia,hepatorenal syndrome,hepatic encephalopathy?grade ?.