Therapeutic Plasma Exchange in Patients With Acute‐On‐Chronic Liver Failure Improves Survival—An Updated Meta‐Analysis

ABSTRACT Background and Aim Acute‐on‐chronic liver failure (ACLF) is a syndrome that develops after an acute insult and is associated with organ failures and high short‐term mortality. Plasma exchange (PLEX) is an emerging modality for treating ACLF patients. We aimed to evaluate the efficacy of PLEX in treating ACLF. Methods We conducted a systematic review and meta‐analysis of studies comparing PLEX versus standard medical therapy (SMT) to treat patients with ACLF across different definitions and etiologies. Pooled risk ratios were determined by the Mantel–Haenszel method within a random effect model. The primary outcome studied was survival at 30 days in PLEX group compared to SMT. Results Twenty‐three studies (5336 ACLF patients with 2724 in PLEX arm, including 4 RCTs) were included. PLEX was associated with a significant reduction in mortality at 30 days (RR 0.70; 95% CI, 0.60–0.81; p < 0.001) and at 90 days (RR 0.81;0.77–0.86; p < 0.001). Six studies (1495 patients; 2 RCTs) with data for 1‐year survival showed better outcomes in the PLEX group (RR 0.85; 0.79–0.92; p < 0.0001) compared to SMT. Among HBV‐related ACLF and alcohol‐related ACLF, there was a significant reduction in mortality among PLEX treated group at 90 days; RR 0.79 (0.74–0.85), p < 0.001 and RR 0.69 (0.52–0.92), p = 0.01 respectively. PLEX was associated with improved 3‐month survival across definitions for ACLF. The most common adverse effects were skin rash and allergic reactions (14%). Conclusions In this up‐to‐date meta‐analysis, significant 1, 3‐month and up to 1‐year survival benefit was noted among patients with ACLF treated with PLEX compared to SMT.