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Prof Piyush Ranjan

Plasma exchange saves patient with acute liver failure

Doctors at Delhi’s Sir Ganga Ram Hospital (SGRH) have developed a unique procedure called plasma exchange (PLEX), which can save the lives of patients with acute liver failure and replace liver transplantation.

The doctors have recently saved the life of a 52-year-old patient with acute liver failure by PLEX. It is a procedure like a dialysis, where the blood is removed from the patient, and the cellular components (RBC, WBC and platelet) are separated from plasma using a centrifuging machine.

The patient was admitted to SGRH with symptoms of jaundice for two weeks, followed by altered consciousness.

He further developed ascites, where fluids accumulate in the abdomen and urine output decreases resulting in acute kidney injury.

On further investigations, he was found to be hepatitis B Virus positive, and a diagnosis of acute on chronic liver failure – (ACLF) secondary to Hepatitis B virus reactivation was made.

At this juncture, dialysis was considered and the patient was offered an option of a liver transplant as his parameters indicated a one-month probability of survival to be around 50%.

Dr Piyush Ranjan, Senior Consultant, Department of Gastroenterology, Sir Ganga Ram Hospital, said, “As there was no donor in the family, we offered an unusual option of plasma exchange (PLEX). We did a total of five sessions of PLEX for him. After the second session, his jaundice started improving, his consciousness improved, and his renal functions also started improving. He was continued on other medical therapy of which the most important is antiviral therapy.”

“Patient was discharged after 20 days of hospitalisation in a stable condition and one month of follow up his ascites (fluid accumulation in the stomach) completely resolved, and jaundice had normalised,” he added.

Pointing out that plasmapheresis is increasingly being used as a bridge for liver transplant and in many cases, a large proportion of these patients may recover by the control of other factors, Dr Ranjan said, “Like, in the case of our patient, treatment of Hepatitis B virus with medication was continued. So in this situation, PLEX acted as support to the failing liver.”

 In PLEX, the plasma is discarded and fresh plasma (FFP) and albumin is mixed along with the cellular components and returned back to the patient. The plasma contains a lot of toxic products which are being produced by the injury to the liver. Since in PLEX the removal of entire plasma leads to filtering out toxins, compared to dialysis and MARS, where the removal is limited by the pore size.

The cost of PLEX for every session is around 30,000 INR and blood donors are required. On average, patients who respond undergo three sessions of PLEX, and some may require more sessions, like the current patient, who needed five sessions, he informed.

In this particular patient, it proved to be lifesaving and provided time for other treatments to take effect.

“We are regularly offering PLEX to our patients with the most common indications being failed steroid treatment for severe alcoholic hepatitis and flare of hepatitis B and autoimmune hepatitis. We select these patients based on well-established criteria. We have done this on ten patients with good results and saved the need of high-cost liver transplant which in today’s date costs around 25 to 30 lakhs in the private sector,” Dr Ranjan said.

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