Therapeutic plasma exchange in severe alcohol-associated hepatitis-related acute-on-chronic liver failure

Objective Severe alcohol-associated hepatitis (AAH) driven acute-on-chronic liver failure (ACLF) carries high short-term mortality, where corticosteroids offer limited benefit. This study evaluated the safety and impact of therapeutic plasma exchange (PLEX) in this setting. Design/method This prospective multicentre study included adults with severe AAH precipitating Asian Pacific Association for the Study of the Liver (APASL)-defined ACLF who received PLEX across 12 tertiary hospitals in Tamil Nadu, India. The primary outcome was 1-month transplant-free survival. Secondary outcomes included changes in disease severity scores after PLEX, survival predictors and adverse events. Results Over 3 months (June–August 2024), 51 patients (98% male, mean age 44 years) underwent PLEX; none received corticosteroids beforehand. 1-month transplant-free survival was 78.4%. Most patients (88.2%) received early PLEX (≤5 days from hospital admission); 74.5% received low-volume PLEX. Low-dose corticosteroids were used with PLEX in 82.4%. Post-PLEX, disease severity scores declined significantly (mean Model for End-Stage Liver Disease (MELD): 31.6 to 26.5; APASL ACLF Research Consortium (AARC): 10.2 to 8.4; both p<0.001), with greater reduction among survivors. Median decline in MELD score was 4 (–4 to 18) in survivors vs 1 (–3 to 10) in non-survivors (p=0.005). AARC grade III decreased from 47.1% to 13.7% post-PLEX, with greater decline in survivors than non-survivors (p=0.001). Post-PLEX AARC score predicted 1-month mortality (Area under the receiver operating characteristic curve (AUC) 0.808; p=0.002). No major adverse events occurred. Conclusions PLEX with low-dose steroids was safe and feasible in AAH-related ACLF. Post-PLEX AARC score predicted 1-month mortality. Greater declines in disease severity scores among survivors suggest their role as early response markers. These findings support further prospective evaluation of PLEX in AAH-related ACLF.