Optimal Timing of Therapeutic Plasma Exchange and Hepatic Encephalopathy Severity as Predictors of Clinical Outcome in Liver Failure: A Retrospective Observational Study

Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are associated with high mortality, and therapeutic plasma exchange (TPE) is increasingly used as a bridging therapy. This retrospective observational study evaluated outcomes and predictors of response in 22 liver failure patients undergoing TPE. Demographic details, hepatic encephalopathy (HE) grade, timing of TPE initiation, laboratory parameters, and clinical outcomes were analyzed. Clinical improvement was defined as ≥ 1-grade HE improvement with hemodynamic stabilization and biochemical recovery. The mean age was 22.9 years, with alcohol-related liver failure and Wilson's disease being the most common indications. Patients with lower HE grades showed significantly better clinical improvement (p = 0.031). Earlier initiation of TPE (< 10 days) demonstrated a trend toward improved outcomes, although not statistically significant. Significant reductions in bilirubin, INR, ALT, and AST were observed following TPE. However, biochemical improvement did not always correlate with clinical recovery. Early TPE may improve clinical and biochemical recovery and potentially prevent progression to advanced encephalopathy; however, larger prospective studies and randomized controlled trials are needed to establish the optimal timing of TPE and evaluate its prophylactic role in preventing worsening HE.