(658) Safety of High-Volume Plasma Exchange in Pediatric Patients With Acute Liver Failure

Introduction: High volume plasma exchange (HVP), defined as plasma exchange using exchange volumes of 15% ideal body weight is used to treat acute liver failure (ALF) in adult patients. There has been a hesitancy to use this therapy in pediatric ALF patients due to lack of research demonstrating safety in pediatrics. The apheresis team at Nemours Children’s Hospital has been performing HVP as a bridge to transplant or recovery after acute and hyperacute pediatric liver failure since 2018. This study reports on safety of HVP in pediatric ALF patients.

Methods: A retrospective analysis of patients who received HVP was performed. Patients who received HVP for acute / hyperacute liver failure were included. Outcomes that were investigated included: successful bridge to transplant or recovery, severe life-threatening adverse events (cardiac arrest, refractory hypotension), and non-severe adverse events including hypotension responsive to escalation or initiation of vasopressor support persisting for 6 hours following the HVP, hypothermia (core body temperature less than 35 degrees C), and citrate lock (defined as total calcium to ionized calcium (in mg/dL) ratio greater than or equal to 2.5). Descriptive statistics are reported, with results reported as percent of total number of HVP treatments.

Results: This review included 12 HVP encounters with 11 individual patients. The average number of HVP treatments per encounter was 5.5 (SD 5.2). In 8 of 12 encounters (67%) HVP resulted in survival to transplant (n=6) or recovery without transplant (n=2). During 66 total HVP treatments, no patient experienced a life-threatening adverse event. Non-severe adverse events occurred during 35/66 HVP treatments (53%), with the most common being citrate lock (19/66 HVP treatments, 29%), responsive hypotension for more than 6 hours following the HVP (8/66 HVP treatments, 12%), and transient hypothermia (4/66 HVP treatments, 6%).

Conclusions: High volume plasma exchange can safely be used to treat pediatric acute liver failure. The majority of patients treated with HVP survived to transplant or recovery. There were no life-threatening adverse events related to the HVP. The most common non-severe adverse event was citrate lock, with a smaller number of patients having transient responsive hypotension or hypothermia. .