A single institution's experience (1982-1999) with plasma-exchange therapyin patients with fulminant hepatic failure

Fulminant hepatic failure is a rare, but often fatal complication of acute viral hepatitis. This condition, in absence of orthotopic liver transplanta tion (OLTx) surgery, is associated with a high mortality rate, despite the improvement of general intensive care. Plasma-exchange (PEx) therapy has been long used to treat FHF; in particula r by removing toxic substances and correcting the severe coagulopathy. In this study we describe our experience with PEx treatment of FHF, beginni ng in 1982. Seventy patients affected with FHF due to various causes (HBV=4 0; cryptogenic/non-A, non-E=15; Amanita phalloides=8; other=7) were treated with PEx (altogether 348 sessions). Overall survival rate, comprising patients undergoing OLTx, was 51%, a litt le higher than what we observed in patients (N=49) treated solely by PEx, i .e., 41%. The best outcome predictor was FHF aetiology, owing to the good survival ra te in patients with Amanita phalloides intoxication and the very poor progn osis of patients suffering from cryptogenic/non-A, non-E FHF: Moreover, the marked increase in prothrombin time and alpha-fetoprotein levels after 48 hours from admission was associated with a good prognosis, whereas the pati ent's age and coma grade were not clearly predictive of survival. Additiona lly, lymphocyte subpopulation, resulting in a CD4/CD8 ratio lower than 1.0 along with CD8 activation with HLA-DR strong expression, were associated wi th a high rate of mortality and morbidity. Our data indicate that PEx therapy can improve survival in patients with su fficient residual capacity of liver regeneration. Moreover the identificati on of certain prognostic factors may be useful for the rational planning of therapeutic strategy in FHF.