Plasma Exchanges for Fulminant Hepatitis

Abstract

Plasma exchange (PE) has played a central role in artificial liver support (ALS) for fulminant hepatitis (FH) and contributed much to improving FH patient survival. Health insurance in Japan limits PEs for FH to less than 7 times for which patients are reimbursed. To study whether this limit is clinically appropriate, we retrospectively studied PEs 46 patients treated at the Chiba University Hospital ICU and diagnosed with FH based on Inuyama symposium criteria. Overall survival was 40.4%. Survival was better in patients with acute FH (50.0%) than in those with subacute FH (12.5%) (p<0.01). Average PEs 4.4±2.7 times in survivors and 7.4±4.1 times in nonsurvivors. Some 14 required PE more than 8 times. Two survived after receiving 9PEs. One patient received 10PEs before successful liver transplantation. PEs averaged 3.6 times in 8 predicted survivors and 7.2 in 38 predicted nonsurvivors based on the guideline proposed by the Acute Liver Failure Study Group of Japan. Some 13 had already received PEs on 5 consecutive days at the second evaluation time of the prognosis proposed by the guideline. We thus conclude that, ethically, it is inappropriate to limit the number of PEs for FH, especially when done as a bridge to liver transplantation. The number of PEs in FH should be discussed separately for acute and subacute FH. A special consideration on this limit should be made for FH patients slated to undergo liver transplantation.