The baseline characteristics of the liver failure patients treated with TPE
Finally, there were 69 patients enrolled in this study, 51 patients in RCA group and 18 patients in heparin group respectively. All patients were Asian. Table 1 shows the baseline characteristics at enrollment of overall patients during the first day after hospital admission.
Table 1
Baseline characteristics of patients with liver failure
Characteristics | RCA group N = 51 | Heparin group N = 18 | P value |
Age, years | 47 ± 14 | 47 ± 17 | 0.9755 |
Male sex, n (%) | 41(80%) | 11(61%) | 0.1208 |
Total Bilirubin, µmol/L | 355.2(178.7 ~ 928.9) | 308.9(185.8 ~ 493.7) | 0.0921 |
Serum Creatinine, µmol/L | 66(18 ~ 403) | 57(30 ~ 214) | 0.2118 |
INR | 2.04(1.50 ~ 4.19) | 2.13(1.55 ~ 4.18) | 0.3401 |
Platelet count, ⅹ109/L | 92(27 ~ 256) | 106(56 ~ 283) | 0.2300 |
Types of liver failure, ALF/ACLF | 15/36 | 6/12 | 0.7722 |
MELDs | 27(22 ~ 44) | 27(22 ~ 35) | 0.7709 |
Continuous variables were presented as mean ± standard deviation. Non-normal distribution data were presented as median (range). |
In RCA group, there were 15 acute liver failure patients, 8 patients were caused by drug, 3 patients were caused by acute hepatitis E virus, 1 patient was caused by acute hepatitis B virus, and 3 patients were unknown etiology. There were 36 acute on chronic liver failure patients, 32 patients had chronic hepatitis B virus, 1 patient had alcoholic liver disease, 2 patients had autoimmune hepatitis, and 1 patient had Wilson’s disease. 14 patients underwent liver transplantation in the end.
In heparin group, there were 6 acute liver failure patients, 3 patients were caused by drug, 1 patient was caused by autoimmune hepatitis, and 2 patients were unknown etiology. There were 12 acute on chronic liver failure patients, 9 patients had chronic hepatitis B virus, 2 patients had alcoholic liver disease, and 1 patient had cirrhosis with unknown etiology. No one underwent liver transplantation in the end.
There was no statistical significance of the age, gender, total bilirubin, serum creatinine, INR, platelet count, types of liver failure and MELD between the RCA group and the heparin group.
Table 2 shows the baseline characteristics of the patients with liver failure who didn't have a liver transplantation in the end. There were 37 patients in RCA group, and 18 patients in heparin group. The INR was significantly lower in RCA group than that in heparin group. However, there was no statistical significance of the age, gender, total bilirubin, serum creatinine, platelet count, types of liver failure and MELD between the RCA group and the heparin group.
Table 2
Baseline characteristics of transplantation free patients with liver failure
Characteristics | RCA group N = 37 | Heparin group N = 18 | P value |
Age, years | 48 ± 15 | 47 ± 17 | 0.8551 |
Male sex, n (%) | 29(78%) | 11(61%) | 0.2082 |
Bilirubin, µmol/L | 358.0(184.1 ~ 928.9) | 308.9(185.8 ~ 493.7) | 0.0635 |
Creatinine, µmol/L | 66(18 ~ 210.0) | 57(30 ~ 214) | 0.1815 |
INR | 1.88(1.50 ~ 3.96) | 2.13(1.55 ~ 4.18) | 0.0267 |
Platelet count, ⅹ109/L | 96(27 ~ 256) | 106(56 ~ 283) | 0.4002 |
Types of liver failure, ALF/ACLF | 14/23 | 6/12 | 0.7755 |
MELDs | 27(22 ~ 34) | 27(22 ~ 35) | 0.2574 |
Continuous variables were presented as mean ± standard deviation. Non-normal distribution data were presented as median (range). |
Outcome Of Liver Failure Patients Treated With Tpe
In overall patients, the 28-day mortality rate was 41% in RCA group and 39% in heparin group (P > 0.05, Fig. 1A). The 90-day mortality rate was 59% in RCA group and 50% in heparin group (P > 0.05, Fig. 1B).
In transplantation free patients, the 28-day mortality rate was 32% in RCA group and 39% in heparin group (P > 0.05, Fig. 2A). The 90-day mortality rate was 43% in RCA group and 50% in heparin group (P > 0.05, Fig. 2B).
Accuracy of the MELD in predicting 28-day mortality of the transplantation free liver failure patients was calculated. MELD best-fit value is 30, and area under the ROC curve is 0.7208 in the transplantation free patients with liver failure in both RCA group and heparin group (Fig. 3A). MELD best-fit value is 30, and area under the ROC curve is 0.7033 in the transplantation free patients with liver failure in RCA group (Fig. 3B). Therefore, the transplantation free patients with liver failure were divided into two groups: MELD ≥ 30 group and MELD < 30 group. The 28-day mortality rate was 25% in MELD < 30 group and 73% in MELD ≥ 30 group (P = 0.0002, Fig. 4A). The 90-day mortality rate was 32% in MELD < 30 group and 100% in MELD ≥ 30 group (P < 0.0001, Fig. 4B).
Safety Of Tpe Treatment
In RCA group, 134 sessions TPE were performed, with an average of 3 sessions per patient. There were 10 times complications: 5 patients with rashes, 1 patient with shiver, 1 patient with shock and 3 patients with aggravation of hepatic encephalopathy. In heparin group, 46 sessions TPE were performed, with an average of 3 sessions per patient. There were 4 times complications: 2 patients with shock and 2 patients with aggravation of hepatic encephalopathy. There was no significant difference in the occurrence of complications between the two groups (P = 0.6561).
The arterial blood gas before RCA and after RCA plasma exchange treatment were analyzed (Table 3). The concentrations of calcium, chloride, hemoglobin, hematocrit, and ionized calcium before RCA plasma exchange treatment were significantly higher than those after RCA plasma exchange treatment. The concentrations of glucose, lactate, actual HCO2, standard HCO2, PH, extracellular base excess, base excess, anion gap, total calcium, and total calcium/ionized calcium before RCA plasma exchange treatment were significantly lower than those after RCA plasma exchange treatment.
Table 3
Arterial blood gas before RCA and after RCA plasma exchange treatment
Characteristics | Before RCA | After RCA | P value |
Sodium, mmol/L | 134.7 ± 4.045 | 134.6 ± 3.455 | 0.8586 |
Potassium, mmol/L | 3.101 ± 0.4204 | 3.034 ± 0.3694 | 0.2374 |
Chloride, mmol/L | 99.66 ± 4.274 | 96.06 ± 4.270 | < 0.0001 |
Glucose, mmol/L | 7.890(4.620 ~ 17.29) | 10.50(6.720 ~ 21.99) | 0.0020 |
Lactate, mmol/L | 2.060(0.2000 ± 3.270) | 2.535 (1.800 ± 5.810) | 0.0018 |
Hemoglobin, g/dl | 11.05 ± 2.014 | 10.42 ± 2.073 | < 0.0001 |
Actual HCO2, mmol/L | 23.80(17.20 ~ 26.60) | 25.15(19.10 ~ 28.40) | 0.0003 |
Standard HCO2, mmol/L | 24.10(19.40 ~ 31.00) | 25.30(21.20 ~ 27.90) | 0.0117 |
PH | 7.432 ± 0.03000 | 7.448 ± 0.02042 | 0.0194 |
Oxygen saturation, % | 98.10(93.60 ~ 99.10) | 98.30(95.50 ~ 99.80) | 0.2779 |
Hematocrit, % | 37.60(22.20 ~ 45.50) | 34.40(20.80 ~ 44.70) | < 0.0001 |
Oxygen partial pressure, KPa | 14.42 ± 2.737 | 14.23 ± 2.190 | 0.6791 |
Carbon dioxide partial pressure | 4.708 ± 0.6280 | 4.739 ± 0.5595 | 0.3236 |
Extracellular base excess, mmol/L | -0.5500(-7.100 ~ 2.600) | 1.150(-4.800 ~ 4.700) | 0.0004 |
Base excess, mmol/L | -0.4000(-6.100 ~ 2.500) | 1.150(-3.900 ~ 4.400) | 0.0007 |
Anion gap, mmol/L | 14.80(5.300 ~ 19.80) | 17.60(4.100 ~ 21.90) | < 0.0001 |
Ionized calcium, mmol/L | 1.090(0.8400 ~ 1.210) | 0.8900(0.7300 ~ 1.040) | < 0.0001 |
Total calcium, mmol/L | 2.154 ± 0.2272 | 2.600 ± 0.2700 | < 0.0001 |
Total calcium/ionized calcium | 1.970(1.730 ~ 3.190) | 2.840(2.200 ~ 3.710) | < 0.0001 |
Blood ammonia, mmol/L | 32.00(9.000 ~ 92.00) | 29.00(9.000 ~ 71.00) | 0.7769 |
Continuous variables were presented as mean ± standard deviation. Non-normal distribution data were presented as median (range). |
The median total calcium/ionized calcium value at the time before RCA plasma exchange was 1.97 (range from 1.73 to 3.19), and that after RCA plasma exchange was 2.84 (range from 2.20 to 3.71). The total calcium/ionized calcium value after RCA plasma exchange was significantly higher than that before RCA plasma exchange (P < 0.0001). The concentration of total calcium after RCA plasma exchange (2.600 ± 0.2700 mmol/L) was significantly higher than that before RCA plasma exchange (2.154 ± 0.2272 mmol/L, P < 0.0001), as well as that at 24 hours after RCA plasma exchange (2.230 ± 0.1747 mmol/L, P = 0.0007) was also significantly higher than that before RCA plasma exchange. However, there was no significant difference between the concentrations of total calcium before RCA plasma exchange and that at 48 hours after RCA plasma exchange (2.183 ± 0.09220 mmol/L, P = 0.6807).