Standard Volume vs. High Volume Plasma Exchange in Pediatric Acute Liver Failure

Aim: To study the efficacy in terms of the native liver survival, of standard volume plasma exchange as compared to high volume plasma exchange in Pediatric ALF.

Study Design: Open label pilot Randomized Control trial. Sample size: Time bound. All cases presenting during the study period will be included in the study.

Standard Medical Therapy:

• All patients are were managed by a multidisciplinary team at Live Coma ICU.
• Intubation and ventilation were undertaken for standard indications in addition to the development of grade 3 encephalopathy or evidence of cerebral edema
• Ventilation was managed by fentanyl and propofol along with the use of atracurium for paralysis wherever required.
• Hemodynamics, ONSD and TCD are monitored routinely.
• All patients received N-acetylcysteine.
• Neuro-protective measures such as hypertonic saline, head end elevation, minimal stimulation, propofol and thiopentone infusion are followed as per protocol.
• Anti-ammonia measures like sodium benzoate, CRRT as well started as per protocol.
• CRRT is done for routine renal indications, hyperlactetmia, hyperammonemia.

Inclusion criteria

• Age: 3 years to 18 years
• Fulfilling PALFSG definition (J Pediatr. 2006 May;148(5):652-658).
• Baseline INR ≥ 2.5, and increasing INR (any value) and/or worsening hepatic. encephalopathy (> 1 grade change) after 6 to 12 hours of standard medical therapy.

Exclusion criteria

• Disseminated intravascular coagulation
• Marked hemodynamic instability requiring a high dose of vasopressors (norepinephrine >0.5 mcg/kg/min)
• Signs of irreversible brain injury
• Any severe cardio-pulmonary pre-existing disease
• Septic Shock