Critical Care volume 29,
Article number: 458 (2025) Published: 30 October 2025
Background
Amatoxin-related
acute liver failure (AT-ALF) carries high mortality without liver
transplantation (LTX). While therapeutic plasma exchange (PEX) might improve
LTX-free survival in other ALF cases, its role in AT-ALF is unclear. Clinical
practice varies, and, given the rarity of this ALF entity, the feasibility of
conducting a randomized controlled trial to investigate PEX in AT-ALF is more
or less impossible.
Methods
The Amanita-PEX
study is a multi-center, international, retrospective study analyzing patients
with AT-ALF from 2013 to 2024. The primary outcome was 28-day LTX-free survival
(composite endpoint: death or LTX) after ALF diagnosis.
Results
The study included
111 patients from 25 centers: 82 received standard-of-care (SOC), and 29
received at least one PEX-session. PEX and SOC-groups were comparable at
baseline, but 76% of PEX- vs. 58% of SOC-patients developed
hepatic-encephalopathy (HE) grade ≥ 2 (p = 0.021).
While the primary outcome of 28-day LTX-free survival in all patients was not
different between the SOC and PEX-groups, in the subgroup of patients with
maximal HE grade ≥ 2, LTX-free survival was 19.1% (n = 8/42)
in the SOC group, while it was 36.4% (n = 8/22) in patients receiving adjunctive PEX
(Gehan-Breslow-Wilcoxon-p = 0.041, Log-Rank-p = 0.060).
PEX was independently associated with reduced risk of the combined endpoint
death or liver transplantation within 28 days from inclusion in patients with
HE grade ≥ 2 (HR 0.37, 95%-CI 0.19–0.73, p = 0.004). After propensity-score-matching,
LTX-free survival was 28% in the SOC- and 52% in the PEX group (Gehan-Breslow-p = 0.036;
Log-Rank-p = 0.035).
Conclusions
In this real-world
study, adjunctive use of PEX was associated with increased LTX-free-survival in
patients with AT-ALF and HE grade ≥ 2.
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