A Case Report on Plasma Exchange for Acute-on-Chronic Liver Failure from Severe Alcoholic Hepatitis with Failed Steroid Therapy

Introduction: Acute-on-chronic liver failure (ACLF) associated with multi-organ failure has a high mortality burden. The mechanisms are thought to be driven by hyperactive inflammatory and immune responses triggered by microbial and nonmicrobial factors. Therapeutic plasma exchange (TPE) is a potential alternative to liver transplant that improves survival. Case Presentation: A 56-year-old man with Child-Pugh C11 alcoholic liver cirrhosis was admitted to the intensive care unit for grade 3 ACLF, precipitated by severe alcoholic hepatitis (albumin 29, bilirubin 414, ALP 133, ALT 40, AST 128, Na 123, creatinine 487, INR 1.82) with MELD score of 39. He required inotropic support and renal replacement therapy. The patient was started on antibiotics and steroids for Maddrey Discriminant Function (MDF) score of 67.9. However, there was no improvement with Lille score 0.958 (<0.45) on day 7; hence, steroids were discontinued. The patient was not a liver transplant candidate due to alcoholism and poor social support. He was commenced on a trial of TPE and completed 3 cycles with standard volume plasma replacement resulting in clinical and biochemical improvement. He was discharged from hospital with 90-day survival at outpatient review. Conclusion: This highlights that TPE is a potential treatment option in alcoholic ACLF patients who would otherwise be at high risk of mortality at 1 month. TPE reduces systemic inflammatory reactions and modulates the adaptive immune response. This is especially important given organ scarcity and limited transplant options for those without social support.