Therapeutic Plasma Exchange as a Bridge to Spontaneous Recovery in Pediatric Acute Liver Failure in a Resource‐Limited Setting: A Prospective Single‐Center Experience in Morocco

In resource-limited settings where liver transplantation is unavailable, pediatric acute liver failure (PALF) carries a markedly high mortality rate. In this context, extracorporeal liver support systems (ELSS), such as therapeutic plasma exchange (TPE), do not serve as a bridge to transplantation, but rather the sole critical bridge to spontaneous liver recovery. We conducted a prospective single-center study in a pediatric intensive care unit, including seven patients admitted with PALF who underwent TPE. Clinical data, biological markers (including transaminase, bilirubin, INR, and ammonia), and patient outcomes were analyzed to evaluate the biological efficacy of TPE and identify factors influencing survival. All seven patients presented with severe biochemical derangement and advanced hepatic encephalopathy (HE) upon admission. TPE demonstrated significant biological efficacy, consistently reducing hepatic cytolysis and ammonia levels. To further optimize continuous ammonia clearance, one patient underwent continuous venovenous hemodialysis (CVVHD) in conjunction with TPE. Despite these biochemical improvements, clinical outcomes remained poor due to significantly delayed presentations. All patients were admitted at least 2 weeks after symptom onset, largely because jaundice was underestimated and not perceived as a life-threatening symptom. TPE is a biologically effective intervention and a vital bridge to spontaneous liver recovery for PALF in settings without liver transplant capabilities. However, its clinical success is severely limited by delayed hospital admission. The pre-existing and irreversible neurological damage caused by prolonged hyperammonemia ultimately drives mortality. Improving survival rates requires a systemic shift toward early recognition of jaundice and immediate intensive care referral. presentation with advanced neurologic injury. The effects of earlier ALF recognition and referral on outcomes require further investigation.