A Novel Anticoagulation Strategy for High‐Volume Plasma Exchange in Pediatric Patients With Acute Liver Failure

BACKGROUND: Pediatric acute liver failure represents a significant health care concern with significant morbidity and mortality. High-volume plasma exchange has been shown to serve as an effective blood purification technique that has allowed patients with ALF to survive to liver transplantation, or in some cases even spontaneous recovery. This study describes a novel anticoagulation protocol using a combination of citrate and heparin for high-volume plasma exchange in pediatric acute liver failure patients and demonstrates the safety of high-volume plasma exchange in pediatric acute liver failure patients. METHODS: This study retrospectively reviews a series of patients younger than 18 years of age with acute liver failure, analyzing the safety of high-volume plasma exchange in a single-center tertiary pediatric intensive care unit. RESULTS: Twelve encounters with 11 unique patients were included. Switching anticoagulation from citrate only to citrate plus heparin decreased the incidence of citrate lock from 80% to 25% (odds ratio 0.083), with no bleeding complications. No patients experienced life-threatening adverse events. Non-severe adverse events occurred in 29 of 66 treatments (44%), including citrate lock (19 of 66 treatments), responsive hypotension (8/66 high-volume plasma exchange treatments), and transient hypothermia (3/66 HVPE treatments). CONCLUSIONS: High-volume plasma exchange is well tolerated in pediatric acute liver failure and can safely be used as a bridge to liver transplantation or spontaneous recovery. Adding heparin to a citrate anticoagulation strategy during high-volume plasma exchange can decrease the frequency of citrate lock without increasing the risk of bleeding.