Patient selection:
(1) end-stage liver disease (severe liver disease, fulminant failure or a failed transplant)
(2) awaiting definitive therapy (transplant or retransplant) or expectant reversal of liver disease
Criteria for plasma exchange - one or more of the following:
(1) required plasma products and albumin infusions for >= 3 consecutive days
(2) fluid overload, impending or actual
(3) significant complication of end-stage liver disease (coagulopathy, encephalopathy, other)
(4) after liver transplant and ABO incompatibility against the donor organ with isohemagglutinin titer >= 1:8
(5) after liver transplant and with pretransplant coagulopathy
Pretransplant coagulopathy - one or more of the following:
(1) PT > 20 seconds
(2) PTT > 45 seconds
(3) fibrinogen < 150 mg/dL
(4) levels of Factors II, V, and/or VII < 20%
Exchanges may be performed 1-2 times per day, with the exchanges involving 1.5 to 4.0 of the calculated plasma volume.
The exchange fluid is a mixture of fresh frozen plasma and cryoprecipitate.
Concerns:
(1) fibrinogen level and coagulation status
(2) fluid overload
(3) citrate overload with low ionized calcium
