Kevy listed criteria for performing plasma exchange in infants and children with hepatic failure. This may be in the setting of severe liver disease, fulminant failure or a failed transplant. The author is from Children's Hospital in Boston.


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.



(1) fibrinogen level and coagulation status

(2) fluid overload

(3) citrate overload with low ionized calcium


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