Therapeutic plasma exchange in amatoxin associated acute liver failure-results from the multi-center Amanita-PEX study.
Publisher DOI
PubMed ID
41163058
Abstract
Background
Amatoxin-related acute liver failure (AT-ALF) carries high mortality without liver transplantation (LTX). While therapeutic plasma exchange (PEX) might improve LTX-free survival in other ALF cases, its role in AT-ALF is unclear. Clinical practice varies, and, given the rarity of this ALF entity, the feasibility of conducting a randomized controlled trial to investigate PEX in AT-ALF is more or less impossible.Methods
The Amanita-PEX study is a multi-center, international, retrospective study analyzing patients with AT-ALF from 2013 to 2024. The primary outcome was 28-day LTX-free survival (composite endpoint: death or LTX) after ALF diagnosis.Results
The study included 111 patients from 25 centers: 82 received standard-of-care (SOC), and 29 received at least one PEX-session. PEX and SOC-groups were comparable at baseline, but 76% of PEX- vs. 58% of SOC-patients developed hepatic-encephalopathy (HE) grade ≥ 2 (p = 0.021). While the primary outcome of 28-day LTX-free survival in all patients was not different between the SOC and PEX-groups, in the subgroup of patients with maximal HE grade ≥ 2, LTX-free survival was 19.1% (n = 8/42) in the SOC group, while it was 36.4% (n = 8/22) in patients receiving adjunctive PEX (Gehan-Breslow-Wilcoxon-p = 0.041, Log-Rank-p = 0.060). PEX was independently associated with reduced risk of the combined endpoint death or liver transplantation within 28 days from inclusion in patients with HE grade ≥ 2 (HR 0.37, 95%-CI 0.19-0.73, p = 0.004). After propensity-score-matching, LTX-free survival was 28% in the SOC- and 52% in the PEX group (Gehan-Breslow-p = 0.036; Log-Rank-p = 0.035).Conclusions
In this real-world study, adjunctive use of PEX was associated with increased LTX-free-survival in patients with AT-ALF and HE grade ≥ 2.
Amatoxin-related acute liver failure (AT-ALF) carries high mortality without liver transplantation (LTX). While therapeutic plasma exchange (PEX) might improve LTX-free survival in other ALF cases, its role in AT-ALF is unclear. Clinical practice varies, and, given the rarity of this ALF entity, the feasibility of conducting a randomized controlled trial to investigate PEX in AT-ALF is more or less impossible.Methods
The Amanita-PEX study is a multi-center, international, retrospective study analyzing patients with AT-ALF from 2013 to 2024. The primary outcome was 28-day LTX-free survival (composite endpoint: death or LTX) after ALF diagnosis.Results
The study included 111 patients from 25 centers: 82 received standard-of-care (SOC), and 29 received at least one PEX-session. PEX and SOC-groups were comparable at baseline, but 76% of PEX- vs. 58% of SOC-patients developed hepatic-encephalopathy (HE) grade ≥ 2 (p = 0.021). While the primary outcome of 28-day LTX-free survival in all patients was not different between the SOC and PEX-groups, in the subgroup of patients with maximal HE grade ≥ 2, LTX-free survival was 19.1% (n = 8/42) in the SOC group, while it was 36.4% (n = 8/22) in patients receiving adjunctive PEX (Gehan-Breslow-Wilcoxon-p = 0.041, Log-Rank-p = 0.060). PEX was independently associated with reduced risk of the combined endpoint death or liver transplantation within 28 days from inclusion in patients with HE grade ≥ 2 (HR 0.37, 95%-CI 0.19-0.73, p = 0.004). After propensity-score-matching, LTX-free survival was 28% in the SOC- and 52% in the PEX group (Gehan-Breslow-p = 0.036; Log-Rank-p = 0.035).Conclusions
In this real-world study, adjunctive use of PEX was associated with increased LTX-free-survival in patients with AT-ALF and HE grade ≥ 2.
Date Issued
2025-10-30
Publication Type
Article
Subject(s)
Subjects
Amanita
•
Liver failure
•
Liver transplantation
•
Mushroom poisoning
•
Plasma exchange
Language(s)
en
Author(s)
Stahl, Klaus | |
Nalbant, Bahar | |
Pape, Thorben | |
Breteau, Isaure | |
Coirier, Valentin | |
Cardoso, Filipe S | |
de Haan, Jubi | |
Janik, Maciej K | |
Wasmuth, Jan-Christian | |
Madaleno, João | |
Merle, Uta | |
Frohme, Josephine | |
Tepasse, Phil-Robin | |
Müller, Martina | |
Große, Karsten | |
Linke, Alexandra | |
Mareljic, Nikola | |
Larsen, Fin Stolze | |
Dahlqvist, Gérladine | |
Schulze, Marie | |
Willuweit, Katharina | |
Janke-Maier, Petra | |
Dondorf, Felix | |
Fierro-Angulo, Óscar M | |
Geerts, Anja | |
Toapanta, David | |
Dejean, Camille | |
Alharthi, Mohamed | |
Reverter, Enric | |
Schenk, Heiko | |
Raevens, Sarah | |
Macías-Rodríguez, Ricardo Ulises | |
Rauchfuß, Falk | |
Berg, Christoph P | |
Schmidt, Hartmut | |
Geier, Andreas | |
Lanthier, Nicolas | |
Bjerring, Peter N | |
Lange, Christian M | |
Sterneck, Martina | |
Bruns, Tony | |
van de Loo, Dominik | |
Demir, Münevver | |
Boettler, Tobias | |
Borges, Catarina | |
Nattermann, Jacob | |
Wronka, Karolina | |
den Hoed, Caroline M | |
Marques, Hugo P | |
Artru, Florent | |
Levesque, Eric | |
Wedemeyer, Heiner | |
Campos-Murguia, Alejandro | |
Taubert, Richard |
Journal
Critical Care
Publisher
BioMed Central
ISSN
1466-609X
1364-8535
Access(Rights)
open.access