Manrai M, Pachisia AV, Dawra S, Shukla S, Jha AA. Navigating the therapeutic tightrope: Precision use of plasmapheresis and continuous renal replacement therapy in liver failure. World J Hepatol 2026; 18(5): 115047 [DOI: 10.4254/wjh.v18.i5.115047]
Corresponding Author of This Article
Manish Manrai, FRCPE, AGAF Professor, Department of Gastroenterology, Command Hospital, Lucknow Cantt, Lucknow 226002, Uttar Pradesh, India. manishmanrai75@gmail.com
Research Domain of This Article
Gastroenterology & Hepatology
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Minireviews
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Manrai M, Pachisia AV, Dawra S, Shukla S, Jha AA. Navigating the therapeutic tightrope: Precision use of plasmapheresis and continuous renal replacement therapy in liver failure. World J Hepatol 2026; 18(5): 115047 [DOI: 10.4254/wjh.v18.i5.115047]
World J Hepatol. May 27, 2026; 18(5): 115047 Published online May 27, 2026. doi: 10.4254/wjh.v18.i5.115047
Navigating the therapeutic tightrope: Precision use of plasmapheresis and continuous renal replacement therapy in liver failure
Manish Manrai, Aditya V Pachisia, Saurabh Dawra, Siddharth Shukla, Atul A Jha
Manish Manrai, Atul A Jha, Department of Gastroenterology, Command Hospital, Lucknow 226002, Uttar Pradesh, India
Aditya V Pachisia, Department of Gastroenterology, Command Hospital, Bangalore 560007, Karnātaka, India
Saurabh Dawra, Department of Gastroenterology, Command Hospital, Udhampur 182101, Jammu and Kashmīr, India
Siddharth Shukla, Department of Gastroenterology, Army Hospital Research and Referral, New Delhi 110010, Delhi, India
Author contributions: Manrai M conceptualized, supervised the review study, and was involved with validation; Manrai M and Pachisia AV were involved in editing; Manrai M, Pachisia AV, Dawra S, Shukla S, and Jha AA were involved with resources and writing. All authors have read and approved the final manuscript.
AI contribution statement: Grammarly was used only for language polishing and editing to improve readability, with no AI-generated main text. No AI tools were employed for study design, data analysis, or result interpretation (not applicable for this review article). No AI-generated images are included.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Corresponding author: Manish Manrai, FRCPE, AGAF Professor, Department of Gastroenterology, Command Hospital, Lucknow Cantt, Lucknow 226002, Uttar Pradesh, India. manishmanrai75@gmail.com
Received: October 9, 2025 Revised: December 26, 2025 Accepted: March 16, 2026 Published online: May 27, 2026 Processing time: 231 Days and 13.1 Hours
Abstract
Liver failure, which includes acute liver failure (ALF) and acute-on-chronic liver failure (ACLF), is a life-threatening condition characterised by severe loss of hepatocytes, systemic inflammation, and multi-organ dysfunction, often leading to mortality rates exceeding 50%. Therapeutic plasma exchange (TPE, also known as plasmapheresis) and continuous renal replacement therapy (CRRT) are essential extracorporeal treatments that detoxify the blood, stabilise patients, and act as a bridge to recovery or transplantation. The debate surrounding the use of TPE and CRRT in liver failure (ALF and ACLF) is ongoing, with a recognised need to clearly define the patient groups, timing, and modality of application. This minireview synthesises evidence from 2016 to 2025, obtained from PubMed, EMBASE, and the Cochrane databases, and examines the mechanisms, indications, protocols, and outcomes of TPE and CRRT in ALF and ACLF. Correct patient selection, timing, and monitoring are essential to optimise benefits while minimising risks such as bleeding, infections, or citrate toxicity. This review examines various aspects of both therapies to help determine the most suitable treatment for liver failure. It highlights the importance of standardised guidelines to improve outcomes across different settings.
Core Tip: Therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) are essential for managing acute liver failure (ALF) and acute-on-chronic liver failure. High-volume TPE excels in ALF for rapid clearance of protein-bound toxins, while standard-volume TPE is better suited for acute-on-chronic liver failure’s hemodynamically fragile patients. CRRT addresses renal failure and ammonia spikes, particularly in ALF’s encephalopathy. Sequential TPE-CRRT is safer and more feasible, while combined approaches are reserved for severe, rapidly deteriorating cases. Emerging biomarkers (e.g., interleukin-6, neutrophil gelatinase-associated lipocalin) hold promise for guiding therapy, but access disparities and non-standardised protocols necessitate global standardisation and innovative solutions to enhance survival. This review synthesises the optimal requirement of TPE and CRRT.
