The Role of Therapeutic Plasma Exchange in Amatoxin-Related Acute Liver Failure: Insights from the Amanita-PEX Study
A recent trial found no overall 28‑day liver transplant–free survival benefit for therapeutic plasma exchange (TPE) across the full amatoxin-associated acute liver failure cohort, but detected a clear survival signal in patients with severe hepatic encephalopathy. investigators reported that TPE was associated with a reduced risk of death or liver transplant in the subgroup with higher-grade encephalopathy on multivariate analysis.
Supportive care and liver transplantation remain the mainstays of management for amatoxin-induced acute liver failure. Extracorporeal approaches such as TPE have been described in case series and center-level protocols; the multicenter Amanita-PEX dataset now provides comparative, real-world evidence where previously only anecdote existed.
The study enrolled 111 adults with amatoxin-associated acute liver failure across 25 tertiary liver-transplant centers between October 2013 and October 2024. Investigators compared patients who received at least one TPE session with those managed with standard care. The predefined primary endpoint was 28‑day liver transplant–free survival (death or liver transplantation), and the analysis used multivariable Cox proportional-hazards models and propensity-score matching to address baseline imbalance.
In the overall cohort, TPE did not improve 28‑day transplant‑free survival compared with standard care. In contrast, among patients who developed severe hepatic encephalopathy (maximum West Haven grade ≥2), adjunctive TPE was independently associated with a lower risk of death or liver transplantation within 28 days (HR 0.37, 95% CI 0.19–0.73; p=0.004), and propensity-score–matched transplant‑free survival favored TPE. Secondary endpoints—length of stay, incidence of acute kidney injury, need for renal replacement therapy, invasive ventilation, and vasopressors—were not improved overall, and the report did not highlight prominent procedure-related safety signals.