Standard-Volume Therapeutic Plasma Exchange Followed by High-Dose Continuous Renal Replacement Therapy in Patients With Hepatitis A Virus-Related Acute Liver Failure.

Acute liver failure (ALF) due to hepatitis A virus (HAV) can lead to multi-organ dysfunction with a high mortality. Extracorporeal therapies like therapeutic plasma exchange (TPE) and continuous renal replacement therapy (CRRT) often have a central role in the management of ALF. Thirteen patients admitted with HAV-related ALF between August 2024 and July 2025 were included in the study. All patients underwent standard-volume TPE (SV-TPE) followed by continuous veno-venous haemodiafiltration (CVVHDF) with an effluent dose target of 45 mL/kg/hour. Nine patients (69.2%) had hyperacute liver failure, and four (30.7%) had ALF. Seven patients met the King's College criteria for liver transplantation. The median number of TPE sessions was one. The median duration and dose of CRRT were 76 hours and 44 mL/kg/hour, respectively. There was sustained improvement in serum bilirubin, lactate, and aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels with the offered treatment. The mean serum ammonia also reduced from 336.68 to 205.91 μmol/L after TPE, and to 123.81, 95.94, and 87.43 μmol/L after 24, 48, and 72 hours of CRRT, respectively. The mean duration of mechanical ventilation was 3.7 days. The mean ICU length of stay was 7.1 days, and the mean hospital length of stay was 13.5 days. Six patients had secondary infections. None of the patients needed liver transplantation at 21 days. The ICU-, in-hospital-, and 28-day mortality was zero; however, three patients were found to have hyperbilirubinemia at 28 days. SV-TPE followed by high-dose CRRT could significantly improve transplant-free survival in HAV-related ALF.