Low-Volume Plasma Exchange Following Double Plasma Molecular Adsorption System in Acute-On-Chronic Liver Failure: A Plasma-Sparing Strategy.

Acute-on-chronic liver failure (ACLF) is associated with significant morbidity and mortality. Plasma exchange (PE) is a primary intervention for toxin removal and the management of coagulopathy. Persistent global plasma shortages highlight the urgent need to develop and implement plasma-sparing strategies that preserve therapeutic efficacy and safety. This retrospective cohort study was conducted on 134 patients at the Department of Gastroenterology, Yan'an Hospital of Kunming, from January 2022 to December 2024. Patients were diagnosed according to the guidelines of the Chinese Medical Association. All patients received DPMAS sequential PE and were assigned to two groups according to the volume of fresh frozen plasma: the low-volume (600-800 mL) plasma group (DPMAS + LVP group, n = 76) and the half-volume (1000-1200 mL) plasma group (DPMAS + HVP group, n = 58). The primary outcome was 28-day transplant-free survival, while secondary outcomes included liver function, coagulation parameters, hematologic parameters, plasma consumption, hospitalization costs, and adverse events. The total bilirubin, serum aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, γ-glutamyl transferase, serum ammonia, coagulation profiles including prothrombin time activity, international normalized ratio, reaction time, maximum amplitude, and clinical severity scores (MELD-Na, CLIF-SOFA, and AARC-ACLF score) showed significant improvement in both groups (p < 0.05). No significant differences were observed between groups in bilirubin reduction (p = 0.695), coagulation profiles, hematologic parameters (all p > 0.05), or 28-day survival rate (74% vs. 76%, p = 0.92). The DPMAS + LVP group achieved 40% plasma conservation (539 mL vs. 1050 mL) and reduced hospitalization costs (51 632 CNY vs. 67 152 CNY), compared to the HVP group (p < 0.05). Adverse events were comparable in the DPMAS + HVP group and the DPMAS + LVP group (all p > 0.05). Multivariate analysis identified baseline MELD-Na as an independent predictor of mortality (OR 1.13 per point, 95% CI 1.03 to 1.23, p = 0.012), while PE volume was not significantly associated with mortality (adjusted OR for HVP 2.06, p = 0.271). DPMAS sequential LVP is a feasible and resource-efficient strategy with comparable short-term efficacy and a favorable safety profile compared to HVP. Prospective studies are needed to validate these results.