Therapeutic Apheresis in Liver Transplantation

Therapeutic apheresis has been used for ABO-incompatible liver transplantation and for liver support therapy during liver transplantation. The receiver operating characteristics (ROC) curve analysis of the clinical indicator of the post operative liver failure concluded that the bilirubin between postoperative day (POD) 4 and 28 (a short-term follow-up period) might be the best predictor of liver prognosis (length of hospital stay > 100 days, re-transplantation, or death). Liver transplantation patients whose post operative liver failure was treated with apheresis after their bilirubin raised above 22.3 mg/dL maintained the increase of bilirubin after apheresis, while apheresis before the bilirubin levels were below 22.3mg/dl ameliorated the increase of bilirubin. In order to treat the post operative liver failure, the inclusion criteria of apheresis might be recommended to be around 20 mg/dl bilirubin, because the bilirubin level where apheresis therapy might be effective was considered under 22.3mg/dl and the inclusion criteria should include safety margin from 22.3mg/dl. There are several possible mechanisms that apheresis can improve liver function during liver transplantation. One is to supply the essential proteins which can ameliorate the patients’ entire condition. Second mechanism is the removal of the many toxic substances, such as bilirubin, anmonium, cytotoxic substances, inflammatory cytokines, and antibody. Artificial and bioartificial liver support devices have been developed. In the clinical use of these devices, the same inclusion criteria, that is around 20mg/dl bilirubin, can be applied.