In resource-limited settings where liver transplantation is not available, pediatric acute liver failure (PALF) carries a very high mortality. Extracorporeal liver support systems, including therapeutic plasma exchange (TPE), can be used not as a bridge to transplant but as the primary interim therapy to support patients until spontaneous liver recovery. This prospective single-center experience from the Mother-Child Intensive Care Unit at Hassan II University Hospital in Fez, Morocco, reports clinical and biological effects of TPE in children with PALF and examines factors influencing survival.
The authors conducted a prospective single-center study in a pediatric intensive care unit. Seven patients admitted with PALF underwent TPE and were included in the analysis. Clinical data, laboratory markers (transaminases, bilirubin, international normalized ratio [INR], and ammonia), and patient outcomes were prospectively collected to evaluate the biological efficacy of TPE and identify determinants of survival in this resource-limited context.
All seven children presented with marked biochemical derangement and advanced hepatic encephalopathy (HE) at the time of admission. The case series emphasizes significantly delayed presentation: each patient was admitted at least two weeks after symptom onset. Delays were attributed largely to underestimation of jaundice by caregivers or community clinicians, with jaundice not being perceived as an immediately life-threatening symptom. Prolonged hyperammonemia and resulting neurological injury were noted as central contributors to poor outcomes.
TPE was used as the primary extracorporeal support modality for all included patients. The intervention produced consistent biological improvements across the cohort. Specifically, TPE led to reductions in hepatic cytolysis markers (transaminases) and decreases in blood ammonia levels. These changes indicate that TPE is effective at removing circulating toxins and biochemical mediators associated with acute liver injury and metabolic derangement.
The authors describe TPE as demonstrating significant biological efficacy in this series: despite severe baseline derangement, measurable laboratory improvements followed TPE sessions. The report frames TPE as a vital supportive modality in settings without liver transplantation, capable of bridging patients toward potential spontaneous hepatic recovery when provided in a timely manner.
To optimize continuous ammonia clearance in severe cases, one patient in the series received continuous venovenous hemodialysis (CVVHD) in addition to TPE. This combined approach was used to maintain ongoing removal of ammonia between plasma exchange sessions. The source notes the use of combined therapy in that single patient but does not provide additional comparative data or protocol specifics beyond reporting that CVVHD was applied to supplement ammonia clearance.
Despite consistent laboratory improvements after TPE, clinical outcomes in this small series were poor. The primary limiting factor identified by the authors was delayed hospital admission with advanced neurologic injury already established. Prolonged hyperammonemia preceding hospital presentation resulted in pre-existing and likely irreversible brain injury, which drove mortality even after biochemical parameters improved.
The study highlights that TPE’s potential to change final clinical outcomes is constrained when patients arrive late in the disease course. The authors specifically point to a systemic issue in which jaundice is commonly underestimated, delaying referral to intensive care until advanced hepatic encephalopathy is present.
From this single-center Moroccan experience, several implications emerge:
In environments without access to liver transplantation, therapeutic plasma exchange can provide meaningful biochemical improvement and functions as a critical bridge to potential spontaneous hepatic recovery.
Timely referral is essential: the survival benefit of TPE is substantially limited when admission is delayed and irreversible neurological injury has occurred from prolonged hyperammonemia.
Strategies to improve early recognition of jaundice and rapid transfer to intensive care may be necessary to realize the clinical benefits of extracorporeal liver support.
The authors note that the effects of earlier acute liver failure recognition and referral on clinical outcomes require further investigation; this study does not provide data on outcomes with earlier presentation or compare TPE to other modalities in this setting.
This prospective series of seven pediatric patients with PALF treated with TPE in a resource-limited Moroccan center demonstrates that TPE is biologically effective, reducing hepatic cytolysis markers and ammonia. However, delayed presentation—every patient was admitted at least two weeks after symptom onset—limited clinical success because prolonged hyperammonemia led to advanced and likely irreversible neurologic injury. Improving survival will depend on earlier recognition of jaundice, faster intensive care referral, and further study of whether earlier application of extracorporeal support can alter neurologic and survival outcomes in PALF where transplantation is not available.
The authors declared no conflicts of interest in the source report.