Early Response to Therapeutic Plasma Exchange as a Prognostic Indicator in Pediatric Liver Transplant Recipients with Early Allograft Dysfunction

Abstract

Background Early allograft dysfunction (EAD) is a major determinant of morbidity and mortality after pediatric liver transplantation. Therapeutic plasma exchange (TPE) is increasingly used as supportive therapy, yet pediatric-specific data remain limited. We aimed to determine whether early response to TPE predicts survival in pediatric liver transplant recipients with EAD.Methods In this retrospective study, 15 pediatric patients (0-18 years) who developed EAD after living donor liver transplantation and received TPE (2015-2023) were analyzed. EAD was defined by Olthoff criteria. Response was assessed within 72 h using predefined criteria. Patients were classified as responders (n = 9) or non-responders (n = 6).Results Among 140 pediatric liver transplant recipients, 15 (10.7%) developed EAD. The median age was 13 months (IQR: 9.1-22.6), and 80% weighed <= 10 kg. Responders showed significant reductions in total bilirubin (17.0 to 9.0 mg/dL; p = 0.004), INR (3.0 to 1.5; p = 0.004), AST (2239 to 150 IU/L; p = 0.004), and ALT (2467 to 200 IU/L; p = 0.004); non-responders showed no meaningful improvement. In-hospital mortality occurred exclusively among non-responders (83.3% vs. 0%; p = 0.001). Kaplan-Meier analysis revealed significant survival divergence (100% vs. 16.7% at day 45; log-rank p = 0.0005). Pre-TPE albumin was significantly lower in non-responders (2.90 vs. 3.20 g/dL; p = 0.013), highlighting albumin as a potential early bedside screening parameter for identifying patients at higher risk of non-response. One-year overall survival was 66.7%.Conclusions Early response to TPE within 72 h strongly discriminates survival in pediatric EAD and may serve as a practical prognostic tool. Prospective multicenter studies are warranted to validate these findings.