**11. Double plasma molecular adsorption system**

The double plasma molecular adsorption system (DPMAS) modality has the particularity of using a CRRT or intermittent hemodialysis machine with second roller pumps. Once the blood is drawn through the catheter with a blood pump flow of 150 ml/min, the blood passes through a high permeability filter to separate the plasma and then, the separated plasma is driven by a second roller pump at 25–50 ml/ min, which enters a first BS330-JAFRON styrene-divinylbenzene cartridge with anion-exchange resin and later the plasma goes through a second HA330 II-JAFRON cartridge with neutral macroporous resin, to then be reconstituted by the plasma in the blood that returns to the patient's catheter (**Figure 10**).

The evidence consulted reports an RCT from China [50], which includes patients with ALF and ACLF. They are randomized into two groups, 20 patients in the SMT and PE group vs. 27 in the SMT and DPMAS group. The result in the primary outcome shows a survival at 4–12 months is similar in both groups (p = 0.887), in the secondary outcomes measurements of bilirubin and CRP are performed, which decrease more

#### **Figure 10.**

*Double plasma molecular adsorption system (DPMAS). A) The blood extracted through the catheter enters a high permeability filter to separate the plasma. B) The separated plasma is driven by a second roller pump that drives the plasma into a first BS330-JAFRON cartridge made of styrene-divinylbenzene with anionexchange resin. C) Subsequently, the plasma passes through a second cartridge HA330 II-JAFRON with neutral macroporous resin.*

significantly with PE (p = 0.002), and the decrease in procalcitonin was similar in both groups, greater hypoalbuminemia in the PE group. The increase in IL-6 is strikingly evident in both groups and is attributed to being a stimulatory factor in liver regeneration.

During a meta-analysis [51] of 11 articles on ACLF due to hepatitis B, where the values of total bilirubin and albumin did not differ in both groups, ALT decreased more in DPMAS+PE than, with PE alone, the levels of I international standardized ratio (INR) and blood platelet (PT) were prolonged, but there were no significant differences between the two groups. In this study, there was a lot of heretogenicity in study quality which could lead to bias.

In another meta-analysis [52] of 11 RCT studies, including 1087 hepatitis B patients with ACLF, comparing two treatment groups with DPMAS + plasma exchange vs. plasma exchange alone, 90-day survival was higher with DPMAS + plasma exchange (P = < 0.00001), and bilirubin and alanine aminotransferase values after treatment were lower with DPMAS + PE (P = < 0.00001) and (P = 0.02), respectively. There was no statistical significance in prothrombin activity (PTA), PT, platelets (PLT), INR, and hemoglobin (HB).

In a retrospective controlled study [53] with DPMAS where 131 with ACLF for hepatitis B were recruited, they were assigned to the plasma exchange group vs. DPMAS + plasma exchange. Low-volume exchange plasma (2–2.4 L) was performed with fresh-frozen plasma in the DPMAS group first and then with exchange plasma. In the DPMAS + plasma exchange group, bilirubin decreases after the procedure, at 24 and 72 hours (P = < 0.05), and survival at 28 days was better (P = 0.043). Prospective studies are needed to assess long-term survival.
