**10. Plasma adsorption perfusion**

Plasma adsorption perfusion (PAP) uses a CRRT or intermittent hemodialysis machine. Once the blood comes out through the catheter with a blood pump flow at 150 ml/min, it allows the blood to enter the plasma exchange filter where it allows the separation of the plasma by filtration. The obtained plasma is mobilized by a second

#### **Figure 9.**

*Plasma adsorption perfusion (PAP). A) The blood exits through the catheter with a blood pump flow at 150 ml/ min, it allows the blood to enter the plasma exchange filter where it allows the separation of the plasma by filtration. B) The obtained plasma is mobilized by a second pump at 25–50 ml/min and enters a cartridge made of the styrene-divinylbenzene copolymer.*

pump at 25–50 ml/min and enters a cartridge made of styrene-divinylbenzene copolymer, with the capacity to adsorb bilirubin, bile acids, and cytokines. This technique has some advantages over the other techniques mentioned, such as it does not require the use of exogenous plasma or albumin infusion, it does not eliminate coagulation factors, and it is less expensive than MARS (**Figure 9**).

A single-center retrospective study [49] evaluated the performance of three therapies (MARS, PAP, and PE) and recruited 103 patients with hyperbilirubinemia due to ALF and ACLF, and extracorporeal liver support therapy was started when the total plasma bilirubin level > 20 mg/dl, or an increase in bilirubin level of more than 2 mg/dl per day for 4 days. When total bilirubin removal is assessed in these therapies, a 25% decrease is considered the optimal value. A greater decrease in bilirubin was seen with PE (35 ± 13%) followed by PAP (30 ± 12%) and the lowest percentage with MARS (24 ± 14%), and the values of transaminases and coagulation tests were not different between the three techniques. In this review, the costs per treatment are mentioned, being the most economical PE, followed by PAP and the most expensive MARS due to equipment and the long time the therapy takes. It is important to mention that an advantage of MARS over the other techniques mentioned is its application in acute kidney injury (AKI) that requires renal support therapy.
