Résumé
Immune checkpoint inhibitors (ICIs) improve cancer survival but can cause severe immune-related hepatitis. Standard therapy with corticosteroids and second-line agents such as mycophenolate mofetil (MMF) fails in some cases. Therapeutic plasma exchange (TPE) has been suggested as rescue therapy, but supporting evidence is limited.
We retrospectively analyzed French multicenter data (March 2021–April 2025) on patients with grade 4 ICI-induced hepatitis refractory to corticosteroids ± other immunosuppressants who underwent TPE.
Thirteen patients (median age 63 years; 54% male) were included. Eleven had acute hepatitis, including 7 with acute liver injury (ALI); two had steroid-refractory cholestatic hepatitis. TPE began a median of 28 days after onset (median MELD 21) and was given in 2–8 sessions. Liver function improved in 8 patients (61.5%), allowing anticancer therapy free of ICI resumption in 5. Three with cirrhosis and hepatocellular carcinoma died of liver failure; three died from other causes. Adverse events associated with TPE were mild to moderate.
TPE is feasible, safe, and may be effective for severe steroid- and immunosuppressant-refractory ICI-induced hepatitis. Early initiation could improve outcomes; prospective studies should clarify timing and selection.
Severe immune checkpoint inhibitor (ICI)-induced hepatitis represents a rare but life-threatening complication for which therapeutic options are limited once corticosteroids and immunosuppressants fail.Our study provides the first multicenter evidence suggesting that therapeutic plasma exchange (TPE) is a feasible and safe approach that may improve hepatic outcomes in this setting.These findings are particularly relevant for oncologists, hepatologists, and intensivists facing refractory ICI-induced liver injury, as TPE could offer a bridge to recovery when liver transplantation is not feasible.Early consideration of TPE, alongside careful patient selection, could optimize outcomes, although larger prospective studies are required to confirm efficacy and define the best timing and indications.
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