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Introduction and Objectives: Non-oncotic albumin functions such as transport, antioxidant and immunomodulatory capacities may be associated with the beneficial effects of albumin therapy in liver disease patients. For acute-on-chronic liver failure (ACLF) patients, characterized mainly by severe systemic inflammation and organ failure, plasma exchange with human serum albumin (PE-A5%) may be an effective treatment. In fact, the effects of PE-A5% on short-term survival in patients with ACLF are currently under investigation (APACHE phase 3 trial, NCT03702920). To characterize albumin levels with intact structure (effective albumin) in patients with ACLF compared with healthy controls (HC) and to assess the effect of PE-A5% treatment on eAlb levels in patients with ACLF. Materials and Methods: Plasma samples from 10 patients included in the Pilot-APACHE trial (NCT01201720) were assessed. This was a prospective, open-label, non-controlled study in which ACLF patients were treated with six PE-A5% for 10 days. At baseline, results were compared with HC (n=10). Albumin post-translational modifications (PTMs) were determined by mass spectrometry (LC_ESI_qTOF-MS). Native albumin (%) (the primary structure preserved form without PTMs) and effective albumin levels (mg/mL) (calculated as (total albumin x native albumin)/100)) were evaluated. Results were expressed as median (IQR). Results: At baseline, ACLF patients showed a significantly lower proportion of native albumin, 19.4% (10.0-28.5), compared with HC, 51.3% (49.0-52.6), P