Extracorporeal Albumin Dialysis in Liver Failure with MARS and SPAD: A Randomized Crossover Trial

<b><i>Introduction:</i></b> Liver failure is associated with hepatic and extrahepatic organ failure leading to a high short-term mortality rate. Extracorporeal albumin dialysis (ECAD) aims to reduce albumin-bound toxins accumulated during liver failure. ECAD detoxifies blood using albumin dialysis through an artificial semipermeable membrane with recirculation (molecular adsorbent recirculating system, MARS) or without (single-pass albumin dialysis, SPAD). <b><i>Methods:</i></b> We performed a randomized crossover open trial in a surgical intensive care unit. The primary outcome of the study was total bilirubin reduction during MARS and during SPAD therapies. The secondary outcomes were conjugated bilirubin and bile acid level reduction during MARS and SPAD sessions and tolerance of dialysis system devices. Inclusion criteria were adult patients presenting liver failure with factor V activity &#x3c;50% associated with bilirubin ≥250 μmol/L and a complication (either hepatic encephalopathy, severe pruritus, or hepatorenal syndrome). For MARS and SPAD, the dialysis flow rate was equal to 1,000 mL/h. <b><i>Results:</i></b> Twenty crossovers have been performed. Baseline biochemical characteristics (bilirubin, ammonia, bile acids, creatinine, and urea) were not statistically different between MARS and SPAD. Both ECAD have led to a significant reduction in total bilirubin (−83 ± 67 μmol/L after MARS; −122 ± 118 μmol/L after SPAD session), conjugated bilirubin (−82 ± 61 μmol/L after MARS; −105 ± 96 μmol/L after SPAD session), and bile acid levels (−64 ± 75 μmol/L after MARS; −56 ± 56 μmol/L after SPAD session), all nondifferent comparing MARS to SPAD. <b><i>Conclusion:</i></b> A simple-to-perform SPAD therapy with equal to MARS dialysate flow parameters provides the same efficacy in bilirubin and bile acid removal. However, clinically relevant endpoints have to be evaluated in randomized trials to compare MARS and SPAD therapies and to define the place of SPAD in the liver failure care program.

Successful elimination of bilirubin in critically ill patients with acute liver dysfunction using a cytokine adsorber and albumin dialysis: a pilot study

There are different methods of artificial liver support for patients with acute liver dysfunction (ALD). However, CytoSorb (CS) might be a new approved option for those patients. Question of interest is whether the elimination performance of CS was comparable to that of advanced organ support (ADVOS). Patients, treated with CS (integrated into high-flux dialysis) or ADVOS and a total bilirubin > 10 mg/dl were included. Laboratory parameters were evaluated before starting therapy (d0) and 12–24 h thereafter (d1). The Wilcoxon-test with associated samples was used for statistical analysis. Thirty-nine patients (33 CS, 6 ADVOS) were included. The median bilirubin at d0 was 16.9 and 17.7 mg/dl and at d1 was 13.2 and 15.9 mg/dl, in the CS and ADVOS group, respectively. There was a significant bilirubin reduction as well in the CS group (p < 0.001, median relative reduction: 22.5%) as in the ADVOS group (p = 0.028, median relative reduction: 22.8%). There was no significant difference in the relative bilirubin reduction between CS and ADVOS therapies. The use of CytoSorb and ADVOS in patients with ALD led to a significant and comparable decrease in total bilirubin. The easy use of CS might be an advantage compared to other procedures.

The use of a single pass albumin dialysis for the management of liver failure- a case series

Intoduction. A single pass albumin dialysis (SPAD) is a form of extracorporeal liver support system for the removal of albumin-bound toxins and water-soluble substances that accumulate in liver failure (LF). Case report. We present a retrospective case series of three patients hospitalized for LF and treated using the SPAD in the Clinical Center of Vojvodina, between 2018 and 2019. Of whom, two patients presenting with acute liver failure and one with acute-on-chronic liver failure. A total of 6 SPAD sessions were performed in each patient, resulting in decreased serum bilirubin and bile acid levels, and hepatic encephalopathy grade. On discharge from the hospital, liver function has been shown to improve in all the patients. Conclusion. SPAD removes the hepatotoxic substances without improvement of synthetic liver function, providing a supportive treatment for LF patients that do not respond to standard of care offering longer time for bridging to organ transplantation or spontaneous recovery of the liver function.

Efficacy of albumin dialysis as a bridge to transplantation in children with end-stage liver disease

Liver transplantation is the only effective treatment modality for end-stage liver disease. However, donor organs are not always available. In some cases, the gravity of the patient’s condition makes transplantation impossible. In this regard, the use of artificial liver support systems helps in preparing a patient for transplant surgery. Objective: to conduct a retrospective study aimed at evaluating the efficiency of fractionated plasma separation and adsorption system. Materials and methods. From January 2019 to May 2020, 139 pediatric liver transplants were. We analyzed the data of 5 pediatric patients (2 girls and 3 boys, aged 12 to 17 years) who received fractionated plasma separation and adsorption (FPSA) sessions as a bridge to transplantation. The main clinical indication for FPSA was severe hepatic encephalopathy (grade 3 according to the West Haven Criteria), which was observed at 350–872 μmol/L (average 597 ± 98 μmol/L) serum bilirubin level. The FPSA sessions were conducted on a Prometheus device using AV-600 hemofilters as dialyzers (Fresenius Medical Care, Germany). Results. Depending on the extent of bilirubinemia in patients, it took from one (in one case) to three (in one case) daily FPSA sessions to restore clear consciousness, appetite and physical activity. Average bilirubin levels after treatment cycles decreased from 597 ± 98 to 236 ± 73 μmol/L. All patients successfully underwent liver transplant surgery within two to five days, two patients received a liver fragment from a living related donor. Conclusion. The FPSA system stabilizes the condition of potential recipients with acute liver failure. Further research is required to develop optimal regimens for albumin dialysis.