Purpose Acute liver failure (ALF) and acute on chronic liver failure (ACLF) still show a poor prognosis. MARS was used in 22 patients with ALF or ACLF to prolong patient survival for liver function recovery or as a bridge to transplantation. Design Evaluation of depurative efficiency, biocompatibility, hemodynamics, encephalopathy (HE) and clinical outcome. Procedures During 71 five-hour sessions we evaluated (0′, 60′, 120′, 180′, 240′, 300′): bilirubin, ammonia, cholic acid (CCA), chenodeoxycholic acid (CCDCA), leukocytes, platelets, hemoglobin and mean arterial pressure (MAP). Serum creatinine, electrolytes, cardiac output, cardiac index (bioimpedence) and HE (West Haven Criteria score) were evaluated at 0' and 300′. Statistical methods and outcome measures: Student's t-test for pre- vs. end-session values was used. For bilirubin and ammonia the correlation test was made between pre- and end-session values and between pre-session values and removal rates (RRS). Main Findings Survival was 90.9% at 7 days, 40.9% at 30 days. Pre- vs. end-session: bilirubin from 37.2±12.5 mg/dL to 24.9±8.9 mg/dL (p<0.01), ammonia from 88.0±60.4 μmol/L to 43.6±32.9 μmol/L (p<0.01), CCA from 42.8±21.0 μmol/L 18.2±9.8 μmol/L (p<0.01), CCDCA from 26.3±6.3 μmol/L to 15.7±7.6 μmol/L (p<0.01). The correlation test between pre-session values of bilirubin and ammonia vs. RRS was respectively 0.32 (p=0.01) and 0.30 (p=0.04). Leukocytes, platelets and hemoglobin remained stable. MAP increased from 82.0±12.0 mmHg to 87.0±13.0 mmHg (p<0.05), West Haven Criteria score decreased from 2.7±0.7 to 0.7±0.7 (p<0.001). Conclusion MARS treatment led in all patients to an improvement of clinical, hemodynamic and neurological conditions, with significant reduction in the hepatic toxins blood level. Treatment biocompatibility and tolerance were satisfactory
SUMMARY AimTo evaluate the acute effect of treatment with the molecular adsorbent recirculating system (MARS) on splanchnic, renal and systemic haemodynamics in patients with end-stage cirrhosis. MethodsTwelve patients with end-stage cirrhosis, undergoing MARS treatment, were enrolled. The following haemodynamic parameters were measured by means of Doppler ultrasonography and thoracic electrical bioimpedance, before and after each session: portal velocity, renal and splenic resistance indices, cardiac output, cardiac stroke volume, heart rate, mean arterial pressure, systemic vascular resistance. ResultsMedian portal velocity increased significantly after treatment (23.7 vs. 20.3 cm ⁄ s, P < 0.05) while renal resistance index (0.72 vs. 0.75, P < 0.05) and splenic resistance index (0.60 vs. 0.65, P < 0.05) decreased significantly. Mean arterial pressure (83 vs. 81 mmHg, P < 0.05) and vascular resistance (899 vs. 749 dyne. s ⁄ cm 5 , P < 0.05) increased significantly, while cardiac output and stroke volume showed no significant changes. ConclusionsData emerging from this investigation suggest that MARS treatment improves significantly various haemodynamic alterations in cirrhotic patients in the short term. The observed decrease in renal vascular resistance and improvement in splenic resistance index, a parameter related to portal resistance, which leads us to hypothesize that these haemodynamic effects are probably mediated by clearance of vasoactive substances during MARS treatment.
At the beginning of the COVID-19 pandemic in Italy, the City Hospital of Lugo (covering an area of over 100,000 people) started to change the organization of its entire Emergency Department. To tackle the COVID-19 emergency, the Local Health Authority chose our hospital to be one of the designated COVID-19 hospitals in Italy. In fact, the medical organization was completely modified, and entire departments (i.e., Physical Medicine and Rehabilitation) were moved to other hospitals in the region, while the remaining departments were reorganized. 1 In this Letter to the Editor, we wish to share our clinical experience of how to organize an emergency room (ER) during the COVID-19 pandemic.The workflow and organization of the ER were modified, and a pretriage tent was set up outside the hospital building to allow for the identification of infected patients, according to regional and national guidelines, 2 as follows:An emergency department during the COVID-19 pandemic
Patients with liver disease or systemic pathology are more prone to develop portal vein thrombosis. Non-neoplastic thrombosis is characterised by absence of intrathrombotic perfusion, corresponding to marked hypoechogenicity at contrast-enhanced ultrasound. We report two cases of portal vein thrombosis in which contrast-enhanced ultrasound showed marked hypoechogenicity in the late phase. This late phase perfusional contrast pattern is consistent with non-neoplastic thrombosis, but is actually similar to that of metastatic liver lesions. Echo-guided needle biopsy indeed yielded histological results consistent with carcinoma. Repeated contrast-enhanced ultrasound showed presence of intratumoural perfusion in the arterial phase, suggestive of the neoplastic nature of the thrombus. Our cases suggest that CEUS with second generation contrast agents in patients with portal thrombosis should include the evaluation of both arterial and portal phases in order to provide accurate non-invasive diagnosis of metastatic portal vein thrombosis.
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