Extracorporeal Liver Support Therapy With Prometheus in Patients With Liver Failure in the Intensive Care Unit

Abstract

Acute liver failure (ALF) and acute-on-chronic liver failure (AoCLF) are associated with a high mortality. In these patients an accumulation of both water-soluble and water-insoluble, protein-bound, metabolic waste products occurs. Conventional extracorporeal blood purification techniques based on diffusion and/or convection such as hemodialysis or hemofiltration may only eliminate small molecular weight, water-soluble compounds. In recent years, fractionated plasma separation and adsorption (FPSA) with the Prometheus system has been introduced for extracorporeal liver support therapy. To date, however, only limited data is available regarding the effect of this treatment on mortality and outcome of patients with advanced liver disease. Here we report on our experience with 23 patients with severe liver failure who were treated with Prometheus in our medical intensive care unit. Fourteen patients had AoCLF, and nine patients experienced ALF. The median bilirubin level at the start of Prometheus therapy was 30.5 mg/dL and the median Acute Physiology and Chronic Health Evaluation II (APACHE II) score was 26. During 40 individual treatment sessions lasting 5-6 h, Prometheus therapy reduced serum bilirubin levels from 23.7 mg/dL to 15.0 mg/dL (median values) (P < 0.001), and the overall survival was 26%. ALF patients had a better survival compared to AoCLF patients (44% vs. 22%; P = 0.022). Apart from one patient who developed hemodynamic instability during a treatment session, Prometheus therapy was well tolerated without relevant side-effects. In conclusion, extracorporeal liver support therapy with Prometheus is a novel and safe treatment option in patients with severe liver failure. In this series, patients with ALF showed a significantly better outcome with Prometheus therapy compared to AoCLF patients.

Liver Depurative Techniques: A Single Liver Transplantation Center Experience

“…Likewise, Oppert et al [4] observed global survival rate of 26% in patients with ALF and AoCLF submitted to Prometheus, with a higher survival rate among ALF patients. These data could not be reproduced in the present study; we did not find any difference in 6-month survival for patients who underwent LT and those who did not undergo LT.…”

Blood purification in intensive care patients with multiple organ dysfunction syndrome and sepsis after cardiac surgery

“…According to several authors, the serum albumin concentration during MARS-therapy remains unchanged because the diameter of the filter pores (50 kDa) does not exceed the size of the albumin molecule (65 kDa). [26,38] However, the albumin loss during Prometheus-therapy can reach 3 g/L (P = 0.055). [31,39] We observed no significant negative dynamics of serum albumin [oscillations: 32 (30-35) and 30 (26)(27)(28)(29)(30)(31)(32)(33)(34)(35) g/L, P = 0.052, before and after MARS-therapy; 33 (31-34) and 31 (28-36) g/L, P = 0.051, before and after Prometheus-therapy], which is probably due to the adequate routine correction of hypoproteinemia in patients with ALF.…”

“…This technique is the most effective for eliminating albumin-bound toxins such as unconjugated bilirubin and bile acids. [37,38] In assessing the safety and efficacy of MARS and Prometheus therapies in adult patients with ALF after cardiac surgery, we analyzed the dynamics of hydrophobic and hydrophilic toxic substance concentrations as well as the severity of hepatocyte cytolysis and the impairment of liver synthetic function. A key aspect in the evaluation of MARS and Prometheus liver support system safety in patients after cardiac surgery was the absence of a negative influence on hemodynamics and lung oxygenation function.…”

Rapid Adsorption of Proinflammatory Cytokines by Graphene Nanoplatelets and Their Composites for Extracorporeal Detoxification

“…such as MARS5 [38] or Prometheus5 [39] where adsorbent materials do not come into direct contact with patient blood and, therefore, mitigate issues of blood cell activation and hemocompatibility.…”