Extracorporeal Support for Patients with Hepatic Failure

Abstract

Extracorporeal support has been advocated for patients with acute and chronic liver failure. Patients with acute liver failure and those with decompensated cirrhosis can be broadly divided into two groups. The first group comprises those with acute liver failure and ongoing hepatic necrosis, and the second, those with long-standing chronic decompensation admitted with one or more complications of liver failure, such as encephalopathy without any evidence of a precipitating factor or accompanying acute deterioration of liver function. This second group includes patients with acute liver failure, where the insult causing hepatic necrosis has been resolved, and those patients with chronic decompensation who suffer another insult to the liver, such as acute infection or variceal hemorrhage that causes further liver injury in the setting of multiorgan failure. These two groups are likely to have different outcomes and may need to be managed differently. In the first group, liver transplantation is the only possible long-term therapeutic option, whereas in the second group, other possibilities such as extracorporeal liver support systems and/or medical therapy may allow these patients to return to their previous state before the acute insult. Over time extracorporeal support has expanded from simple peritoneal dialysis and hemodialysis, to the development of circuits designed primarily to remove both water and lipid-soluble toxins and, in addition, bioartificial devices to provide replacement synthetic hepatic function. Because many of the patients with an acute liver insult have ongoing chronic liver disease and develop hepatorenal syndrome, this group of patients has been targeted by several groups to study the role of liver support systems.

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

“…[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. [39] Likewise, despite published data on the loss of coagulation factors during Prometheus-therapy, [40] we did not observe clinically significant hemorrhagic complications.…”

“…[27,28] SPAD therapy uses standard equipment for kidney replacement therapy with a highly porous membrane dialyzers and albumin containing dialysis solutions to remove hydrophobic substances.…”

Dialysis-dependent acute kidney injury in children with end-stage liver disease: prevalence, dialysis modalities and outcome

“…Acute kidney injury (AKI) is a major complication in children with hepatic failure [1], resulting in increased morbidity and mortality [2]. The need for and duration of renal replacement therapy (RRT) have an impact on liver transplant survival and kidney function after orthotopic liver transplantation (OLT) in adults [3].…”

“…However, this was only an estimation, and one which is highly skewed by referral patterns and availability of resources. There are several causes of kidney injury in patients with severe hepatic dysfunction, such as infections, especially sepsis, cardiogenic or hypovolemic shock and nephrotoxic drugs [2]. These complications frequently accompany liver failureinduced intrarenal vasoconstriction and are associated with kidney dysfunction in the critically ill patient [4].…”

Multiorgan Dysfunction: the State-of-the-Art and Current Approaches to Its Treatment Using Low Flow-Rate Membrane Technologies

“…Применение традиционных методов заме стительной почечной терапии, таких как гемодиализ, гемофиль трация или гемодиафильтрация, не приводит к удалению из плазмы связанных с белками токсинов, поскольку эти методики обеспечивают только контроль водорастворимых молекул. Не смотря на то, что эти методы эффективно удаляют высокоток сичное водорастворимое соединение аммиак, уровень которого значительно повышается при печеночной недостаточности, в исследованиях не было отмечено улучшения показателей выжи ваемости при использовании фильтрационных методик [75].…”