Hemoadsorption in isolated conjugated hyperbilirubinemia after extracorporeal membrane oxygenation support. Cholestasis of sepsis: A case report and review of the literature on differential causes of jaundice in ICU patient

Abstract

Hyperbilirubinemia occurs in up to 40% of critically ill. In ICU, hyperbilirubinemia is an independent factor that influences patients’ morbidity and mortality. Jaundice can reflect the course of disease or be caused by treatment (e.g. extracorporeal membrane oxygenation (ECMO)), thus can be difficult to differentiate. Sepsis was also associated with development of jaundice secondary to intrahepatic cholestasis. Prolonged cholestasis should be addressed to avoid liver damage. The patient with diagnosis of septic shock and severe acute respiratory distress syndrome was retrieved to our hospital for ECMO. Three days after initiation of ECMO, the patient developed jaundice, with increase of bilirubin, Gamma-glutamyltransferase and Alkaline phosphatase, without elevation of alanine aminotransferase and INR. Although ECMO was stopped, bilirubin serum levels were increasing, reaching the peak of 18.41 mg/dL of total and 15.67 mg/dL of direct bilirubin. Abdominal computed tomography showed homogeneous liver and non-dilated bile ducts. Viral hepatitis was excluded. CIOMS/RUCAM score was 0. Sepsis-related cholestasis was diagnosed. Despite cessation of sedation, the patient remained unconscious. Hemoadsorption therapy was initiated due to prolonged high levels of conjugated bilirubin. After 48 h of CytoSorb treatment, total bilirubin level was decreased to 2.4 mg/dL, the patient regained spontaneous eyes opening and could be transferred to regional hospital. Hyperbilirubinemia did not return in 3 months. Sepsis-related cholestasis is a diagnosis of exclusion that should be considered in case of jaundice in critically ill patients. In our patient, CytoSorb was a useful therapeutic option in prolonged cholestasis. Adsorption therapy was able to facilitate long-term regain of balance between inflammatory process, cytokine production and bilirubin turnover in the liver.

Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb®—Basics, Indications and Perspectives—A Scoping Review

“…In up to 40% of critically ill patients, hyperbilirubinemia is present with an increased risk of death [ 93 ]. Clinical and paraclinical findings typically include varying degrees of icterus, lactic acidosis, coagulation disorders, hepatic encephalopathy, and circulatory insufficiency.…”

“…This is true even when used for several weeks [ 62 ]. CytoSorb ® therapy may be a simple, user-friendly alternative to bridge to functional recovery or orthotopic liver transplantation [ 93 , 101 ]. Initial clinical trial results appear positive [ 69 ].…”

Pericarditis caused by Enterococcus faecium with acute liver failure treated by a multifaceted approach including antimicrobials and hemoadsorption

“…The combination of the adsorption and elimination of bilirubin and bile acids, the modulation of involved cytokines and the reduction of excess ammonia levels via a parallel renal replacement procedure allows to bridge the time until functional recovery or orthotopic liver transplantation (21). This concept has been described by several authors (22)(23)(24).…”

Applications of Cytosorb in clinical practice

“…The case of cardiac surgery patient showed a bilirubin drop from 24.5 mg/dL to 10.8 mg/dL after three days of Cytosorb therapy [32]. The Cytosorb was reported to be useful in patient with hyperbilirubinemia due to hepatic failure [33], in drug-induced cholestasis, alcoholic hepatitis [34], and cholestasis in sepsis [35]. It was used successfully in a liver cirrhosis patient with a pre-existing hepatitis C infection [36].…”