Soporte hepático extracorpóreo: situación actual y expectativas de futuro

[Liver transplantation: influence of donor-related factors]

OBJECTIVE

To detect donor characteristics related to graft function after orthotopic liver transplantation (OLT).

DESIGN

Retrospective cohort study.

CONTEXT

Polyvalent intensive care unit.

PATIENTS

145 liver transplant recipients and their respective donors.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

In donors: age, hypernatremia, and infection. In recipients: reperfusion syndrome, coagulopathy, infection, ARDS, shock, kidney failure, primary graft dysfunction, and mortality.

RESULTS

71.7% of recipients were male. Mean recipient age was 54.5 +/- 9.9 years; 66.2% of patients were classified as Child B and and 19.3% as Child C. The mean model for end-stage liver disease (MELD) score was 14.6 +/- 4.8 and the mean APACHE II score was 17.3 +/- 4.9. A total of 64.1% of the donors were male. Mean donor age was 42.3 +/- 16.3 years, and mean APACHE II score was 22.3 +/- 5.8. Donor age > 65 years was associated to higher recipient aspartate aminotransferase (AST) levels but not to increased complications or mortality. No other donor factors (including age, sex, serum sodium, severity level, transfusions, hemodynamic alterations, renal dysfunction, or infection) were associated to evolution or prognosis. Infection was diagnosed in 18 recipients (12.4%) in the postoperative period; the incidence of infection in recipients that received an organ from infected donors was not different from those that received an organ from an uninfected donor (14.6% versus 11.5%; p > 0.05).

CONCLUSIONS

We detected no donor characteristics related to graft function or the appearance of complications in recipients during the immediate postoperative period. Donor age > 65 years and documented but appropriately treated bacteremia posed no risk for the viability of the liver after transplantation.

[Safety and efficacy of the MARS therapy applied by continuous renal replacement therapy (CRRT) monitors]

OBJECTIVE

Analyze the utility and safety of MARS therapy applied with the CRRT monitor.

DESIGN

Prospective study of cohorts.

SCOPE

Polyvalent ICU in tertiary university hospital with hepatic transplantation program.

PATIENTS

Thirty one patients: 9 (22.6%) with acute liver failure (ALF) (1 hepatic surgery, 1 primary graft failure, 7 other causes) and 22 (71%) with acute-on-chronic failure (AoCLF).

INTERVENTIONS

For the treatment, the patients with ALF are maintained in the ICU but those with AoCLF are admitted for the performance of the different sessions, that are programmed for a duration of at least 15 hours in AoCLF and in ALF are maintained continuously, changing the circuit every 24 hours.

VARIABLES OF INTEREST

Metabolic control and complications registered in 75 sessions on 31 patients.

RESULTS

Urea decrease was 33.5 (29-38%), creatinine 36 (31-41%), total bilirubin 29 (25-33%) and direct bilirubin 34 (30-38%). Clearance was slower, but sustained, after the first 4 hours of each session both for urea (p<0.001) as well as for bilirubin (p<0.05). The hemodynamic parameters improved and the hematological ones were not altered. We detected decrease in platelets (131 to 120x109/L, p<0.01). In 95 of the sessions in which heparin was used and in 6% where epoprostenol was used, we observed mild bleeding. We cultured albumin of the circuit at the end of the session in 50 occasions and only obtained growth in 3 cases (6%) (2 Staphylococcus epidermidis, 1 S. haemolyticus) without signs of contamination in the patients.

CONCLUSIONS

The MARS system applied by CRRT monitors provide adequate bilirubin clearance percentages and is safe, even in serious patients. Prolongation of the duration of the sessions was not accompanied by an increase in the risk of infection secondary to the albumin contamination.

[MARS (Molecular Absorbent Recirculating System) as hepatic extracorporeal care in serious acute liver failure of alcoholic etiology]

Acute liver failure with criteria of seriousness and alcoholic etiology is a picture of worldwide distribution, with an elevated mortality, of approximately 50%, that requires admission to the ICU. Acute serious alcoholic hepatitis is defined by a Maddrey score value > 32 and/or spontaneous encephalopathy. Together with the classical treatment with corticosteroids and nutritional supplements, alcoholic abstinence and others such as anti-TNF therapy, we introduce MARS (Molecular Adsorbent recirculating System) as a extracorporeal liver assistance system with detoxification function, that is presented as a support measure that makes it possible to maintain the patient in good conditions until an organ becomes available or until the functional recovery of the native liver. In our case, MARS has shown some spectacular results and above all, results maintained over time, associated to the rest of the therapeutic measures characteristic of this disease.

[Albumin dialysis in patients with acute exacerbation of chronic liver failure in an intensive care unit]

BACKGROUND AND OBJECTIVE

To describe our experience with albumin dialysis (Molecular Adsorbent Recirculating System [MARS]) in patients who are in an intensive care unit due to an acute exacerbation of chronic liver failure.

PATIENTS AND METHOD

From January 2004 to October 2005 10 patients, aged 40 to 65 years (mean age 58.8), were admitted due to acute exacerbation of chronic liver failure. All of them suffered from an encephalopathy and were candidates for a liver transplantation. One to six MARS sessions were applied. Clinical parameters were registered before and after each session.

RESULTS

Of the 10 patients treated, 9 survived and 1 died. Five out of the 9 survivors were successfully transplanted. In 2 patients (one of them was the deceased one) the grade of encephalopathy was > I (II and III respectively), and in both improved to grade I. In the other ones, the encephalopathy did not worsen. The serum bilirubin diminished from 39.2 to 28.2 mg/dl (p < 0.01). In the 3 patients with serum creatinin > 1.5 mg/dl, this parameter diminished from 2.6 to 1.5 mg/dl (p < 0.01). Two patients had thrombocytopaenia and haemorrhage, and in one of them the MARS treatment had to be interrupted. No hypotension was observed.

CONCLUSIONS

The reduction in the serum bilirrubin and creatinin, as well as the clinical improvement of the two patients with encephalopathy grade > I, make us to think that the MARS can be useful to patients with acute exacerbation of a chronic liver failure as a bridge to a liver transplantation.