The series-parallel circuit in the treatment of fulminant hepatitis

Therapeutic plasma exchange in liver failure

The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure (ACLF) is thought to be mediated by overwhelming systemic inflammation triggered by both microbial and non-microbial factors. Therapeutic plasma exchange (TPE) has been proven to be an efficacious therapy in autoimmune conditions and altered immunity, with more recent data supporting its use in the management of liver failure. Few therapies have been shown to improve survival in critically ill patients with liver failure who are not expected to survive until liver transplantation (LT), who are ineligible for LT or who have no access to LT. TPE has been shown to reduce the levels of inflammatory cytokines, modulate adaptive immunity with the potential to lessen the susceptibility to infections, and reduce the levels of albumin-bound and water-bound toxins in liver failure. In patients with acute liver failure, high volume TPE has been shown to reduce the vasopressor requirement and improve survival, particularly in patients not eligible for LT. Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF. TPE may be most favorably employed as a bridge to LT in patients with ACLF. In this review, we discuss the efficacy and technical considerations of TPE in both acute and acute-on-chronic liver failure.

Artificial liver support systems

Artificial liver systems are used to bridge between transplantation or to allow a patient's liver to recover. They are used in patients with acute liver failure (ALF) and acute-on-chronic liver failure. There are five artificial systems currently in use: molecular adsorbent recirculating system (MARS), single-pass albumin dialysis (SPAD), Prometheus, selective plasma filtration therapy, and hemodiafiltration. The aim is to compare existing data on the efficiency of these devices. A literature search was conducted using online libraries. Inclusion criteria included randomized control trials or comparative human studies published after the year 2000. A systematic review was conducted for the five individual devices with a more detailed comparison of the biochemistry for the SPAD and MARS systems. Eighty-nine patients were involved in the review comparing SPAD and MARS. Results showed that there was an average reduction in bilirubin (-53 μmol/L in MARS and -50 μmol/L in SPAD), creatinine (-19.5 μmol/L in MARS and -7.5 μmol/L in SPAD), urea (-0.9 mmol/L in MARS and -0.75 mmol/L in SPAD), and gamma-glutamyl transferase (-0.215 μmol/L·s in MARS and -0.295 μmol/L·s in SPAD) in both SPAD and MARS. However, there was no significant difference between the changes in the two systems. This review demonstrated that both MARS and SPAD aid recovery of ALF. There is no difference between the efficiency of MARS and SPAD. Because of the limited data, there is a need for more randomized control trials. Evaluating cost and patient preference would aid in differentiating the systems.

Continuous plasma exchange with dialysis for thrombotic microangiopathy in intensive care unit: Retrospective observational study

Continuous plasma exchange with dialysis is a novel method of blood purification and is a modification of the plasma exchange. Technically, this process suggests a reduction in adverse events, cost-effectiveness, and compatibility with hemodynamic instability. The therapeutic effect of plasma exchange on thrombotic microangiopathies has been established. We present three clinical cases in the intensive care unit that illustrate continuous plasma exchange with dialysis as a flexible blood purification therapy for critically ill patients; a radical treatment, thrombotic microangiopathies; supportive therapy, multiple organ failure; and fluid balance regulator. The retrospective analysis of 13 continuous plasma exchange with dialysis sessions showed that the platelet count increased significantly (p = 0.0096) after its administration. The total protein, albumin, fibrinogen, or calcium did not decrease significantly after continuous plasma exchange with dialysis, suggesting therapeutic efficacy and fewer adverse events. A prospective study on thrombotic microangiopathies for continuous plasma exchange with dialysis is currently underway.

Description of parallel and sequential configurations for concurrent therapeutic plasma exchange and continuous kidney replacement therapy in adults

Therapeutic plasma exchange (TPE) and continuous kidney replacement therapy (CKRT) are extracorporeal therapeutic procedures often implemented in management of patients. Critically ill patients may be afflicted with disease processes that require both TPE and CKRT. Performing TPE discontinuous with CKRT is technically easier, however, it disrupts CKRT and may compromise with CKRT efficiency or hemofilter life. Concurrent TPE with CKRT offers several advantages including simultaneous control of disease process and correction of electrolyte, fluid, and acid-base disturbances that may accompany TPE. Additionally, TPE may be performed by either centrifugation method or membrane plasma separation method. The technical specifications of these methods may influence the methodology of concurrent connections. This report describes and reviews two different approaches to circuit arrangements when establishing concurrent TPE and CKRT.

Selective Plasma Exchange for Critically Ill Patients Accompanied With Thrombocytopenia

Selective plasma exchange is a blood purification therapy in which simple plasma exchange is performed using a selective membrane plasma separator (pore size of 0.03 µm). Seven critically ill patients accompanied with thrombocytopenia were treated with selective plasma exchange using fresh frozen plasma. The total bilirubin levels and prothrombin time international normalized ratios decreased significantly after treatment. The total protein, albumin, and fibrinogen levels increased significantly after treatment. Selective plasma exchange may be a useful blood purification therapy for removing causal substances and retaining coagulation factors in patients accompanied with thrombocytopenia.

Fulminant liver failure resulting from massive hepatic infarction associated with hemolysis, elevated liver enzymes, and low platelets syndrome

Hepatic infarction is an extremely rare and fatal complication associated with hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome. It can develop into fulminant liver failure, which increases both maternal and neonatal mortality rates. A 34-year-old woman with no remarkable past medical history developed eclampsia after delivery at 40 weeks of gestation. Imaging indicated massive hepatic infarction and rupture followed by cardiac arrest and fulminant liver failure. Despite liver replacement therapy with plasma exchange and continuous hemodiafiltration, the patient gradually deteriorated with persistent bacterial infection until death at 98 days after delivery. The management of fulminant liver failure complicated with HELLP syndrome should be multidisciplinary. Liver transplantation, the only radical treatment for fulminant liver failure, is worth attempting, if applicable.

Selective plasma exchange with dialysis in patients with acute liver failure

Selective plasma exchange with dialysis is a blood purification therapy in which simple plasma exchange is performed using a selective membrane plasma separator while the dialysate flows out of the hollow fibers. To evaluate the effect of plasma exchange with dialysis, biochemical examination of the blood, for example, the oxidative stress regulation system and interleukin 18 levels, was performed in patients with acute liver failure. We studied four patients with acute liver failure in whom the therapy was performed (nine times in total). The degree of hepatic encephalopathy and interleukin 18 levels decreased significantly after treatment. However, total protein levels did not change significantly. The level of reactive oxygen species and total antioxidant capacity did not change significantly. Plasma exchange with dialysis may be a useful blood purification therapy in cases of acute liver failure in terms of the removal of water-soluble and albumin-bound toxins.

Multicenter study of plasma diafiltration in patients with acute liver failure

Plasma diafiltration (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside the hollow fibers. A prospective, multicenter study was undertaken to evaluate the changes in bilirubin, IL-18, and cystatin C, as well as the 28-day and 90-day survival rates, with the use of PDF according to the level of severity as measured by the Model for End-Stage Liver Disease (MELD) score. Twenty-one patients with liver failure were studied: 10 patients had fulminant hepatitis and PDF therapies were performed 28 times; 11 had acute liver failure with the therapy performed 96 times. Levels of total bilirubin, IL-18, and cystatin C decreased significantly after treatment. The 28-day survival rate was 70.0% and that at 90 days was 16.7%. According to the severity of the MELD score, each of the results compared well with the use of Molecular Adsorbent Recirculating System or Prometheus therapy. In conclusion, PDF appears to be one of the most useful blood purification therapies for use in cases of acute liver failure in terms of medical economics and the removal of water-soluble and albumin-bound toxins.

A case report of acute renal failure and fulminant hepatitis associated with edaravone administration in a cerebral infarction patient

A 60-year-old male with cerebral infarction was admitted to our hospital and treated with edaravone. On day 12 of hospitalization, he suddenly lost consciousness and went into shock. Based on the laboratory findings, acute renal failure (ARF), fulminant hepatitis, and disseminated intravascular coagulation (DIC) were diagnosed. We immediately initiated continuous hemodiafiltration for three days and performed three sessions of plasma exchange. Following this, a gradual improvement was observed in the patient's general condition and laboratory values. On day 17 of hospitalization, intermittent hemodialysis (HD) was initiated. On day 20 of hospitalization, his renal function started to improve with an increase in urine volume. HD was successfully discontinued on the same day. Although the drug lymphocyte stimulation test for edaravone was negative, edaravone-induced fulminant hepatitis was suggested based on liver biopsy findings. We present a case of ARF, fulminant hepatitis, and DIC due to edaravone administration that was successfully treated with blood purification techniques. Since the use of edaravone treatment is expected to increase in the future, it is essential that clinicians consider the potential adverse effects of this treatment. It is suggested that blood purification is effective in inducing remission in patients with complications due to edaravone treatment.

A Case Report of Hepatorenal Syndrome Treated With Plasma Diafiltration (Selective Plasma Filtration with Dialysis)

Plasma diafiltration (PDF) (selective plasma filtration with dialysis) is blood purification therapy in which simple plasma exchange is performed using a membrane plasma separator (Evacure EC-2A) while dialysate flows outside of the hollow-fibers. A 74-year old man with hepatorenal syndrome underwent four sessions of PDF and three sessions of HDF. Finally he recovered from hepatorenal syndrome. In this therapy, the levels of total bilirubin, interleukin-18, creatinine, and cystatin C were significantly reduced. On the other hand, there were no significant differences in the total protein and albumin levels before and after PDF. PDF may be one of the most useful blood purification therapies for hepatorenal syndrome in terms of medical economics.

Study of safe usage of high-flow three-way stopcocks in a blood circuit

To examine the safety of using a high-flow three-way stopcock in a blood circuit during extracorporeal blood purification therapy, we studied the risk of development of hemolysis and clot formation in both ex vivo and in vivo extracorporeal circulation. In the ex vivo study, no significant difference was observed in the decrease in hematocrit (HCT) or increase in the potassium level between the three-way stopcock group and the control group. Nor was there a significant difference in the change in inlet pressure between the two groups. Thus, it was shown that the risk of hemolysis caused by the use of a high-flow three-way stopcock on both the outlet side and inlet side would be small. In the in vivo cases, there was no significant difference in the decrease in HCT or the increase in inlet pressure between the three-way stopcock group and control group, suggesting that it is clinically possible to incorporate a high-flow three-way stopcock into a blood circuit.

Combining continuous endotoxin apheresis and continuous hemodiafiltration in the treatment of patients with septic multiple organ dysfunction syndrome

When septic multiple organ dysfunction syndrome (MODS) occurs as a result of endotoxemia, diverse chemical mediators are excessively produced, and the patient becomes seriously ill. Under such circumstances, it is difficult to improve the patient's condition by endotoxin apheresis alone and hemodiafiltration should be carried out to remove excessive chemical mediators. Series-parallel treatment combining continuous endotoxin apheresis and hemodiafiltration is recommended for patients with septic MODS.

The Dose of Nafamostat Mesilate During Plasma Exchange With Continuous Hemodiafiltration in the Series-Parallel Circuit

We studied nafamostat mesilate (NM) and interleukin (IL)-18 levels to determine whether the dose of NM is reduced during plasma exchange (PE) with continuous hemodiafiltration (CHDF) when the series-parallel circuit is used. The subjects of the current study included four patients with acute hepatic failure who underwent PE with CHDF. The four patients underwent a total 15 PE + CHDF procedures, and for each procedure, they were randomized to receive either a half-dose of NM or no NM in the CHDF circuit. Eight procedures were carried out with NM administration, and seven were carried out without NM administration. The dose of NM in the NM group was significantly higher than that in the non-NM group (P = 0.040). No significant differences were observed between the two groups in the inlet NM concentration, the outlet NM concentration, or the rate of IL-18 removal. No statistical correlation was observed between the IL-18 level and the NM dose, the inlet NM concentration, or the outlet NM concentration. There was no blood access difficulty such as catheter failure or clotting of the filter. Thus, it might be possible to carry out PE and CHDF with the series-parallel method without administration of NM in the CHDF circuit.

Effectiveness of combining plasma exchange and continuous hemodiafiltration in patients with postoperative liver failure

Nine patients with postoperative liver failure were treated with plasma exchange (PE) or PE and continuous hemodiafiltration (CHDF), and various biochemical parameters were determined before and after treatment. Although citrate levels increased significantly after treatment compared with pretreatment levels in both the PE group and the PE + CHDF group (P < 0.0001 and P < 0.0001, respectively), the percentage of the increase in citrate levels was significantly higher in the PE group than in the PE + CHDF group (P = 0.0051). Total bilirubin (T-Bil) levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0001, respectively). There were no significant differences in T-Bil levels between the two groups (P = 0.5181). There were no significant differences in interleukin (IL)-6 levels before and after treatment in both the PE and PE + CHDF groups (P = 0.1281 and P = 0.2273, respectively). IL-18 levels were significantly lower after treatment in both the PE and PE + CHDF groups (P < 0.0001 and P = 0.0002, respectively), but there were no significant differences in the removal rate of IL-18 in both the PE and PE + CHDF groups (P = 0.8749). These results indicate that combining PE and CHDF in a series-parallel circuit is an effective modality for suppressing the elevation of blood citrate levels. This finding may have important implications for the development of an effective treatment for patients with postoperative liver failure.

Correlation Between Serum Nafamostat Mesilate and Activated Coagulation Time During Continuous Hemodiafiltration

We analyzed the relationship between nafamostat mesilate (NM) level and activated coagulation time (ACT) as measured using an Actalyke MINI system vs. an ACTester system in patients with fulminant hepatitis undergoing continuous hemodiafiltration. The hemofilter was made with a polyacrylonitrile membrane, and NM was used as the anticoagulant. Significant correlation was found between the NM dose and the prehemofilter ACT measured by the Actalyke MINI system (r = 0.561, P = 0.0352, n = 14). However, no significant correlation was found between the NM dose and the prehemofilter ACT measured by the ACTester. Neither was a significant correlation found between the prehemofilter NM level and the prehemofilter ACT measured by either system. No significant correlation was found between the NM dose and the posthemofilter ACT measured by either system. The ACTester uses a test tube containing celite and a small amount of kaolin as a coagulation activator. The results of the present study suggest that the ACTester can adsorb NM and that this feature can affect ACT measurement. Considering this influence and the need to minimize the dose of NM in patients with fulminant hepatitis to avoid hemorrhagic tendencies, it is advisable to use the Actalyke MINI system.