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Ocak I. Value of extracorporeal artificial liver support in pediatric acute liver failure: A single-center experience of over 10 years. Front Pediatr 2023; 11:979619. [PMID: 36861080 PMCID: PMC9968919 DOI: 10.3389/fped.2023.979619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 01/19/2023] [Indexed: 02/15/2023] Open
Abstract
PURPOSE Acute liver failure (ALF) is a life-threatening disease characterized by rapid-onset liver dysfunction, coagulopathy, and encephalopathy in patients without chronic liver disease. Today, the combined application of continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PEX), which are forms of supportive extracorporeal therapy (SECT), with conventional liver therapy in ALF is recommended. This study aims to retrospectively analyze the effects of combined SECT in pediatric patients with ALF. MATERIALS AND METHODS We retrospectively analyzed 42 pediatric patients, followed in the liver transplantation intensive care unit. The patients had ALF and received PEX supportive therapy with combined CVVHDF. The biochemical lab values of the results for the patients before the first combined SECT and after the last combined SECT were analyzed comparatively. RESULTS Of the pediatric patients included in our study, 20 were girls and 22 were boys. Liver transplantation was performed in 22 patients, and 20 patients recovered without transplantation. After the discontinuation of combined SECT, all patients had significantly lower serum liver function test results (total bilirubin, alanine transaminase, aspartate transaminase), ammonia, and prothrombin time/international normalized ratio levels than the previous levels (p < 0.01). Hemodynamic parameters (i.e., mean arterial pressure) also improved significantly. DISCUSSION AND CONCLUSION Combined CVVHDF and PEX treatment significantly improved biochemical parameters and clinical findings, including encephalopathy, in pediatric patients with ALF. PEX therapy combined with CVVHDF is a proper supportive therapy for bridging or recovery.
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Affiliation(s)
- Ilhan Ocak
- Department of Liver Transplant Intensive Care Unit, Memorial Sisli Hospital, Şişli, Turkey
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Ryu LN, Hwang S, Ha S. Therapeutic plasma exchange as an effective salvage measure for post-hepatectomy hepatic failure: A case report. Ann Hepatobiliary Pancreat Surg 2021; 25:270-275. [PMID: 34053931 PMCID: PMC8180401 DOI: 10.14701/ahbps.2021.25.2.270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 11/17/2022] Open
Abstract
Major hepatectomy can result in post-hepatectomy hepatic failure (PHHF) and therapeutic plasma exchange (TPE) can be used as a salvage procedure for liver support. We herein present a case of 69-year-old male patient with perihilar cholangiocarcinoma who was successfully managed with salvage TPE. Preoperative portal embolization was performed to reduce the parenchymal resection rate. The extent of surgery was right hepatectomy with partial excision of the ventral portion of the segment IV, caudate lobectomy, bile duct resection and extensive lymph node dissection. No noticeable surgical complications occurred after the operation, but serum total bilirubin level increased gradually and reached 10 mg/dl at 1 month after the operation. At postoperative day 38, total bilirubin level raised to 19.8 mg/dl and prothrombin time deteriorated significantly, thus salvage TPE was started. TPE was performed three times per week for 2 weeks; consequently, the total bilirubin level was maintained below 10 mg/dl. A few days later, a rebound of total bilirubin occurred; accordingly, 2 sessions of TPE were performed additionally. Overall, a total of 8 sessions of TPE were performed. The patient was discharged at 84 days after operation. The total bilirubin level returned to normal at 5 months after operation. This patient is doing well for past 9 months. In Korea, TPE for liver support has been approved by the social health insurance since August 2020. In conclusion, salvage TPE is an effective liver support measure for PHHF, thus we suggest starting TPE if serum total bilirubin level reaches 10 mg/dl after hepatectomy.
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Affiliation(s)
- Lee Na Ryu
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suhyeon Ha
- Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Ocak İ, Topaloğlu S, Acarli K. Posthepatectomy liver failure. Turk J Med Sci 2020; 50:1491-1503. [PMID: 32718126 PMCID: PMC7605090 DOI: 10.3906/sag-2006-31] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/26/2020] [Indexed: 01/02/2023] Open
Abstract
Liver surgery is one of the most complex surgical interventions with high risk and potential for complications. Posthepatectomy liver failure (PHLF) is a serious complication of liver surgery that occurs in about 10% of patients undergoing major liver surgery. It is the main source of morbidity and mortality. Appropriate surgical techniques and intensive care management are important in preventing PHLF. Early start of the liver support systems is very important for the PHLF patient to recover, survive, or be ready for a liver transplant. Nonbiological and biological liver support systems should be used in PHLF to prepare for treatment or organ transplantation. The definition of the state, underlying pathophysiology and treatment strategies will be reviewed here.
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Affiliation(s)
- İlhan Ocak
- Department of Critical Care Unit, İstanbul Memorial Hospital, İstanbul, Turkey
| | - Serdar Topaloğlu
- Department of Surgery, School of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Koray Acarli
- Department of Organ Transplantation, Department of Surgery, İstanbul Memorial Hospital, İstanbul, Turkey
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Abstract
Extracorporeal liver support systems (ELSS), encompassing artificial and bioartificial devices, have been used for decades, with the aim of supporting patients with acute liver failure and acute-on chronic liver failure, as a bridge to recovery (acute liver failure only) or liver transplantation, in an era of organ donation shortage. Although biochemical efficacy has been consistently demonstrated by these devices, translation into clinical and survival benefits has been unclear, due to study limitations and lack of reliable prognostic scoring in liver failure. Consequently, extracorporeal devices are not widely accepted as routine therapy in adult liver failure. Recent large multicentre trials using artificial liver systems have not revealed beneficial outcomes associated with albumin dialysis but plasma exchange practices have shown some potential. In paediatric liver failure, data on extracorporeal systems is scarce, comprising few reports on albumin dialysis (namely, Molecular Adsorbent Recirculating System; MARS) and plasma exchange. When extrapolating data from adult studies differences in disease presentation, aetiology, prognosis and the suitability, and safety of such devices in children must be considered. The aim of this review is to critically appraise current practices of extracorporeal liver support systems to help determine efficacy in paediatric liver failure.
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Stenbøg P, Busk T, Larsen FS. Efficacy of liver assisting in patients with hepatic encephalopathy with special focus on plasma exchange. Metab Brain Dis 2013; 28:333-5. [PMID: 23572273 DOI: 10.1007/s11011-013-9403-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2013] [Accepted: 03/13/2013] [Indexed: 11/24/2022]
Abstract
Severe liver injury result in development of hepatic encephalopathy (HE) and often also in brain edema that is a potentially fatal complication. HE and brain edema are correlated to the level and persistence of hyperammonemia and the presence of systemic inflammation. Treatment of HE and brain edema is based on restoring and keeping normal physiological variables including tonicity, blood gasses, lactate, temperature and vascular resistance by a wide variety of interventions. In addition liver support devices improve the stage of HE, cerebral metabolic rate for oxygen and glucose, and are used either as a bridge to liver transplantation or liver recovery in patients with fulminant hepatic failure and in patients with acute-on-chronic liver failure. This short review will mainly focus on the management and efficacy of doing plasma exchange on HE in patients with acute HE.
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Affiliation(s)
- Poul Stenbøg
- Department of Hepatology, A-2121, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Role of plasmapheresis as liver support for early graft dysfunction following adult living donor liver transplantation. Transplant Proc 2012; 44:749-51. [PMID: 22483485 DOI: 10.1016/j.transproceed.2012.01.054] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Severe early graft dysfunction has been occasionally encountered following adult living donor liver transplantation (LDLT). We have assessed the effectiveness of plasmapheresis (PP) as liver support for LDLT recipients with severe early graft dysfunction. METHODS Of the 789 adult LDLTs performed between January 2007 and December 2009, 50 patients (6.3%) underwent PP as a supportive measure during the first month. RESULTS The mean time from LDLT to start of plasmapheresis was 11.2 ± 6.8 days (range 2-28). The 50 patients underwent 517 sessions of PP, or a mean of 10.3 ± 6.8 sessions per patient, over a mean 21.6 ± 9.4 days. Thirty-four patients (68%) required concurrent hemodiafiltration. Mean serum total bilirubin concentration before PP was 16.2 ± 6.7 mg/dL, peaking at 20.3 ± 7.9 mg/dL during PP, and decreasing to 13.4 ± 5.4 mg/dL 1 week after completion of PP (P < .001 compared with before PP). Except for prothrombin time, no other biochemical parameter was significantly altered by PP. There were no serious complications related to PP. Of the 50 patients, 17 (34%) died soon or a few months after PP. The 6-month graft survival rate after completion of PP was 66%; the overall 1-year patient survival rate was 64.0%. CONCLUSION PP appeared to have beneficial effects for LDLT recipients with severe early graft dysfunction, namely total bilirubin concentrations greater than 10 mg/dL.
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Lee JY, Kim SB, Chang JW, Park SK, Kwon SW, Song KW, Hwang S, Lee SG. Comparison of the molecular adsorbent recirculating system and plasmapheresis for patients with graft dysfunction after liver transplantation. Transplant Proc 2011; 42:2625-30. [PMID: 20832557 DOI: 10.1016/j.transproceed.2010.04.070] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2009] [Revised: 01/04/2010] [Accepted: 04/08/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND Graft dysfunction after liver transplantation (OLT) is a life- threatening condition. Molecular adsorbent recirculating system (MARS) or plasmapheresis (PLP) may be effective supportive therapy of graft dysfunction for patients who cannot undergo retransplantation. The aim of this study was to compare the effects of MARS and PLP in patients with graft dysfunction after OLT. METHODS Between January 2002 and July 2007, 31 OLT recipients who experienced graft dysfunction, defined as hyperbilirubinemia (>10 mg/dL) without bile duct obstruction and/or presence of hepatic encephalopathy, were treated with MARS or PLP. Biochemical and hemodynamic data and survival were compared in MARS and PLP groups. RESULTS Fifteen patients were treated with 41 MARS sessions and 16 with 105 PLP sessions. After a single MARS session, patients showed significant reductions in creatinine, urea nitrogen, bilirubin, and ammonia. After a single PLP session, patients showed significant improvements in prothrombin time, bilirubin, alanine aminotransferase, alkaline phosphatase, and albumin. After the completion of treatment, Both MARS and PLP significantly improved bilirubin values. at 90 days there were no differences in overall survival rates; 53% in MARS versus 56% in PLP. CONCLUSION Both MARS and PLP are alternative supportive treatments for graft dysfunction after OLT.
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Affiliation(s)
- J Y Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan, Seoul, Republic of Korea
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Hwang S, Kwon SW, Park GC, Yu YD, Kim KW, Choi NK, Choi YI, Park PJ, Park GB, Jung DH, Song GW, Moon DB, Ahn CS, Kim KH, Ha TY, Min Y, Hong SK, Kyoung KH, Park JI, Lee SG. Effectiveness of Plasmapheresis as a Liver Support for Graft Dysfunction Following Adult Living Donor Liver Transplantation. ACTA ACUST UNITED AC 2009. [DOI: 10.4285/jkstn.2009.23.3.244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Affiliation(s)
- Shin Hwang
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Seog-Woon Kwon
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Dong Yu
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kwan-Woo Kim
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nam-Kyu Choi
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Il Choi
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Pyung-Jae Park
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geum Borae Park
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - YuSun Min
- Department of Laboratory Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Suk-Kyung Hong
- Department of Surgery, Division of General Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyu-Hyouck Kyoung
- Department of Surgery, Division of General Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jeong-Ik Park
- Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Sung-Gyu Lee
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Abstract
PURPOSE OF REVIEW Acute kidney failure in the perioperative liver transplant recipients results in an increased hospital length of stay, acute rejection, infection rate and overall mortality. Thus, it is of great importance to be able to recognize, prevent and treat kidney injury. RECENT FINDINGS Immediate post liver transplant kidney dysfunction is increased in those with pretransplant kidney failure, hepato-renal syndrome, intraoperative hypotension, intraoperative hypovolemia, aprotinin use and those requiring transfusion of more units of blood products or needing to return to the operating room. SUMMARY To date, avoiding risky clinical situations, maintaining homeostasis and a multidisciplinary approach to care have been reasonable approaches to decrease the incidence of postoperative acute kidney injury.
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Abstract
PURPOSE OF REVIEW Liver support devices are used either as a bridge to liver transplantation or liver recovery in patients with acute or acute-on-chronic liver failure. The review analyzes the recent literature and asks if the current enthusiasm for these devices is justified. RECENT FINDINGS Many liver support devices exist and are discussed. Clinical data on artificial devices are rapidly emerging, especially on the molecular adsorbents recirculating system, and fractionated plasma separation and adsorption (Prometheus). While hepatic encephalopathy is improved by the molecular adsorbents recirculating system and probably Prometheus too, neither system has been shown to improve survival. Less clinical data exist for bioartificial support devices. These may use human hepatocytes, such as the extracorporeal liver assist device, although most devices use porcine hepatocytes, such as HepatAssist. SUMMARY Enthusiasm in liver support devices is justified as many nonrandomized studies have suggested some biochemical and clinical benefits. The results of several ongoing multicenter randomized controlled trials are anxiously awaited. Meanwhile, because mortality without liver transplantation remains high despite the use of liver support devices, these devices should only be used in the research setting or by experts proficient in their use and as a bridge to liver transplantation rather than liver recovery.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
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Hwang S, Ha TY, Ahn CS, Kim KH, Lee SG. Reappraisal of plasmapheresis as a supportive measure in a patient with hepatic failure after major hepatectomy. Case Rep Gastroenterol 2007; 1:162-7. [PMID: 21487563 PMCID: PMC3073805 DOI: 10.1159/000107510] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Major resection of cirrhotic livers can result in hepatic failure, but no supportive treatment has been found to be generally effective. We successfully treated a 63-year-old woman with post-hepatectomy liver failure with plasmapheresis. Following right hepatectomy, the initial postoperative recovery of liver function was favorable, except for ascites. One month later, however, the amount of drained ascites increased up to 2 l/day. In addition, serum cholesterol concentration gradually decreased to around 30 mg/dl, and serum total bilirubin rose to 11.1 mg/dl. Plasmapheresis was performed, and after just 2 sessions, serum cholesterol level was rapidly corrected and prothrombin time was restored. After 3 sessions of plasmapheresis, the usual rebound rise of serum bilirubin disappeared, and the amount of ascites drained also decreased slowly. The patient underwent a total of 5 sessions of plasmapheresis over 2 weeks, after which liver function improved slowly, and she was finally discharged 72 days after liver resection. Mild ascites requiring diuretic therapy persisted over 3 months. She is doing well to date 10 months after liver resection without tumor recurrence or hepatic decompensation. This limited experience suggests that plasmapheresis can be a useful liver support for post-hepatectomy liver failure.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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