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Kounis I, Sacleux SC, Ordan MA, André S, Boudon M, Coilly A, Sobesky R, De Martin E, Samuel D, Ichaï P, Saliba F. Efficiency and safety of total plasma exchange in critically ill cirrhotic patients with acute on chronic liver failure: A pilot study. Clin Res Hepatol Gastroenterol 2023; 47:102206. [PMID: 37714512 DOI: 10.1016/j.clinre.2023.102206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/26/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND AND AIMS Treatment of patients with acute on chronic liver failure (ACLF) admitted to the ICU is very limited. The aim of this pilot study was to evaluate the efficiency on liver function and safety of therapeutic plasma exchange (TPE) in critically ill cirrhotic patients admitted with ACLF in a liver ICU. METHODS This is a prospective cohort of patients with ACLF grade > 2 treated by TPE admitted to the ICU that was matched to a control group. TPE was performed using a plasma filter (TPE2000, BAXTER®) on a CRRT machine (Prismaflex®, Baxter®). Ratio and type of fluid replacement were 50 % with 5 % albumin solution followed by 50 % with fresh frozen plasma. RESULTS Seven patients with a mean age of 50.6 ± 7.8 years (all males) and 14 controls matched to age, sex, etiology and cause of decompensation were recruited. At ICU admission, mean MELD score was 39.1 ± 2.7, mean SOFA score was 11.6 ± 5.2 and mean CLIF SOFA score was 12.9 ± 2.6. The grade of ACLF was 3 for 3 patients (42.9 %) and 2 for 4 patients (57.1 %). The TPE group had significantly higher levels of bilirubin (392.3 ± 117.1μmol/l vs. 219 ± 185μmol/l , p = 0.04), and INR values (5.7 ± 3.4 vs. 3.5 ± 0.9, p < 0.005) compared to the control group. Patient survival was respectively 28.6 % and 14.3 % at 30 and 90 days in the TPE group and 35.7 % and 7.14 % in the control group respectively (HR: 1 (95 % CI 0.19- 5.2; p = 1). One patient in the TPE group had a liver transplantation 13 days after admission to ICU and is still alive and none in the control group. Two (28.6 %) patients died from complications related to the double lumen catheter used for TPE. CONCLUSION This pilot study of TPE in patients with ACLF grade 2 and 3 showed a marked but transient improvement in liver function tests. TPE worth to be evaluated in large trials in ACLF patients, with a liver transplant project, and less organ failure.
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Affiliation(s)
- Ilias Kounis
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Sophie Caroline Sacleux
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Marie Amelie Ordan
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France
| | - Stéphane André
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France
| | - Marc Boudon
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Rodolphe Sobesky
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Philippe Ichaï
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Faouzi Saliba
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France.
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Agarwal B, Cañizares RB, Saliba F, Ballester MP, Tomescu DR, Martin D, Stadlbauer V, Wright G, Sheikh M, Morgan C, Alzola C, Lavin P, Green D, Kumar R, Sacleux SC, Schilcher G, Koball S, Tudor A, Minten J, Domenech G, Aragones JJ, Oettl K, Paar M, Waterstradt K, Bode-Boger SM, Ibáñez-Samaniego L, Gander A, Ramos C, Chivu A, Stange J, Lamprecht G, Sanchez M, Mookerjee RP, Davenport A, Davies N, Pavesi M, Andreola F, Albillos A, Cordingley J, Schmidt H, Carbonell-Asins JA, Arroyo V, Fernandez J, Mitzner S, Jalan R. Randomized, controlled clinical trial of the DIALIVE liver dialysis device versus standard of care in patients with acute-on- chronic liver failure. J Hepatol 2023; 79:79-92. [PMID: 37268222 DOI: 10.1016/j.jhep.2023.03.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/01/2023] [Accepted: 03/07/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterized by severe systemic inflammation, multi-organ failure and high mortality rates. Its treatment is an urgent unmet need. DIALIVE is a novel liver dialysis device that aims to exchange dysfunctional albumin and remove damage- and pathogen-associated molecular patterns. This first-in-man randomized-controlled trial was performed with the primary aim of assessing the safety of DIALIVE in patients with ACLF, with secondary aims of evaluating its clinical effects, device performance and effect on pathophysiologically relevant biomarkers. METHODS Thirty-two patients with alcohol-related ACLF were included. Patients were treated with DIALIVE for up to 5 days and end points were assessed at Day 10. Safety was assessed in all patients (n = 32). The secondary aims were assessed in a pre-specified subgroup that had at least three treatment sessions with DIALIVE (n = 30). RESULTS There were no significant differences in 28-day mortality or occurrence of serious adverse events between the groups. Significant reduction in the severity of endotoxemia and improvement in albumin function was observed in the DIALIVE group, which translated into a significant reduction in the CLIF-C (Chronic Liver Failure consortium) organ failure (p = 0.018) and CLIF-C ACLF scores (p = 0.042) at Day 10. Time to resolution of ACLF was significantly faster in DIALIVE group (p = 0.036). Biomarkers of systemic inflammation such as IL-8 (p = 0.006), cell death [cytokeratin-18: M30 (p = 0.005) and M65 (p = 0.029)], endothelial function [asymmetric dimethylarginine (p = 0.002)] and, ligands for Toll-like receptor 4 (p = 0.030) and inflammasome (p = 0.002) improved significantly in the DIALIVE group. CONCLUSIONS These data indicate that DIALIVE appears to be safe and impacts positively on prognostic scores and pathophysiologically relevant biomarkers in patients with ACLF. Larger, adequately powered studies are warranted to further confirm its safety and efficacy. IMPACT AND IMPLICATIONS This is the first-in-man clinical trial which tested DIALIVE, a novel liver dialysis device for the treatment of cirrhosis and acute-on-chronic liver failure, a condition associated with severe inflammation, organ failures and a high risk of death. The study met the primary endpoint, confirming the safety of the DIALIVE system. Additionally, DIALIVE reduced inflammation and improved clinical parameters. However, it did not reduce mortality in this small study and further larger clinical trials are required to re-confirm its safety and to evaluate efficacy. CLINICAL TRIAL NUMBER NCT03065699.
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Affiliation(s)
- Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK; Institute for Liver & Digestive Health, University College London, London, UK
| | - Rafael Bañares Cañizares
- Department of Gastroenterology and Hepatology, Gregorio Marañón General University Hospital, Spain; Health Research Institute Gregorio Marañón, Department of Medicine Complutense University of Madrid, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM unit N° 1193, Université Paris-Saclay, France
| | - Maria Pilar Ballester
- INCLIVA Biomedical Research Institute, Hospital Clínico Universitario de Valencia, Spain; Digestive Disease Department, Hospital Clínico Universitario de Valencia, Spain
| | - Dana Rodica Tomescu
- Carol Davila University of Medicine and Pharmacy, Romania; Fundeni Clinical Institute Bucharest, Romania
| | - Daniel Martin
- Peninsula Medical School, University of Plymouth, UK
| | - Vanessa Stadlbauer
- Department of Internal Medicine, Division of Gastroenterology und Hepatology, Medical University of Graz, Austria
| | - Gavin Wright
- Basildon and Thurrock University Hospital, Mid and South Essex NHS Foundation Trust, Basildon, UK
| | - Mohammed Sheikh
- Institute for Liver & Digestive Health, University College London, London, UK
| | | | | | - Phillip Lavin
- Boston Biostatistics Research Foundation, Inc, Framingham MA, USA
| | | | | | - Sophie Caroline Sacleux
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM unit N° 1193, Université Paris-Saclay, France
| | - Gernot Schilcher
- Department of Internal Medicine, Division of Gastroenterology und Hepatology, Medical University of Graz, Austria
| | | | | | | | - Gema Domenech
- Medical Statistics Core Facility IDIBAPS - Hospital Clinic, Barcelona, USA
| | - Juan Jose Aragones
- Medical Statistics Core Facility IDIBAPS - Hospital Clinic, Barcelona, USA
| | - Karl Oettl
- Division of Medicinal Chemistry, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Margret Paar
- Division of Medicinal Chemistry, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | | | | | - Luis Ibáñez-Samaniego
- Department of Gastroenterology and Hepatology, Gregorio Marañón General University Hospital, Spain; Health Research Institute Gregorio Marañón, Department of Medicine Complutense University of Madrid, Spain
| | - Amir Gander
- Tissue Access for Patient Benefit, Royal Free Hospital, UK
| | - Carolina Ramos
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, United Kingdom
| | - Alexandru Chivu
- Department of Surgical Biotechnology, Division of Surgery and Interventional Science, University College London, United Kingdom
| | - Jan Stange
- University Hospital Rostock, Germany; Fraunhofer IZI, Germany
| | - Georg Lamprecht
- Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock University, Medical Center, Rostock, Germany
| | | | | | - Andrew Davenport
- Institute for Liver & Digestive Health, University College London, London, UK
| | - Nathan Davies
- Institute for Liver & Digestive Health, University College London, London, UK
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, USA
| | - Fausto Andreola
- Institute for Liver & Digestive Health, University College London, London, UK
| | - Agustin Albillos
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain; Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain; Universidad de Alcalá, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS)
| | - Jeremy Cordingley
- Perioperative Medicine - Critical Care, St. Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Hartmut Schmidt
- Department of Gastroenterology, Hepatology and Transplant Medicine, University Hospital Essen, 45147 Essen, Germany
| | | | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, USA
| | | | - Steffen Mitzner
- Fraunhofer IZI, Germany; Department of Medicine II, Division of Gastroenterology and Endocrinology, Rostock University, Medical Center, Rostock, Germany
| | - Rajiv Jalan
- Institute for Liver & Digestive Health, University College London, London, UK; European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, USA.
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Catano J, Sacleux SC, Gornet JM, Camus M, Bigé N, Saliba F, Azoulay E, Dumas G, Zafrani L. Gastrointestinal bleeding in critically ill immunocompromised patients. Ann Intensive Care 2021; 11:130. [PMID: 34420114 PMCID: PMC8380218 DOI: 10.1186/s13613-021-00913-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Acute gastrointestinal bleeding (GIB) may be a severe condition in immunocompromised patients and may require intensive care unit (ICU) admission. We aimed to describe the clinical spectrum of critically ill immunocompromised patients with GIB and identify risk factors associated with mortality and severe GIB defined by hemorrhagic shock, hyperlactatemia and/or the transfusion of more than 5 red blood cells units. Finally, we compared this cohort with a control population of non-immunocompromised admitted in ICU for GIB. RESULTS Retrospective study in 3 centers including immunocompromised patients with GIB admitted in ICU from January, 1st 2010 to December, 31rd 2019. Risk factors for mortality and severe GIB were assessed by logistic regression. Immunocompromised patients were matched with a control group of patients admitted in ICU with GIB. A total of 292 patients were analyzed in the study, including 141 immunocompromised patients (compared to a control group of 151 patients). Among immunocompromised patients, upper GIB was more frequent (73%) than lower GIB (27%). By multivariate analysis, severe GIB was associated with male gender (OR 4.48, CI95% 1.75-11.42, p = 0.00), upper GIB (OR 2.88, CI95% 1.11-7.46, p = 0.03) and digestive malignant infiltration (OR 5.85, CI95% 1.45-23.56, p = 0.01). Conversely, proton pump inhibitor treatment before hospitalization was significantly associated with decreased risk of severe GIB (OR 0.25, IC95% 0.10-0.65, p < 0.01). Fifty-four patients (38%) died within 90 days. By multivariate analysis, mortality was associated with hemorrhagic shock (OR 2.91, IC95% 1.33-6.38, p = 0 .01), upper GIB (OR 4.33, CI95% 1.50-12.47, p = 0.01), and long-term corticosteroid therapy before admission (OR 2.98, CI95% 1.32-6.71, p = 0.01). Albuminemia (per 5 g/l increase) was associated with lower mortality (OR 0.54, IC95% 0.35-0.84, p = 0.01). After matching with a control group of non-immunocompromised patients, severity of bleeding was increased in immunocompromised patients, but mortality was not different between the 2 groups. CONCLUSION Mortality is high in immunocompromised patients with GIB in ICU, especially in patients receiving long term corticosteroids. Mortality of GIB is not different from mortality of non-immunocompromised patients in ICU. The prophylactic administration of proton pump inhibitors should be considered in this population.
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Affiliation(s)
- Jennifer Catano
- Intensive Care Unit, Saint-Louis Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France
| | - Sophie Caroline Sacleux
- Intensive Care Unit, Paul Brousse Hospital, INSERM N°1193, Assistance Publique Des Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Jean-Marc Gornet
- Gastroenterology Department, Saint-Louis Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France
| | - Marine Camus
- Department of Digestive Endoscopy, Saint-Antoine Hospital, Sorbonne Université, INSERM, Centre de Recherche Saint-Antoine and Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Naike Bigé
- Intensive Care Unit, Saint-Antoine Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France
| | - Faouzi Saliba
- Intensive Care Unit, Paul Brousse Hospital, INSERM N°1193, Assistance Publique Des Hôpitaux de Paris, Université Paris-Saclay, Villejuif, France
| | - Elie Azoulay
- Intensive Care Unit, Saint-Louis Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France
| | - Guillaume Dumas
- Intensive Care Unit, Saint-Louis Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France
| | - Lara Zafrani
- Intensive Care Unit, Saint-Louis Hospital, Assistance Publique Des Hôpitaux de Paris, Paris, France.
- INSERM UMR976, Paris University, Paris, France.
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