Advanced support of Acute Liver Injury
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Advanced support of Acute Liver Injury
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From CodaZero Live, Alex Rowell reviews the available advanced liver supports for patients with acute liver failure. Artificial supports for the liver are quite complex and difficult. This is largely due to the liver's complex function. Some of the advanced liver supports include CVVHDF, Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and high volume plasma exchange. In this podcast, Alex takes us through the research and evidence for these supports and shares some guidance on when they should be used. CVVHDF is familiar and effective but we need to remember to use it early with acute liver failure patients. Furthermore, Molecular Adsorbent Recirculating System (MARS) is widely studied but unfortunately not available in all places. Single Pass Albumin Dialysis (SPAD) is easily implemented. Although there is less evidence on SPAD, it is generally agreed to be an effective support. Unfortunately, there are no mortality benefits in any of these supports. They are however, useful tools in bridging to transplant. From #CodaZero tune in to a quick, sharp & informative talk by Alex Rowell on Acute Liver Injury.
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Advanced support of Acute Liver Injury
- ADVANCED SUPPORT IN ACUTE LIVER FAILURE Alexandra Rowell Intensivist Sir Charles Gairdner Hospital, Perth WA
- OUTLINE • Advanced liver supports • CVVHDF • MARS • SPAD • Plasmaphoresis
- ACUTE LIVER FAILURE • Acute liver injury • Encephalopathy • Impaired synthetic function • No pre-existing liver disease
- ROLE OF THE LIVER • Synthesis • Heat production • Detoxification • Regulation
- CVVHDF • Instituted early in ALF patients • Ammonia clearance, management of acidosis and metabolic abnormalities • Continuous rather than intermittent – avoid fluctuations • Dose • Anticoagulation
- LIVER SUPPORT SYSTEMS • ARTIFICIAL • MARS – molecular adsorbent recirculating system • SPAD – single pass albumin dialysis • Prometheus • SEPET • BIOARTIFICIAL • ELAD – extracorporeal liver assist device • BAL- bioartificial liver • MELS – modular extracorporeal liver support • HYBRID
- MOLECULAR ADSORBENT RECIRCULATING SYSTEM • Developed in 1993 then used clinically since 1999 • CVVHDF • 2-4% albumin dialysis • 3 filter system
- MARS Yet to show true survival benefit RCT - Saliba et al. 2013 - no survival benefit - most only had one treatment Expensive and needs specialist centre
- SINGLE PASS ALBUMIN DIALYSIS
- SPAD • CVVHDF • Standard membrane • 2% albumin dialysate used • Can be done in most units • 1 bottle 20% albumin per hour Image MIMS
- SPAD • As good at clearing bilirubin as MARS • Easier • Optimal dose and concentration unknown • No large studies of SPAD vs SMT
- SPAD VS MARS VS CVVHDF • MARS – more widely studied • SPAD – cheaper depending on concentration • CVVHDF - effective ammonia reduction
- HIGH VOLUME PLASMA EXCHANGE • Rationale: removal of cytokines from plasma, attenuates innate immune activation which decreases multiorgan dysfunction • RCT 2016 (Larson et al.) : • 3 days of high volume plasma exchange • Improved survival in patients who don’t receive a transplant • Review in 2020 (Tan et. al.): improved survival in ALF and ACLF
- SUMMARY • CRRT is familiar/ relatively easy • MARS most widely studied and useful in centres that are familiar with it • SPAD can be done easily, less evidence • No mortality benefit for any but fairly safe for bridging to transplant • Plasma exchange – mortality benefit in non-transplant candidates, use early
- THANKYOU