Predictive criteria for the outcome of patients with acute liver failure treated with the albumin dialysis molecular adsorbent recirculating system.
The aim of this study was to evaluate the improvement of prognostic parameters after treatment with the molecular adsorbent recirculating system (MARS) in patients with fulminant hepatitis (FH). The parameters conducive to a positive prognosis include: Glasgow Coma Scale (GCS) score >/=11, intracranial pressure (ICP) <15 mm Hg or an improvement of the systolic peak flow of 25-32 cm/s via Doppler ultrasound in the middle cerebral artery, lactate level <3 mmol/L, tumor necrosis factor-alpha <20 pg/mL, interleukin (IL)-6 <30 pg/mL, and a change in hemodynamic instability from hyperkinetic to normal kinetic conditions, and so define the timing (and indeed the necessity) of a liver transplant (LTx). From 1999 to 2008 we treated 45 patients with FH with MARS in the intensive care unit of our institution. We analyzed all the parameters that were statistically significant using univariate analysis and considered the patients to be candidates for inclusion in a multivariate logistic regression analysis. Thirty-six patients survived: 21 were bridged to liver transplant (the BLT group) and 15 continued the extracorporeal method until native liver recovery (the NLR group) with a positive resolution of the clinical condition. Nine patients died before transplantation due to multi-organ failure. We stratified the entire population into three different groups according to six risk factors (the percentage reduction of lactate, IL-6 and ICP, systemic vascular resistance index values, GCS <9, and the number of MARS treatments): group A (0-2 risk factors), group B (3-4 risk factors), and group C (5-6 risk factors). Analyzing the prevalence of these parameters, we noted that group A perfectly corresponded to the NLR group, group B corresponded to the BLT group, and group C was composed of patients from the non-survival group; thus, we were able to select the patients who could undergo a LTx using the predictive criteria. For patients with an improvement of neurological status, cytokines, lactate, and hemodynamic parameters, LTx was no longer necessary and their treatment continued with MARS and standard medical therapy.
"Paride Stefanini" Department of General Surgery and Organ Transplantation, La Sapienza University, Rome, Italy.
Gilnardo
G
Novelli
Massimo
M
Rossi
Giancarlo
G
Ferretti
Francesco
F
Pugliese
Franco
F
Ruberto
Quirino
Q
Lai
Simone
S
Novelli
Vincenzo
V
Piemonte
Luca
L
Turchetti
Vincenzo
V
Morabito
Maria C
MC
Annesini
Pasquale B
PB
Berloco
D000328:Adult; D000418:Albumins / Q000008:administration & dosage*; D003422:Critical Care; D016207:Cytokines / Q000378:metabolism; D003956:Dialysis / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D019344:Lactic Acid / Q000378:metabolism; D017114:Liver Failure, Acute / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D016031:Liver Transplantation / Q000379:methods; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012307:Risk Factors; D015996:Survival Rate; D016896:Treatment Outcome; D055815:Young Adult
D000418:Albumins; D016207:Cytokines; D019344:Lactic Acid