title: Management of sepsis during MARS treatment in acute on chronic liver failure.
abstract: BACKGROUND
  The aim of our study was a 30-day follow-up of the use of early detection of endotoxin by the endotoxin activity assay (EAA) for patients with acute liver failure superimposed on chronic liver disease (AoCLF) and treated with polymyxin-B hemoperfusion-based (PMX-DHP) treatment and albumin dialysis in the molecular adsorbent recirculating system (MARS).
  
  
  METHODS
  From February 2008 to July 2010, we evaluated 10 AoCLF patients experiencing systemic inflammatory response syndrome (SIRS) in association with suspected infection and an EAA-positive test (>0.60). These patients awaiting liver transplantation (OLT) showed similar Model End-Stage Liver Disease (MELD) scores (range, 19-25) and encephalopathy grade ≤ 2. Five patients received therapy to remove endotoxins with PMX-DHP with MARS treatment for liver failure (group A); the other 5 patients received MARS treatment only (group B).
  
  
  RESULTS
  Two PMX-DHP treatments were performed in 4 group A patients (average EA=0.66 [range, 0.61-0.70]) and 3 treatments for 1 patient (EA=0.92). All 5 subjects underwent an average of 4 MARS treatments (range, 3-5). At the end of therapy, the median EA level was 0.42 (range, 0.37-0.48). As reported in the literature, we achieved a significant improvement in liver and kidney functions using MARS. Measurements of lactate, interleukin (IL)-6, and tumor necrosis factor (TNF)-α were significantly improved among patients treated with the extracorporeal therapies. At 30 days of observation, all 5 patients treated with MARS plus PMX-DHP are alive. In group B, a mean of 7.5 MRAS treatments were performed. We observed an improvement in hemodynamic and liver functions with reduced levels of proinflammatory cytokines and lactates in 4 patients. One patient showed no improvement in clinical status with the development of sepsis and subsequent multiorgan failure after 24 days.
  
  
  CONCLUSIONS
  The possibility of an early diagnosis using the EAA in AoCLF patients could prevent the progression of the sepsis cascade. The use of PMX-DHP and MARS in these patients, could lead to resolution of clinical status in a short time.
authors.affiliation: Dipartimento P. Stefanini, Chirurgia Generale e Trapianti d'Organo, Sapienza Università di Roma, Rome, Italy. novelligilnardo@virgilio.it
authors.forename: G
authors.initials: G
authors.lastname: Novelli
authors.forename: V
authors.initials: V
authors.lastname: Morabito
authors.forename: F
authors.initials: F
authors.lastname: Pugliese
authors.forename: G
authors.initials: G
authors.lastname: Ferretti
authors.forename: S
authors.initials: S
authors.lastname: Novelli
authors.forename: S
authors.initials: S
authors.lastname: Ianni
authors.forename: Q
authors.initials: Q
authors.lastname: Lai
authors.forename: M
authors.initials: M
authors.lastname: Rossi
authors.forename: P B
authors.initials: PB
authors.lastname: Berloco
mesh_terms: D000328:Adult; D000418:Albumins / Q000008:administration & dosage* / Q000009:adverse effects; D000900:Anti-Bacterial Agents / Q000008:administration & dosage* / Q000009:adverse effects; D015415:Biomarkers / Q000097:blood; D002908:Chronic Disease; D004731:Endotoxins / Q000097:blood; D005112:Extracorporeal Circulation / Q000009:adverse effects; D005260:Female; D006464:Hemoperfusion / Q000009:adverse effects; D006801:Humans; D007558:Italy; D008107:Liver Diseases / Q000097:blood / Q000150:complications / Q000628:therapy*; D017114:Liver Failure, Acute / Q000097:blood / Q000209:etiology / Q000628:therapy*; D008297:Male; D008875:Middle Aged; D011112:Polymyxin B / Q000008:administration & dosage* / Q000009:adverse effects; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D018805:Sepsis / Q000097:blood / Q000209:etiology / Q000382:microbiology / Q000628:therapy*; D018746:Systemic Inflammatory Response Syndrome / Q000097:blood / Q000209:etiology / Q000382:microbiology / Q000628:therapy*; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000418:Albumins; D000900:Anti-Bacterial Agents; D015415:Biomarkers; D004731:Endotoxins; D011112:Polymyxin B