Case of the week 24/2016
First description of single-pass albumin dialysis combined with cytokine adsorption in liver failure and hemophagocytic syndrome resulting from generalized herpes simplex virus 1 infection
Frimmel S, Schipper J, Henschel J, Tsui TY, Mitzner SR, Koball S. Division of Nephrology, Department of Medicine, Rostock University Medical Center, Rostock, Germany
This case study reports on a 50-year-old immunocompetent woman who was admitted to hospital for acute hepatitis with acute liver failure.
Case presentation
Liver biopsy revealed acute liver cell necrosis due to herpes simplex virus type 1 (HSV-1)
Despite antiviral therapy liver failure progressed and patient was transferred to ICU
Rapid development of MOF with hepatic coma, severe coagulopathy, acute anuric renal failure, respiratory insufficiency and arterial hypotension
Patient was listed for highly urgent liver transplantation
Additional diagnosis of hemophagocytic lymphohistiocytosis (HLH), secondary to HSV-1-infection
Hemodialysis and extracorporeal liver support were initiated using MARS ® -therapy (6 hours 1 st day, 19 hours 2 nd day)
Increasing need for NE and excessively elevated concentrations of inflammatory markers indicated ongoing severe SIRS
Hence extracorporeal therapy was changed to CVVHD with SPAD (12 hours of treatment)
Treatment
One session of CytoSorb treatment was performed with a treatment duration of 20 hours
CytoSorb was integrated in a predialyzer position
Regional anticoagulation was performed using sodium citrate
Measurements
Need for vasopressors
IL-6, bilirubin
Results
IL-6 levels fell from 81059 pg/ml to 17177 pg/ml after 12 hours of treatment
Noradrenaline dosage was reduced to 0.25 µg/kg/min
No further clinical deterioration of the patient
Antiinfective therapy was conducted with Acyclovir, with no reported adaption of dosage during CytoSorb treatment
Reduction of the moderately elevated bilirubin with SPAD + CytoSorb
Patient Follow-Up
Successful OLT on 4th day on ICU
Further improvement after OLT
Conclusions
First report of the combined use of CytoSorb with SPAD in a patient suffering from ALF and probable HLH with severe SIRS listed for liver transplantation
Major results of the intervention were a marked decrease of IL-6, and bilirubin, as well as a reduction of vasopressor need
Treatment was safe and well-tolerated, without any adverse events
Existing liver support technique (MARS ® treatment) had no effect on the reduction of bilirubin
CytoSorb might be a useful tool for patients with acute liver failure and severe hyperinflammatory syndromes
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