Case of the week 45/2016
Use of CytoSorb in ethyltoxic liver failure and hepatic encephalopathy
Dr. Enrico Klömich#, Dr. Lukas Lindner#, Dr. Matthias Schellner*, Dr. Frank Fröhlich# # Clinic for Anesthesiology and Intensive Care Medicine * Clinic for Internal Medicine DRK Hospital Chemnitz-Rabenstein
This case study reports on a 62-year-old male patient (previous medical history of liver cirrhosis Child-Pugh B, arterial hypertension, long-term alcohol abuse with previous withdrawal attempts), who was admitted to hospital via emergency ambulance with suspected ethyltoxic liver failure.
Case presentation
Admission to the internal ward
2 days later transfered to the intensive care unit due to the development of hepatic encephalopathy (ammonia 229 µmol/l) as well as extremely high bilirubin values (> 600 µmol/l), parameters of cholesetasis and transaminases (GGT 4620 U/l, ALT 89 U/l, AST 332 U/l)
Spontaneous breathing with adequate gas exchange
Normal coagulation parameters
Kidney function also normal: spontaneous diuresis 1800 ml/6h
Patient catecholamine-free at all times
No antibiotic therapy necessary
Initiation of a liver supportive co-medication: L-ornithine-L-aspartate 3x 5g daily, human albumin (20%)
3×50 ml daily, vitamin B1 1x 100 mg daily as a short infusion, ACC 2x 300 mg daily, additional subcutaneous anticoagulation with Fondaparinux 1x 2.5 mg daily
Initial care with Central Venous Catheter, arterial catheter and Shaldon-catheter
A combination treatment with CVVH and CytoSorb was commenced 6 hours after transfer to ICU with the rationale to avoid kidney failure and to relieve the liver
Treatment
In total seven treatments with CytoSorb were run (treatments 24 hours each)
CytoSorb was used in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHD mode
Blood flow rate: 100-120 ml/min
Anticoagulation: citrate
CytoSorb adsorber position: pre-hemofilter
Measurements
Ammonia
Markers of cholestasis and liver failure (ALT, AST, GGT, total bilirubin)
Inflammatory parameters (CRP)
Results
CRP continuously low between 20-30 mg/l during all treatment cycles
Patient Follow-Up
On the 5th day in ICU, X-ray diagnosis confirmed pneumonic infiltrates, which could however be well controlled with a course of Rocephin 1x 2g daily as a short infusion
Termination of renal replacement therapy together with the last CytoSorb treatment followed by a 2-day polydiuretic phase
Intensive care for another 2 days
Transfer to internal ward
3 days later transfer to a peripheral facility for extended alcohol withdrawal
Significant reduction in hepatic encephalopathy, patient was more alert, hemodynamically stable and with sufficient spontaneous diuresis
CONCLUSIONS
Rapid and clear reduction in hepatic encephalopathy using CytoSorb therapy
Combined CVVH/CytoSorb therapy resulted in a significant decrease in bilirubin and a concomitant decrease in the parameters of cholestasis as well as in transaminases, which is a clear sign of recovery in hepatic function
After cessation of CVVH/CytoSorb therapy, bilirubin levels increased, however ALT, AST and GGT remained low and further decreased also suggesting the recovery of liver integrity
CytoSorb represents a good and practicable treatment option for patients with high levels of ammonia and bilirubin in order to facilitate relief and ultimately regeneration of the liver (function)
According to the medical team and since the treatment of this patient, the use of CytoSorb is now being considered in patients with developing or already manifest liver failure
There was no clotting of the system over the entire treatment period
Treatment with CytoSorb was safe and easy to apply
