Case of the Week 27
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Use of CytoSorb hemoadsorption for the management of acute liver failure
Dr. Vinod Singh | Institute of Critical Care Medicine, Sir Gangaram Hospital, New Delhi, India
07/06/2022
New!Reduction in catecholaminesSafetyImprov. resp functionBilirubinCase of the weekCase reportCritical CareCRRT pre filterImprov. hep. encephalopathyLiver failure
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Summary
CoW 27/2022 – This case reports on a 28-year-old female patient who was referred intubated and ventilated from an intensive care unit (ICU) of another tertiary care hospital to Sir Gangaram Hospital, Delhi, with a confirmed diagnosis of acute liver failure with grade II hepatic encephalopathy and coagulopathy.
Case presentation
Before her initial admission to the peripheral hospital, the patient had a history of fever associated with chills and rigors for 7 days and was also suffering from abdominal pain. She also had a history of taking ayurvedic medicine for jaundice
Following hospitalization at the Sir Gangaram hospital, the patient’s vitals were recorded. Blood pressure and respiratory rate were 120/82 mmHg and 16/min, respectively
Subsequently, she was transferred to the intensive care unit (ICU) with impaired oxygenation and a PaO2/FiO2 ratio of 195 mmHg
Lab investigations showed a total leukocyte count of 13.9×103/µl as well as a platelet count of 67×103/µl. Coagulation tests revealed a grossly elevated International Normalized Ratio (INR) of 4.07
Her liver function tests were markedly abnormal (bilirubin 19.2 mg/dl, serum glutamic-oxaloacetic transaminase (SGOT) 164 U/L, serum glutamic-pyruvic transaminase (SGPT) 140 U/L) indicating pronounced and already established liver failure while she was also suffering from intermittent episodes of altered sensorium
Furthermore, she had elevated serum lactate levels (3.37 mmol/L)
However, serum creatinine level was normal at 1.19 mg/dl and urinary output was 4185 ml/day
The patient’s Glasgow Coma Scale (GCS) score was 6 while Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were 13 and 12, respectively
Model for End-Stage Liver Disease (MELD) score was estimated to be 40
She also exhibited hemodynamic instability requiring norepinephrine support up to 3 µg/min
Abdominal ultrasound examination showed an enlarged liver and a contracted bladder with moderate free fluid in the peritoneal cavity, all signs suggestive of acute liver failure
The decision was made to perform 4 cycles of plasma exchange therapy
Given the patient’s critical condition and in order to accelerate liver toxin removal, but also to control the septic/hyperinflammatory condition, a CytoSorb hemoadsorption cartridge was additionally integrated into the plasma exchange therapy cycle
Rotational thromboelastometry (ROTEM) was used throughout the treatment interval to control for any changes in the coagulatory status. Accordingly, four units of fresh frozen plasma (FFP) and albumin had to be administered over this time
Measurements
Hemodynamics
Liver function
Lactate
Renal function
Respiratory parameters
GCS
SOFA score
Treatment
One CytoSorb therapy session was performed for a duration of 24 hours
The CytoSorb device was run in conjunction with plasma exchange therapy (Prismaflex, Baxter)
Blood flow rate: 150 ml/min
Anticoagulation: none
Results
Mean arterial pressure remained stable during CytoSorb therapy. Norepinephrine could be weaned off 2 hours after CytoSorb therapy completion
Treatment was associated with a rapid and sustained decline in bilirubin plasma levels with a concomitant decrease in liver transaminases
There also was a reduction in serum lactate under hemoadsorption treatment
Renal function improved as evidenced by an increase in urinary output
Lung function/oxygenation remained stable with a PaO2/FiO2 of 198 mmHg
GCS showed a slight improvement
SOFA score could be reduced
Parameters Before CytoSorb therapy After CytoSorb therapy
Mean arterial pressure (mmHg) 90 90
Bilirubin (mg/dL) 19.2 7.97
SGOT (U/L) 140 115
SGPT (U/L) 164 81
Serum lactate (mmol/L) 3.37 2.70
Urinary output (ml/day) 4185 4600
PaO2/FiO2 195 198
GCS Score 6 7
SOFA score 13 12
Patient Follow-Up
On suspecting autoimmune related acute liver failure the patient was put on steroids, and her acute kidney injury was managed conservatively. The patient was extubated as her condition improved and she was transferred to a high-dependency unit
Later, transjugular liver biopsy showed features of chronic venous hepatic congestion, and ultrasound doppler flow axis examination revealed hepatomegaly with bilateral mild pleural effusion and moderate ascites
As the steroids were not showing any effect on the patient’s condition, they were stopped. She was managed with IV antibiotics, anti-hepatic encephalopathy (HE) measures, diuretics, and other supportive measures
The patient’s family was informed about the need for liver transplantation based on above mentioned medical conditions
Patient was referred to a surgical gastroenterologist for evaluation of a liver transplant, and she decided to undergo cadaveric liver transplantation while simultaneously opting for discharge. Hence, she was discharged from hospital after 28 days of hospitalization in a stable condition and advised to follow-up with a liver clinic
Conclusions
In this case of a patient with acute liver failure, CytoSorb hemoadsorption in combination with plasma exchange and standard of care therapy resulted in a stabilization of her liver function including a rapid decrease in plasma bilirubin levels as well as a reduction in serum lactate levels and an overall improvement in the patient’s clinical condition
According to the authors, in this special case CytoSorb contributed towards controlling the hyperinflammation, and it also acted as an effective means of controlling the hyperbilirubinemia
CytoSorb in combination with plasma exchange therapy was safe and easy to apply.
