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

Summary:

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.

button_EN

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

erg_en

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