38/2016
Use of CytoSorb in decompensated alcoholic steatohepatitis

Dr. Stefan Büttner#, PD Dr. Harald Fanik*, Dr. Benjamin Koch#, Dr. Helge Weiler#, Prof. Christoph Sarrazin*, Prof. Helmut Geiger# University Hospital Frankfurt # Medical Clinic III, Cardiology, Angiology and Nephrology * Medical Clinic I, Gastroenterology and Hepatology

Summary:

This case study reports on a 36-year-old patient (chronic viral hepatitis C, longtime chronic alcohol abuse up to the point of admission to hospital), who was transferred an external hospital with decompensated cirrhosis.

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Case presentation

  • Direct admission of the patient to the intensive care unit with an initial diagnosis of decompensated ethanol toxic liver cirrhosis
  • At this point the patient was hypotonic, tachycardic, in cardiogenic shock, oliguric, with upper gastrointestinal bleeding and a MELD score of 40
  • Development of hepatic encephalopathy
  • Attempt to stabilize the patient using albumin infusion and multiple paracenteses
  • Hepatorenal syndrome due to decompensated cirrhosis and subsequent dialysis dependency
  • Portal vein thrombosis was excluded
  • Consequently the patient was treated for more than a month in the intensive care unit to stabilize the cirrhosis and acute kidney injury
  • During this time, an evaluation as to whether the patient could be listed for a liver transplantation or not was rejected by the Liver Board due to the ongoing alcohol abuse up to the point of admission to ICU
  • Since no transplant option existed, physicians continued therapy with available treatment options. The patient received a steroid therapy with 40 mg per day, however this did not result in any significant improvement
  • Plasma bilirubin concentrations showed a significant increase of up to 24.5 mg/dl, ammonia levels were 130 µg/dl, albumin was 2.4 g/dl
  • In addition, transaminases (GOT 259 U/L, GPT 59 U/L) as well as µGT (352 U/L) were markedly elevated
  • Markers for spontaneous coagulation at this time were also poor with a Quick of 26%, Antithrombin III of 49%, PTT 42, INR 2.87
  • Inflammation markers were: leukocytes 43,000/µl, CRP low at 3.46 mg/dl, and IL-6 42 pg/ml
  • During this phase, the patient received a low-dose norepinephrine infusion (<0.025 µg/kg/min)
  • As a „last resort“ therapy, CytoSorb treatment was also started with the rationale to remove inflammation-triggering factors and liver toxins (bile acids, bilirubin, ammonia) in the context of his systemic inflammatory condition as well as his acute-on-chronic liver failure
  • Subsequent final diagnosis: Liver cirrhosis and alcohol-related steatohepatitis (ASH) with pre-existing hepatitis C infection

Treatment

  • In total two treatments with CytoSorb were carried out, 1st treatment for 6 hours, followed by a treatment pause for 5 days to wait for the therapy effect due to non-existing evidence in this kind of patients, 2nd treatment for 6 hours
  • 1st CytoSorb was performed in conjunction with CRRT (Multifiltrate, Fresenius Medical Care) performed in CVVHDF mode, 2nd treatment was performed in hemoperfusion mode
  • Blood flow rate: 200 ml/min
  • Anticoagulation: heparin
  • CytoSorb adsorber position: pre-hemofilter

Measurements

  • Ammonia (pre/post adsorber)
  • Bilirubin
  • Bile acids (pre/post adsorber)
  • Inflammatory parameters (IL-6, CRP, leucocytes)

Results

  • After the first treatment ammonia reduced to 88 µg/dl. During the 2nd treatment ammonia levels were measured pre and post adsorber: pre-adsorber 89 µg/dl – directly post adsorber 70 µg/dl; two hours later and also during treatment 2 ammonia levels pre-adsorber were 76 µg/dl and directly post adsorber 60 µg/dl, patient significantly improved both during and after the treatment sessions
  • Reduction of bilirubin in the course of the first treatment from 24.5 mg/dl to 16.3 mg/dl after 4 hours (thereafter no further reduction, probably due to saturation of the adsorber), between the 1st and 2nd treatment bilirubin rose to 31.5 mg/dl. During the 2nd treatment session levels reduced again to 25.9 mg/dl within 4 hours
  • Measurement of bile acids pre and post adsorber during the 2nd treatment were as follows:
    pre-adsorber 145 µmol/l – directly post-adsorber 119.7 µmol/l
  • Increase of IL-6 during the first hour of the first treatment to 255.7 pg/ml (suspected catheter-associated infection, however with no subsequent successful pathogen detection), in the further course during the first treatment reduction to 33.5 pg/ml, no more valid measurement performed during 2nd treatment
  • Leucocytes continuously reduced during both treatments to 20,000/µl after the first and 15,000/µl after the second treatment
  • CRP was continuously low between 2-4 mg/dl during both treatment cycles
  • During the first treatment, renal function and thus diuresis improved rapidly, so that CVVH could be discontinued after the first treatment

Patienten Follow-Up

  • Termination of renal replacement therapy directly after the first CytoSorb session with stable diuresis and stable creatinine
  • Patient initial clinical recovering with planned discharge to his home environment due to the lack of a transplant option
  • Subsequent development of a nosocomial pneumonia, after which the patient went into another episode of fulminant pneumogenic sepsis and died on IMC three weeks after the last CytoSorb treatment

CONCLUSIONS

  • CytoSorb represents a good and viable treatment option for patients with alcoholic steatohepatitis (ASH) and may be especially effective in young patients with severe inflammatory response in the context of their ASH
  • CytoSorb worked extremely well and effectively as a liver replacement in this case, hepatic encephalopathy improved significantly due to removal of liver toxins
  • In addition, measurement of pre/post adsorber values indicates that the removal of ammonia and bile acids is directly attributable to the adsorber
  • According to the medical team, the impressive course of the patient has led to the initiation of a specific study project for such patients
  • The installation of the absorber into the CVVH circuit and the application of CytoSorb itself was easy and safe