Albumin dialysis in cirrhosis with superimposed acute liver injury: A prospective, controlled study

Abstract

Patients with liver cirrhosis and a superimposed acute injury with progressive hyperbilirubinemia have a high mortality. A prospective, controlled study was performed to test whether hyperbilirubinemia, 30-day survival, and encephalopathy would be improved by extracorporeal albumin dialysis (ECAD). Twenty-four patients were studied; 23 patients had cirrhosis; 1 had a prolonged cholestatic drug reaction and was excluded from per protocol (PP) analysis. Patients had a plasma bilirubin greater than 20 mg/dL and had not responded to prior standard medical therapy (SMT). Patients were randomized to receive SMT with ECAD or without (control). ECAD was performed with an extracorporeal device that dialyzes blood in a hollow fiber dialyzer (MW cutoff < 60 kd) against 15% albumin. Albumin-bound molecules transfer to dialysate albumin that is regenerated continuously by passage through a charcoal and anion exchange column and a conventional dialyzer. ECAD was associated with improved 30-day survival (PP, 11 of 12 ECAD, 6 of 11 controls; log rank P <.05). Plasma bile acids and bilirubin decreased on average by 43% and 29%, respectively, in the ECAD group after 1 week of treatment, but not in the control group. Renal dysfunction and hepatic encephalopathy improved in the ECAD group, but worsened significantly in the control group. ECAD was safe, with adverse events being rare and identical in both groups. In conclusion, ECAD appears to be effective and safe for the short-term treatment of patients with cirrhosis and superimposed acute injury associated with progressive hyperbilirubinemia and may be useful for increasing survival in such patients awaiting liver transplantation.

Alterations in the functional capacity of albumin in patients with decompensated cirrhosis is associated with increased mortality†‡§

“…4,[10][11][12] Current hypotheses suggest that the removal of excess protein-bound toxins in the extracorporeal circuit is likely to regenerate the native albumin, thereby enhancing its functional capacity so that it may be able to transport and detoxify more toxins. Contrary to this existing hypothesis, albumin dialysis using MARS did not improve the measured functional capacity of the patient's circulating albumin.…”

“…One such device that is commercially available is the Molecular Adsorbents Recirculating System (MARS) (Gambro, Lund, Sweden) and studies using this device show beneficial pathophysiological and clinical effects particularly in reducing the severity of hepatic encephalopathy with small studies also showing possible survival benefit in liver failure patients. [10][11][12] However, at present, detailed functional characteristics of the different binding sites in cirrhosis have not been determined. The overall aim of this study was to perform a detailed qualitative and quantitative assessment of the functional capacity of albumin in patients with liver disease of varying severities and to determine whether these alterations could be used as a marker of disease severity and prognosis.…”

Extracorporeal liver support

“…52 Of note, the presence of renal failure requiring dialysis was specifically excluded in this study. Because the investigators used the trend of bilirubin (which is outcome specific in alcoholic hepatitis only) as a "surrogate marker," the study also excluded patients who responded to conventional therapy, indicated by a spontaneous decrease of bilirubin, implementing a 3-5 days long "pre-phase" prior to enrollment.…”

Molecular adsorbent recirculating system in patients with early allograft dysfunction after liver transplantation: A pilot study

“…7,8 In addition, improved outcome has been demonstrated in patients with hepatorenal syndrome and acute-on-chronic liver failure. 9, 10 The aim of this study was to assess the safety, efficacy, and feasibility of MARS treatment in patients with EAD after OLT.…”