Fractionated Plasma Separation and Adsorption Significantly Decreases Intracranial Pressure in Acute Liver Failure: Experimental Study

Ryska, Miroslav; Lasziková, Eva; Pantoflicek, Tomas; Ryska, O; Prazák, J; Koblihová, E

doi:10.1159/000208790

Cited by 19 publications

(9 citation statements)

References 46 publications

(29 reference statements)

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“…The rise in ICP observed in the FPSA group, even if it was significantly less than the ALF group, suggests a multiple causes for the intracranial hypertension associated with ALF [14], which can only be partially ameliorated by the supporting toxin-eliminating method. Our findings support the conclusions of previous studies and confirm the efficacy of toxin elimination in as a treatment for intracranial hypertension in ALF [3] . The most significant difference between the ICP measured in the FPSA and control groups was observed 9 hours after surgery (7 hours after initiation of FPSA therapy).…”

Section: Discussionsupporting

confidence: 93%

“…A variety of approaches may be taken to meet homeostatic needs during the critical period when a donor organ is sought (bridging therapy). Supportive therapy using fractionated plasma separation and adsorption (FPSA) appears to have a beneficial effect on intracranial hypertension [3]. The efficacy of FPSA therapy in treatment of ALF-related brain injury is usually monitored by measuring ICP.…”

Section: Introductionmentioning

confidence: 99%

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Cerebral microdialysis reflects the neuroprotective effect of fractionated plasma separation and adsorption in acute liver failure better and earlier than intracranial pressure: a controlled study in pigs

et al. 2013

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BackgroundCerebral edema is a well-recognized and potentially fatal complication of acute liver failure (ALF). The effectiveness of treatments that address intracranial hypertension is generally assessed by measuring intracranial pressure (ICP). The aim of this study was to determine the role of cerebral microdialysis in monitoring the efficacy of fractionated plasma separation and adsorption (FPSA) treatment for ALF. We hypothesized that in ALF cerebral microdialysis reflects the benefits of FPSA treatment on cerebral edema before ICP.MethodsA surgical resection model of ALF was used in 21 pigs. We measured plasma ammonia concentration, brain concentrations of glucose, lactate, pyruvate, glutamate and glutamine, and ICP. Animals were randomized into three groups: in one group eight animals received 6 hours of FPSA treatment 2 hours after induction of ALF; in another group 10 animals received supportive treatment for ALF only; and in the final group three underwent sham surgery.ResultsThe ICP was significantly higher in the ALF group than in the FPSA group 9 hours after surgery. The lactate/pyruvate (L/P) ratio was significantly lower in the FPSA group than the ALF group 5 hours after surgery, before any significant difference in ICP was detected. Indeed, significant changes in the L/P ratio could be observed within 1 hour of treatment. Glutamine levels were significantly lower in the FPSA group than the ALF group between 6 hours and 10 hours after surgery.ConclusionsBrain lactate/pyruvate ratio and concentration of glutamine measured by cerebral microdialysis reflected the beneficial effects of FPSA treatment on cerebral metabolism more precisely and rapidly than ICP in pigs with fulminant ALF. The role of glutamine as a marker of the efficacy of FPSA treatment for ALF appears promising, but needs further evaluation.

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Section: Discussionsupporting

confidence: 93%

Section: Introductionmentioning

confidence: 99%

Cerebral microdialysis reflects the neuroprotective effect of fractionated plasma separation and adsorption in acute liver failure better and earlier than intracranial pressure: a controlled study in pigs

et al. 2013

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“…These more pronounced effects on cerebral perfusion pressure are supported by elimination of ammonia by Hepa Wash. In the animal studies on MARS and Prometheus [21,22], the intracranial pressure was significantly reduced, though no significant elimination of ammonia was found. The lower levels of intracranial pressure in our ALF model compared with the other models and the resultant difficulty in showing significant differences may explain the different results.…”

Section: Discussionmentioning

confidence: 99%

Evaluation of the Hepa Wash®treatment in pigs with acute liver failure

et al. 2013

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BackgroundMortality of patients with acute liver failure (ALF) is still unacceptably high. Available liver support systems are still of limited success at improving survival. A new type of albumin dialysis, the Hepa Wash® system, was newly introduced. We evaluated the new liver support system as well as the Molecular Adsorbent Recycling System (MARS) in an ischemic porcine model of ALF.MethodsIn the first study animals were randomly allocated to control (n=5) and Hepa Wash (n=6) groups. In a further pilot study, two animals were treated with the MARS-system. All animals received the same medical and surgical procedures. An intraparenchymal intracranial pressure was inserted. Hemodynamic monitoring and goal-directed fluid therapy using the PiCCO system was done. Animals underwent functional end-to-side portacaval shunt and ligation of hepatic arteries. Treatment with albumin dialysis was started after fall of cerebral perfusion pressure to 45 mmHg and continued for 8 h.ResultsAll animals in the Hepa Wash group survived the 13-hour observation period, except for one that died after stopping treatment. Four of the control animals died within this period (p=0.03). Hepa Wash significantly reduced impairment of cerebral perfusion pressure (23±2 vs. 10±3 mmHg, p=0.006) and mean arterial pressure (37±1 vs. 24±2 mmHg, p=0.006) but had no effect on intracranial pressure (14±1 vs. 15±1 mmHg, p=0.72). Hepa Wash also enhanced cardiac index (4.94±0.32 vs. 3.36±0.25 l/min/m2, p=0.006) and renal function (urine production, 1850 ± 570 vs. 420 ± 180 ml, p=0.045) and eliminated water soluble (creatinine, 1.3±0.2 vs. 3.2±0.3 mg/dl, p=0.01; ammonia 562±124 vs. 1382±92 μg/dl, p=0.006) and protein-bound toxins (nitrate/nitrite 5.54±1.57 vs. 49.82±13.27 μmol/l, p=0.01). No adverse events that could be attributed to the Hepa Wash treatment were observed.ConclusionsHepa Wash was a safe procedure and improved multiorgan system failure in pigs with ALF. The survival benefit could be the result of ameliorating different organ functions in association with the detoxification capacity of water soluble and protein-bound toxins.

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“…Animal studies have demonstrated a decrease in intracranial pressure after treatment with FPSA [14]. A favorable shift in the amino acid profile toward branched chain amino acids, reduction in plasma ammonia levels and oxygen saturation of jugular venous bulb blood (SjVO 2 ) have also been reported [15,16].…”

Section: Hepatic Encephalopathy In Aclfmentioning

confidence: 98%

Liver dialysis in acute-on-chronic liver failure: current and future perspectives

et al. 2014

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Patients with acute-on-chronic liver failure (ACLF) are known to have a very high mortality rate as the majority of these patients succumb to multiorgan failure. Liver transplant remains the only option for these patients; however, there are problems with its availability, cost and also the complications and side effects associated with immunosuppression. Unlike advanced decompensated liver disease, there is a potential for hepatic regeneration and recovery in patients with ACLF. A liver support system, cell or non-cell based, logically is likely to provide temporary functional support until the donor liver becomes available or the failing liver survives the onslaught of the acute insult and spontaneously regenerates. Understanding the pathogenesis of liver failure and regeneration is essential to define the needs for a support system. Removal of hepatotoxic metabolites and inhibitors of hepatic regeneration by liver dialysis, a non-cell-based hepatic support, could help to provide a suitable microenvironment and support the failing liver. The current systems, i.e., MARS and Prometheus, have failed to show survival benefits in patients with ACLF based on which newer devices with improved functionality are currently under development. However, larger randomized trials are needed to prove whether these devices can enable restoration of the complex dysregulated immune system and impact organ failure and mortality in these patients.

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Fractionated Plasma Separation and Adsorption Significantly Decreases Intracranial Pressure in Acute Liver Failure: Experimental Study

Cited by 19 publications

References 46 publications

Cerebral microdialysis reflects the neuroprotective effect of fractionated plasma separation and adsorption in acute liver failure better and earlier than intracranial pressure: a controlled study in pigs

Cerebral microdialysis reflects the neuroprotective effect of fractionated plasma separation and adsorption in acute liver failure better and earlier than intracranial pressure: a controlled study in pigs

Evaluation of the Hepa Wash®treatment in pigs with acute liver failure

Liver dialysis in acute-on-chronic liver failure: current and future perspectives

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