Intermittent high‐flux albumin dialysis with continuous venovenous hemodialysis for acute‐on‐chronic liver failure and acute kidney injury

Abstract

Acute‐on‐chronic liver failure (ACLF) requiring intensive medical care and associated with acute kidney injury (AKI) has a mortality rate as high as 90% due to the lack of effective therapies. In this study, we assessed the effects of intermittent high‐flux single‐pass albumin dialysis (SPAD) coupled with continuous venovenous hemodialysis (CVVHD) on 28‐day and 90‐day survival and an array of clinical and laboratory parameters in patients with severe ACLF and renal insufficiency. Sixteen patients were studied. The diagnosis of ACLF and AKI was made in accordance with current EASL Clinical Practice Guidelines, including the recommendations of the International Club of Ascites. All patients received SPAD/CVVHD treatments as the blood purification therapy to support liver, kidneys, and other organs. Five patients were transplanted and 11 were not listed for transplantation because of active alcoholism. Data at the initiation of SPAD/CVVHD were compared with early morning data after the termination of the extracorporeal treatment phase. All patients had ACLF and renal insufficiency with 13/16 additionally fulfilling the AKI criteria. A total of 37 SPAD/CVVHD treatments were performed [2.3 ± 1.4]. The baseline MELD‐Na score was 37.6 ± 6.6 and decreased to 33.4 ± 8.7 after SPAD/CVVHD (P < 0.001). In parallel, the CLIF‐C ACLF grade and OF score, estimated at 28‐ and 90‐day mortality, AKI stage, hepatic encephalopathy grade, and liver function tests were lowered (P = 0.001–0.032). The 28‐ and 90‐day survivals were 56.2% overall and 53.8% in AKI. Survival in patients not transplanted (n = 11) was 45.4%. In patients with severe ACLF and AKI, the renal replacement therapy coupled with high‐performance albumin dialysis improved estimated 28‐ and 90‐day survival and several key clinical and laboratory parameters. It is postulated that these results may be further improved with earlier intervention and more SPAD treatments per patient. High‐performance albumin dialysis improves survival and key clinical and laboratory parameters in severe ACLF and AKI.

Leukocytes, Systemic Inflammation and Immunopathology in Acute-on-Chronic Liver Failure

“…Other therapies based on HSA but alternative to infusions are extracorporeal liver support systems based on albumin dialysis or plasma exchange. This is the case of recent studies showing that patients treated with extracorporeal liver support systems had improved survival [106][107][108].…”

Predicting mortality for hepatorenal syndrome with liver‐specific scores

“…Such scores, as the MELD and CLIF‐SOFA, have also been shown to prognosticate recovery of renal function 59 . If RRT is needed, an intermittent high flux albumin dialysis with continuous venovenous haemodialysis has been shown to be more effective than regular haemodialysis 60 …”

“…59 If RRT is needed, an intermittent high flux albumin dialysis with continuous venovenous haemodialysis has been shown to be more effective than regular haemodialysis. 60 Some studies have shown CLIF-SOFA to be superior to other liver-specific scores in prognostication for cirrhotic patients. [61][62][63] This has been demonstrated for alcoholic cirrhosis, 64 alcoholic hepatitis, 62 for extra-hepatic insults 36,65 and for spontaneous bacterial peritonitis.…”

Continuous renal replacement therapy under special conditions like sepsis, burn, cardiac failure, neurotrauma, and liver failure

“…97 This may have been due to the fixed capacity of the sorbents to remove albuminbound toxins. An alternative approach has been to add albumin to the dialysate in the CRRT circuit, and observational studies using this single-pass albumin dialysis (SPAD) technique have reported improved toxin clearances and bridging patients to transplantation or recovery 98,99 (Figure 7). However, there have been no randomized trials to examine whether SPAD offers an advantage over standard supportive care, and there is the cost of the albumin.…”