Successful elimination of bilirubin in critically ill patients with acute liver dysfunction using a cytokine adsorber and albumin dialysis: a pilot study

Scharf, Christina; Liebchen, Uwe; Paal, Michael; Becker-Pennrich, Andrea; Irlbeck, Michael; Zöller, Michael; Schroeder, Ines

doi:10.1038/s41598-021-89712-4

Cited by 41 publications

(41 citation statements)

References 38 publications

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“…Our results show that hemoadsorption effectively removes bilirubin from the blood, which has only been shown by a few studies with small sample size or on retrospectively collected data [ 21 , 22 , 23 ]. The mean serum bilirubin level was 12 mg/dL, which corresponds to the highest score (+4) in the SOFA score system, indicating that, in most patients, hyperbilirubinemia was present.…”

Section: Discussionmentioning

confidence: 58%

Hemoadsorption in ‘Liver Indication’—Analysis of 109 Patients’ Data from the CytoSorb International Registry

Ocskay

Tomescu

Faltlhauser

et al. 2021

JCM

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Background: Our aim is to report the results of the ‘liver indication’ subset of patients in the CytoSorb International Registry. Methods: Structured data were recorded. Treatment characteristics and changes from T1 (start of hemoadsorption) to T2 (termination) were evaluated with a special focus on bilirubin, C-reactive protein, procalcitonin, interleukin-6, platelet levels, SOFA scores, mortality, and subjective assessment by the attending physicians. Results: Until January 2021, from the total 1434 patients, 109 (age: 49.2 ± 17.1 years, 57.8% males) received treatment for hyperbilirubinemia. APACHE II-predicted mortality was 49.6 ± 26.8%. In the study, 91% of patients were alive at the termination of hemoadsorption and improvement was observed by the physicians in 75 cases. Overall, 65 (59.6%) patients died in the hospital, and 60 (55.0%) died in the ICU. Patients received a median of two treatments for a median of 43 h (interquartile range: 24–72 h) in total. Serum bilirubin levels reduced significantly to −4.6 (95% CI: −6.329 to −2.8) mg/dL. Thrombocytopenia was reported in four patients as an adverse event. Conclusions: We report the largest case series on hemoadsorption for ‘liver indication’ from the CytoSorb International Registry. The finding of significant bilirubin removal observed in our study could have substantial impact in designing and executing further studies on the effects of hemoadsorption in liver dysfunction, which are certainly warranted.

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Section: Discussionmentioning

confidence: 58%

Hemoadsorption in ‘Liver Indication’—Analysis of 109 Patients’ Data from the CytoSorb International Registry

Ocskay

Tomescu

Faltlhauser

et al. 2021

JCM

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“…However, water-soluble metabolites, including ammonia with 17 kDa, are only removed by high-flux hemodialysis [ 30 , 31 , 32 , 33 , 34 , 35 ]. While the effectiveness of additional hemadsorption to eliminate protein-bound bilirubin and water-soluble ammonia has been described previously in critically ill patients with acute liver failure, treatment efficacy in SSC-CIP has not yet been reported [ 54 , 55 , 56 ]. The pathogenesis of SSC-CIP remains elusive, but current concepts suggest that the primary insult is hypoperfusion of the biliary vasculature.…”

Section: Discussionmentioning

confidence: 99%

“…The main limitation is a case description, and further clinical research is required to strengthen our observations. Moreover, hemadsorption has already been described in the context of acute liver failure [ 54 , 55 , 56 ]. This is particularly relevant since it has been reported that about one-third of patients critically ill with COVID-19 suffer from liver dysfunction associated with high mortality [ 60 ].…”

Section: Discussionmentioning

confidence: 99%

Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19

et al. 2021

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In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver’s excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.

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“…Table 3. Indications (para-) clinical criteria for the use of the CytoSorb ® adsorber modified from [66,69]. Hemoadsorption with CytoSorb ® requires an extracorporeal circuit, e.g., in the context of CRRT, ECMO or as a standalone procedure in the context of hemoperfusion.…”

Section: Indicationsmentioning

confidence: 99%

“…CytoSorb ® therapy may be a simple, user-friendly alternative to bridge to functional recovery or orthotopic liver transplantation [ 93 , 101 ]. Initial clinical trial results appear positive [ 69 ].…”

Section: Hemoadsorption With Cytosorb ®mentioning

confidence: 99%

Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb®—Basics, Indications and Perspectives—A Scoping Review

Köhler

Schwier

Praxenthaler

et al. 2021

IJMS

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The “normal” immune response to an insult triggers a highly regulated response determined by the interaction of various immunocompetent cells with pro- and anti-inflammatory cytokines. Under pathologic conditions, the massive elevation of cytokine levels (“cytokine storm”) could not be controlled until the recent development of hemoadsorption devices that are able to extract a variety of different DAMPs, PAMPs, and metabolic products from the blood. CytoSorb® has been approved for adjunctive sepsis therapy since 2011. This review aims to summarize theoretical knowledge, in vitro results, and clinical findings to provide the clinician with pragmatic guidance for daily practice. English-language and peer-reviewed literature identified by a selective literature search in PubMed and published between January 2016 and May 2021 was included. Hemoadsorption can be used successfully as adjunct to a complex therapeutic regimen for various conditions. To the contrary, this nonspecific intervention may potentially worsen patient outcomes in complex immunological processes. CytoSorb® therapy appears to be safe and useful in various diseases (e.g., rhabdomyolysis, liver failure, or intoxications) as well as in septic shock or cytokine release syndrome, although a conclusive assessment of treatment benefit is not possible and no survival benefit has yet been demonstrated in randomized controlled trials.

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Successful elimination of bilirubin in critically ill patients with acute liver dysfunction using a cytokine adsorber and albumin dialysis: a pilot study

Cited by 41 publications

References 38 publications

Hemoadsorption in ‘Liver Indication’—Analysis of 109 Patients’ Data from the CytoSorb International Registry

Hemoadsorption in ‘Liver Indication’—Analysis of 109 Patients’ Data from the CytoSorb International Registry

Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19

Therapeutic Modulation of the Host Defense by Hemoadsorption with CytoSorb®—Basics, Indications and Perspectives—A Scoping Review

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