Authors (including presenting author) :
Kwok PY(1), Lai CK(1)
Affiliation :
(1)Adult Intensive Care Unit, Queen Mary Hospital
Introduction :
Acute liver failure (ALF) is a life-threatening disease associated with sepsis, multiorgan failure, cerebral edema and increased hospital mortality. Recent studies suggested that high-volume plasma exchange (HV-PE) can be used as the first line treatment to increase survival rate of patients with ALF through removal of albumin-bound and water-soluble toxins that leads to multiorgan failure in ALF. This paper aims to share the preliminary experience of a local adult intensive care unit in using HV-PE as a bridging therapy for patients presented with ALF.
Objectives :
1. To enhance the multimodal model of management for patient with ALF.
2. To develop an evidence-based HV-PE protocol that minimizes the risk with the therapy.
3. To facilitate future development of bridging therapy to liver transplantation for patients with ALF.
Methodology :
Ms. Chan was admitted for ALF due to uncertain cause in early September. Her condition worsened with decline in consciousness, so she was transferred to Adult ICU for close monitoring.
HV-PE with 15% of Ms. Chan’s ideal body weight, i.e., approximately 8 liters of plasma was replaced overnight. Citrate toxicity and subsequent hypocalcemia and metabolic alkalosis are common adverse effects in HV-PE particularly in liver failure patients due to high citrate content in plasma replacement fluid and the impaired hepatic metabolism of patients. In order to tackle this, continuous renal replacement therapy (CRRT) was started simultaneously with HV-PE via two separate intravascular accesses to remove citrate gained during HV-PE. Arterial blood gas analysis was performed every 30 minutes to check for any acid-base and electrolyte imbalance and aid treatment adjustment.
Calcium replacement was also started and titrated according to ionized calcium level to prevent hypocalcemia throughout the procedure.
Result & Outcome :
No significant complication was observed during HV-PE in parallel with CRRT. Mild metabolic alkalosis (pH 7.51) was observed after plasma exchange. During HV-PE, hypocalcemia (ionized calcium 0.94mmol/L) was noted and immediately corrected by bolus calcium chloride replacement and subsequent high dose calcium chloride infusion. Hemodynamics was stable all along.
After replacing 8 liters of plasma, improvement in Ms. Chan’s liver function was observed. Her bilirubin dropped from 160 U/Lto 58 U/L, alkaline phosphatase dropped from 141 U/L to 62 U/L, alanine aminotransferase dropped from 1241 U/L to 145 U/L, aspartate aminotransferase dropped from 460 to 60 U/L, and INR improved from 3.8 to 1.2.
Liver transplant workup was undergone overnight. Ms. Chan successfully underwent living donor liver transplantation the next day. Her consciousness fully recovered, and liver function further improved after transplantation.
It is a preliminary experience of HV-PE successfully bridging a patient with ALF to liver transplantation.