Septic shock after liver transplantation successfully treated with endotoxin and cytokine adsorption continuous renal replacement therapy: a case report and literature review

Endotoxins and cytokines play an important role in multiple organ failure pathogenesis in patients with severe Gram-negative bacterial infection. We present a clinical case where an oXiris hemofilter was used for continuous renal replacement therapy (CRRT) treatment in a patient with septic shock after liver transplantation. A 35-year-old man with a 20-year history of hepatitis B presented with jaundice, loss of appetite, and decreased urine output. He was diagnosed with decompensated cirrhosis with acute-on-chronic liver failure, and liver transplantation was indicated. The day after surgery, he developed hyperthermia, hypotension, anuria, and a progressive increase in blood inflammatory markers and creatinine. Combined with the donor source and blood culture results, septic shock after transplantation was considered. The patient was immediately treated with endotoxin and cytokine adsorption CRRT (oXiris hemofilter) with tigecycline, caspofungin, and ganciclovir as anti-infectives. After 48 hours on CRRT, his blood pressure gradually stabilized, the CLIF Consortium Acute-on-Chronic Liver Failure score decreased from 63 to 43. Procalcitonin, endotoxin, and the inflammatory factors interleukin (IL)-6 and IL-10 also decreased gradually. The patient’s liver and kidney functions were completely restored. Our experience suggests that oXiris CRRT combined with antibacterial therapy is an effective treatment for septic shock after liver transplantation.

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The Potential Benefits of Renal Replacement Therapy in Combination with a Hemadsorption Column in Critically Ill Patients with Acute on Chronic Liver Failure

10.21203/rs.3.rs-54770/v1 ◽

2020 ◽

Author(s):

Tomescu Dana ◽

Mihai Popescu ◽

Gheorghe Liliana ◽

Iacob Speranța ◽

Dima Simona ◽

...

Keyword(s):

Liver Transplantation ◽

Renal Replacement Therapy ◽

Liver Failure ◽

Replacement Therapy ◽

Chronic Liver ◽

C Reactive Protein ◽

Chronic Liver Failure ◽

Reactive Protein ◽

Main Adverse Effect ◽

Registration Number

Abstract Background. Acute on chronic liver failure (AoCLF) represents a life-threatening complication of liver cirrhosis with high mortality if patients cannot be bridged to emergency liver transplantation. The aim of this study was to assess clinical and paraclinical effects of renal replacement therapy (RRT) in combination with a hemadsorption column in patients with AoCLF. Methods. Patients were included in the study after Intensive Care Unit (ICU) admission and RRT in combination with CytoSorb® was started for three consecutive sessions. Clinical and paraclinical data were recorded before the first session and after the end of the third session. 28-days mortality was also noted. Results. Fourteen patients were included in the final data analysis. The use of CytoSorb® was associated with a decrease in bilirubin levels (p = 0.03) and creatinine (p = 0.02) and an increase in urine output (p = 0.02). Although we observed a significant decrease in platelet count (p = 0.05), no haemorrhagic complications were noted. C-Reactive Protein significantly decreased after the therapy (p = 0.05), but we did not observe a similar decrease in leucocyte count (p = 0.87) or procalcitonin levels (p = 0.18). Seven patients underwent emergency liver transplantation and survival was 100% in this group. Conclusion. The use of CytoSorb® was associated with an improvement in liver and renal functions and a decrease in C - Reactive Protein. Thrombocytopenia represents the main adverse effect of the therapy, but no haemorrhagic complications were recorded. In patients that could be bridged to liver transplantation, survival was 100%. Trial registration number: NCT04511507

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Voriconazole Pharmacokinetics Are Not Altered in Critically Ill Patients with Acute-on-Chronic Liver Failure and Continuous Renal Replacement Therapy: An Observational Study

Microorganisms ◽

10.3390/microorganisms9102087 ◽

2021 ◽

Vol 9 (10) ◽

pp. 2087

Author(s):

Jörn Grensemann ◽

Christoph Pfaffendorf ◽

Sebastian G. Wicha ◽

Christina König ◽

Kevin Roedl ◽

...

Keyword(s):

Steady State ◽

Renal Replacement Therapy ◽

Liver Failure ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Chronic Liver ◽

Therapeutic Drug ◽

Chronic Liver Failure

Infection and sepsis are a main cause of acute-on-chronic liver failure (ACLF). Besides bacteria, molds play a role. Voriconazole (VRC) is recommended but its pharmacokinetics (PK) may be altered by ACLF. Because ACLF patients often suffer from concomitant acute renal failure, we studied the PK of VRC in patients receiving continuous renal replacement therapy (RRT) with ACLF and compared it to PK of VRC in critically ill patients with RRT without concomitant liver failure (NLF). In this prospective cohort study, patients received weight-based VRC. Pre- and post-dialysis membrane, and dialysate samples obtained at different time points were analyzed by high-performance liquid chromatography. An integrated dialysis pharmacometric model was used to model the available PK data. The recommended, 50% lower, and 50% higher doses were analyzed by Monte-Carlo simulation (MCS) for day 1 and at steady-state with a target trough concentration (TC) of 0.5–3mg/L. Fifteen patients were included in this study. Of these, 6 patients suffered from ACLF. A two-compartment model with linear clearance described VRC PK. No difference for central (V1) or peripheral (V2) volumes of distribution or clearance could be demonstrated between the groups. V1 was 80.6L (95% confidence interval: 62.6–104) and V2 106L (65–166) with a body clearance of 4.7L/h (2.87–7.81) and RRT clearance of 1.46L/h (1.29–1.64). MCS showed TC below/within/above target of 10/74/16% on day 1 and 9/39/52% at steady-state for the recommended dose. A 50% lower dose resulted in 26/72/1% (day 1) and 17/64/19% at steady-state and 7/57/37% and 7/27/67% for a 50% higher dose. VRC pharmacokinetics are not significantly influenced by ACLF in critically ill patients who receive RRT. Maintenance dose should be adjusted in both groups. Due to the high interindividual variability, therapeutic drug monitoring seems inevitable.

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