High-volume plasma exchange in patients with acute liver failure: An open randomised controlled trial

详细信息    查看全文

• 作者：Fin Stolze Larsen¹ ; ^{stolze@post3.tele.dk" class="auth_mail" title="E-mail the corresponding author} ; Lars Ebbe Schmidt¹ ; Christine Bernsmeier² ; Allan Rasmussen³ ; Helena Isoniemi⁴ ; Vishal C. Patel² ; Evangelos Triantafyllou² ; William Bernal² ; Georg Auzinger² ; Debbie Shawcross² ; Martin Eefsen¹ ; Peter Nissen Bjerring¹ ; Jens Otto Clemmesen¹ ; Krister Hockerstedt⁴ ; Hans-Jø ; rgen Frederiksen⁵ ; Bent Adel Hansen¹ ; Charalambos G. Antoniades² ; ⁶ ; ^&dagger ; ; Julia Wendon² ; ^&dagger ;
• 关键词：ALF ; acute liver failure ; ALT ; alanine-aminotransferase ; CI ; confidence interval ; CLIF ; Chronic liver failure consortium ; FiO2 ; fractional inspired oxygen ; HR ; hazard ratio ; ICP ; intracranial pressure ; ITT ; intention to treat ; NH3 ; ammonia ; LPS ; lipopolysaccharide ; PE ; plasma exchange ; RR ; respiratory rate ; IQR ; interquartile range ; SD ; standard deviation ; SMT ; standard medical treatment ; SIRS ; systemic inflammatory response syndrome ; SOFA ; sequential organ failure score
• 刊名：Journal of Hepatology
• 出版年：2016
• 出版时间：January 2016
• 年：2016
• 卷：64
• 期：1
• 页码：69-78
• 全文大小：1153 K

文摘

Acute liver failure (ALF) often results in cardiovascular instability, renal failure, brain oedema and death either due to irreversible shock, cerebral herniation or development of multiple organ failure. High-volume plasma exchange (HVP), defined as exchange of 8–12 or 15% of ideal body weight with fresh frozen plasma in case series improves systemic, cerebral and splanchnic parameters.

Methods

In this prospective, randomised, controlled, multicentre trial we randomly assigned 182 patients with ALF to receive either standard medical therapy (SMT; 90 patients) or SMT plus HVP for three days (92 patients). The baseline characteristics of the groups were similar. The primary endpoint was liver transplantation-free survival during hospital stay. Secondary-endpoints included survival after liver transplantation with or without HVP with intention-to-treat analysis. A proof-of-principle study evaluating the effect of HVP on the immune cell function was also undertaken.

Results

For the entire patient population, overall hospital survival was 58.7% for patients treated with HVP vs. 47.8% for the control group (hazard ratio (HR), with stratification for liver transplantation: 0.56; 95% confidence interval (CI), 0.36–0.86; p = 0.0083). HVP prior to transplantation did not improve survival compared with patients who received SMT alone (CI 0.37 to 3.98; p = 0.75). The incidence of severe adverse events was similar in the two groups. Systemic inflammatory response syndrome (SIRS) and sequential organ failure assessment (SOFA) scores fell in the treated group compared to control group, over the study period (p <0.001).

Conclusions

Treatment with HVP improves outcome in patients with ALF by increasing liver transplant-free survival. This is attributable to attenuation of innate immune activation and amelioration of multi-organ dysfunction.