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Acute liver failure is a serious consequence of hepatocyte injury that occurs abruptly and can develop within days or weeks with a poor prognosis. Clinically, it manifests as encephalopathy, jaundice, and coagulopathy. Severe hepatocellular injury may affect the detoxification function, resulting in the elevation of ammonia, bilirubin, and bile acids, thereby increasing the risk of death in patients.
We present a clinical case of a patient with acute liver failure, encephalopathy, and hyperbilirubinemia treated with sequential extracorporeal support.
A 56-year-old male was admitted to ICU following a Whipple's surgery, during which intraoperative biopsy revealed pancreatic adenocarcinoma. Two days after surgery, nephrology was called for an 8-hour of anuria. The patient demonstrated jaundice, elevated creatinine, transaminases, and hyperbilirubinemia of 14.8 mg/dL, mostly direct bilirubin. Subsequently, the patient's evolution was torpid with an instable hemodynamic status, higher bilirubin levels, and anuria, leading to the initiation of renal support therapy with CRRT in CVVHDF with a dose of 30 ml/kg/h without anticoagulation due to TPT value and thrombocytopenia. However, after 24 hours of therapy initiation, the total bilirubin worsened to 16 mg/dL, which prompted the decision to start support therapy with SPAD (Single Pass Albumin Dialysis). Despite receiving one dose of SPAD, the patient's total bilirubin remained elevated at 19.8 mg/dL. Molecular Absorbent Recirculating System (MARS) support therapy was employed for management, resulting in a successful reduction of bilirubin levels to 12 mg/dL. Nevertheless, the patient exhibited deteriorating hemodynamic stability and experienced cardiac and respiratory arrest, failing to respond to resuscitation efforts 48h later.
Conclusions
The treatment of patients with acute liver failure in ICU mainly consists in organ support, with the primary goal of achieving hemodynamic and metabolic homeostasis. However, in severe cases of elevated bilirubin and transaminases, and encephalopathy along with worsening overall status, the use of extracorporeal support therapy is a very useful tool, dependent on the availability of the hospital center. In this patient, we decided to provide SPAD due to its availability. However, due to the persistent elevation of bilirubin and a higher risk of AKI secondary to pigment and crystals, we initiated MARS, considering that at least 33% of patients can fully recover hepatic function and might have curative possibilities.