Replacement Therapy in Acute Liver Failure

Abstract

Acute liver failure is generally a fatal disease, although mortality is highly dependent on etiology. Renal failure is a common complication in patients with severe liver disease, and may be due to pre-renal causes, acute tubular necrosis, hepatorenal syndrome and chronic renal disease associated with the underlying chronic liver disease. Orthotopic Liver Transplantation (OLTx) has become the accepted treatment of choice for patients with advanced liver disease; dialytic treatment may be useful in treating renal complication, and to gain time either for liver regeneration or for the acquisition of a donor liver. Among the natural toxic causes of ALF, Amanita Phalloides poisoning (APP) is one of the most frequent. Managing patients suffering from APP may be very challenging; furthermore, treatment must be started in time to be effective. In this study we report our experience on replacement therapy in ALF due to APP.

We retrospectively evaluated 6 patients suffering from APP and hospitalized within our Intensive Care Unit, by assessing different kinds of treatment: two different dialytic techniques, namely Continuous Renal Replacement Therapy (CRRT) and Charcoal Plasmaperfusion-(CPP), and Orthotopic Liver Transplantation (OLTx).

Three patients treated with CRRT+CPP, one patient treated with CRRT only, and the patient treated with OLTx recovered. One patient, undergoing CRRT only, died after 14 days of treatment. During the CRRT+CPP treatment no relevant complication occurred. The transplanted patient received dialytic treatment for 17 days after transplantation, in order to support renal function impairment and to favor liver function recovery.

In conclusion, we can say that the clinical management of patients suffering from APP requires a multiple disciplinary intervention, therefore it is recommended to treat these patients in a specialized dialysis department in collaboration with an organ transplantation team. In the near future we wish to associate to dialytic treatment with a bioartificial liver device, which could bridge the time to liver transplantation.