High-volume continuous veno-venous haemofiltration in hyper-acute liver failure: a pilot study

Background

Once defined clinical criteria are fulfilled in hyper-acute liver failure (ALF) mortality without liver transplantation (OLT) approaches 90%. Patients clinical condition may deteriorate whilst awaiting a graft, such that transplantation becomes impossible due to the rapid progression of multiple organ failure. There is need for therapies that may stabilise the patient and thus provide a 'bridge to transplantation'. Animal studies suggest that high-volume continuous veno-venous haemofiltration (HVF) in septic shock is associated with improvements in haemodynamic stability and a reduction in the requirement for vasopressor support. We report findings of a pilot study of HVF in patients with ALF.

Patients and methods

Eight patients fulfilling transplantation criteria with acetaminophen induced ALF were studied. Median age was 28 years (range 19–51), INR 4.6 (1.9–15), pH 7.23 (7.1–7.42), lactate 9.4 mmol/l (6.7–17) and APACHE II 24 (22–34). Six patients (75%) were receiving vasopressor support with noradrenaline at 0.29 μg/kg/min (0.03–0.5) and all were in anuric renal failure. Five patients were already established on conventional veno-venous filtration. HVF (Baxter system) was commenced 2 days (1–4) after admission using buffer-free dialysate at 4000 ml/h (3500–6000) with concurrent NaHCO₃ infusion and filter surface area 1.25 m² for a median of 34 h (22–72).

Results

HVF resulted in a rapid correction of pH and significant reductions in both serum lactate and base deficit within 24 h. Mean arterial pressure was increased after 6 and 12 h of HVF (P < 0.13) without corresponding increases in vasopressor support (Figure). After 24 h of HVF four (50%) patients required noradrenaline at 1.45 μg/kg/min (0.025–0.4). Two patients underwent OLT and survived, and 1 patient survived without transplantation.

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Conclusions

HVF effectively corrects acidosis in patients with ALF and is associated with improvements in haemodynamic stability. Its use in the support of patients awaiting transplantation deserves further investigation.