Abstract
In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver’s excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.
Highlights
Licensee MDPI, Basel, Switzerland.In critically ill patients, liver dysfunction potentially results in coagulopathy and encephalopathy and is associated with high mortality [1,2]
Direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels
Bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in sclerosing cholangitis in critically ill patients (SSC-CIP) following extracorporeal membrane oxygenation (ECMO) therapy and severe COVID-19
Summary
Secondary sclerosing cholangitis (SSC) has been observed after hypoxic liver injury, and in critically ill patients (SSC-CIP) requiring extracorporeal membrane oxygenation (ECMO) therapy [7]. Liver support systems include therapeutic plasma exchange, which has been shown to improve outcomes but may lead to hypotension and increased bleeding risk [14,15,16,17]. Another approach is albumin dialysis, as described with molecular adsorbent recirculating system (MARS) or advanced organ support (ADVOS) [18,19,20]. We describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP following ECMO therapy and coronavirus disease 2019 (COVID-19)
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