PowerPoint-Präsentation - PCRRT

Continuous Veno-Venous `Single Pass Albumin Haemodiafiltration (SPAD) in Acute Liver Failure (ALF) in Childhood H. I. G. Ringe, V.Varnholt, M. Zimmering*,W. Luck**, I.. M.Sauer *** Pediatric Interdisciplinary Intensive Care Unit * Department of Pediatric Nephrology, ** Department Pediatric Gastroenterology,*** Department of Experimental Transplant Surgery Charit Campus Virchow Berlin Germany Albumin dialysis membrane 50 K Da Continuous Veno- Venous Single Pass Albumin Haemodiafiltration ( SPAD) Roler pump 1 Substitute 330m l/h Roler pump 2 Albumin 20% . 70 ml/h Substitute pump Highfluxfilter Blood pump Substitute 400ml/h Filtrate pum p W aste 800ml/h Substitute Albumin 20% Roler pump Subsitute pump Blood pump

Patient Sex Age years Body weight Kg Diagnosis D f 3 18 ALF, pyrrolizidine alkaloid like intoxication, aplastic anaemia B f 7 24 Amanita poisoning R m 12 58 ALF unknown origin H f 5

16 post re- LTX failure of the donated organ unsuitable for Re-Transplantation m 11 52 Valproate intoxication, hepatitis A, kidney failure, LTX failure, haemodialysis K m 12 60 Streptococcal -A -septicaemia, CPR, MOF, haemodialysis, HFO M1+2 m 6 22 M . Wilson crisis, kidney failure, haemolysis F f 14 61 ALF unknown origin Indication for SPAD and LTX Patient

INR >4 Bilirubin >20 mg/dl Others Encephalopathy grade (14) D yes yes NH3 3 B yes no NH3 3-4 R yes yes - 2-3 H no yes 2nd LTx unsuitable for re-LTX

1-2 3-4 K no yes yes CVVH for hepato-renal-failure no MOF CVVH elemination of endotoxin and TNF- etc 1-2 1 M1+2 3,6 + >4 yes NH3, Wilson crisis haemolysis, M2 post -tx hepatorenal failure F 2,5 yes NH3 intubated sedated paralized Goals Reduction of toxins Laboratory results: bilirubin, bile-acid, NH3 Encephalopathy score

Blood pressure stabilisation Recovery of liver function : Laboratory results: fibrinogen, PTZ Cytokines ? Side effects Platelet count Cytokines (IL2-Receptor, IL6, IL 8, IL 10, TNF-, LPS BP) Clinical data mg/dl mol/l Bilirubin, bile acid and NH3 mean serum levels pre, 12 and 24 hours post SPAD 206 150 105 100 87 79 54 50 22 14 0 0 mean bilirubin mg/dl 12 mean bile acid mol/l 17

11 24 hours mean NH3 mol/l MAP during SPAD MAP mm Hg 120 100 80 60 40 20 0 -1 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15

16 17 Hours before and during SPAD D K H R B M1 M2 F Median Fibrinogen during SPAD 450 SPAD ceased 400 H D* R* K B M1* M2* F Fibrinogen mg/dl 350 300 250 200

150 100 * = FFP 6 hourly 50 0 0 12 24 36 48 60 72 96 108 120 132 SPAD duration hours Pro-thrombine time (PTZ ) under SPAD PTZ % 80 *=FFP 6 hourly SPAD ceased H 70 D* 60 50 R*

40 K 30 B 20 M1* 10 M2* F 0 0 12 24 36 48 60 72 96 SPAD duration hours 108 120 132 Platelets under SPAD Platelets /nl SPAD 250 425 ceased

H D* 200 R* K 150 B M1* 100 M2* F 50 * = FFP 6 hourly 0 0 12 24 36 48 60 72 96 SPAD duration hours 108 120 132 Follow up in auxiliary transplantation

Patient D Patient B Patient Hepatic Encephalopathy Grade pre/post SPAD Length of SPAD SPAD bridge Outcome D 3 / 2 51 hours yes - auxilary LTX successful, SAA BMT 6 month later, GVHD died B 3-4 / 2-3 18 hours yes ++ auxillary LTX, own liver recovered, alive R 2-3 / 1 36 hours yes + LTX, alive

H 1-2 / 0 3-4 / 3-4 2 hours no Bioreactor, Re- LTX,aspergillus septicaemia, died K intubated sedated paralized 35 hours yes - treatment withdrawal, brain death 24 hours continuous 3 yes/ no Re-LTX days 4-11 hours /d Organ recovered, alive M1+2 1-2/1-2 15/42 hours Yes -/ Yes- LTX and Re-LTX , Aspergillus septicaemia, brain haemorrhage, died F 1/0

20 hours yes + successfully bridged to LTX , alive Serum [email protected] pg/ml during 24 hour SPAD and urine plus SPAD extraction g/kg/min and SPAD clearance ml/min 1,73m 2(n=3) 44 40 35 28 30 25 25 19 24 20 15 13 17 17 14 5 5 10 5 0 6 10 14 15

13 9 9 13 11 1 pg/kg/min ml / pg/ml F min 1,73 pg/ml pg/kg/min M1 ml / min 1,73 pg/kg/min ml / pg/ml min 1,73 D Serum 0 hours Serum 12 hours Serum 24 hours Urine SPAD 0- 6 hours

SPAD 6-12 hours SPAD 12-24 hours Clearnace TNF-a IL 6 serum levels pg/ml during 24 hour SPAD and urine and SPAD clearance ml/min/1,73 m 2(n=3) 1,000 848 254 296 100 128 64 68 10 18 14 24 7 1 2 pg/ml 0 0 ml/min/1,73 F Serum 0 hours pg/ml Serum 12 hours ml/min/1,73

M1 Serum 24 hours pg/ml ml/min/1,73 D Urine SPAD Serum IL-8 pg/ml during 24 hour SPAD and urine plus SPAD extraction g/kg/min and SPAD clearance ml/min 1,73m 2 (n=2) ml/min 1.73 pg/kg/min pg/ml Serum pg/ml 10,000 Serum pg/ml 3223 1392 1393 Serum pg/ml 415 1,000 110 67 100 48 19 10 26 25 25 C l

15 e a r a n c e C l e a r a n c e 58 4 4 7 3 SPAD pg/kg/min SPAD pg/kg/min SPAD pg/kg/min SPAD Clearance ml/min 1.73m2 Urine pg/kg/min Urine pg/kg/min 1 0 12 24h 6 12 24 h Patient F 6 12 24 h

0 12 24h 6 12 24 h Patient M1 Urine pg/kg/min Serum PCT and PTH pg/ml during 24 hour SPAD and their urine and SPAD extraction pg/kg/hour 221 261 100 95 90 80 85 70 60 66 50 40 30 20 10 14 13.0 18 0.2 6 0 PCT pg/ml Serum 0 hours

pg/kg/min Serum 12 hours PTH pg/ml Serum 24 hours pg/kg/in Urine Dialysate TNF alpha, IL2-Receptor and IL 6 serum levels during SPAD and urine- and SPAD-clearance ml/min/1,73 m2 10,000 Serum 0 hours Serum 12 hours Serum 24 hours Urine SPAD 3128 2811 2667 1,000 254296 100 24 10 1 25 14 17 2 18 2 2 0 TNF-a pg/ml ml/min/KO

IL 2 R IU/ml ml/min /KO 1 IL 6 pg/ml ml/min/KO Cytokine serum levels during SPAD and urineand SPAD-clearance ml/min 1,73m 2 136 60 50 56 54 48 46 45 40 26 30 19 17 20 9.7 10 IL 8 pg/ml ml/min KO Serum 0 hours 6 0 0.3 0 0 7 IL 10 pg/ml ml/min KO Serum 12 hours LPS b P g/ml ml/min KO

Serum 24 hours Urine SPAD Costs: SPAD versus MARS S P A D HA 20% Filter 2-4 L/d 1 Filter 235- 470 Euro 43 Euro Bag production 2 Bags 20 Euro Substitute solution 9-18 L/d 21- 42 Euro SPAD Sum/d 338 574 Euro MARS system M A R S 8 hours effective

HA 20% MARS 2 Adsorbers 1 Filter 600 ml Sum / d 1840 Euro 70 Euro 1910 Euro Conclusion SPAD : - lowers effectively bilirubin, bile acids und ammonium in ALF - reduces hepatic encephalopathy - is well tolerated in case of SPAD System pre-filling even in a catecholamine dependant patient - stabilizes children prior to LTX and is helpful for bridging to transplantation. Conclusion Side effects Allergic reaction to human albumin Thrombocytopenia (HIT) Unclear Whether SPAD can replace liver function until liver recovery appears Role of cytokine reduction / stimulation Definition of criteria to distinguish between those who recover or not is needed (Cytokines, Coagulation, HE ?) SPAD is easy to set up and cheaper than MARS

Recently Viewed Presentations

  • Annual state and local government accounting update - What's ...

    Annual state and local government accounting update - What's ...

    DEFINITION OF A LEASE. ... If restatement for prior periods is not practicable, the cumulative effect, if any, of applying this Statement should be reported as a restatement of beginning net position (for the earliest period restated.
  • Iran

    Iran

    Import financing (raw materials, intermediary and capital goods) From bank's own resources. From foreign bank credit lines. Investments. Iranian investments abroad. Mobilizing foreign resources. Under doc credits with tenors of up to one year.
  • Course Introduction Classroom Expectations, Grading, Home Page, GradebookWizard.com,

    Course Introduction Classroom Expectations, Grading, Home Page, GradebookWizard.com,

    Course Introduction Classroom Expectations, Grading, Home Page, GradebookWizard.com, Course Overview
  • Jukebox Active Learning - University of Arizona

    Jukebox Active Learning - University of Arizona

    Software Challenges Specifications may be incomplete Software product is expected to be used for a long time Ever more complex systems, high expectations Requirements change We don't know what the customer wants The customers don't know what they want One...
  • MS Algebra A-REI-1 - helpmeteach.weebly.com

    MS Algebra A-REI-1 - helpmeteach.weebly.com

    MS Algebra A-REI-1 - Ch. 3.2Properties of Equality & Multiple Step Problems. Mr. Deyo. ... Kim has a job where she makes . $8 per hour plus tips. Yesterday, Kim made. $53, including $13 from tips. How many hours did...
  • Measuring What Matters -- CTC's New Approach to Measuring PR ...

    Measuring What Matters -- CTC's New Approach to Measuring PR ...

    Highlight sweet spot, put a pic of Prince William and Kate in center. then grow the center. Could we do visuals in the circles? or is that too busy? Where do I start? Is a question I get frequently, and...
  • Finance Pkg No Gra - HELOA

    Finance Pkg No Gra - HELOA

    THE STUDENT FINANCE INFORMATION TEAM. i. Provide training, updates CPD opportunities for staff and practitioners. Assist in providing student finance updates at appropriate events (parents) Signposting to a range of free resources. Student finance mailing list (East of England specific)...
  • Lottery Update - Institute of Fundraising Insight Group

    Lottery Update - Institute of Fundraising Insight Group

    About Marie Curie Cancer Care. Marie Curie Hospices. Marie Curie has nine hospices. It is the largest provider of hospice beds outside the NHS. Marie Curie Hospices provide care for patients with cancer and other illnesses and provide support for...