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
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
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