Treatment of acute liver failure: Could MARS® help?
Dr Faouzi Saliba
Acute liver failure in ICU patients is associated with poor outcomes yet treatment options are limited. Often liver transplantation is the only possibility but many patients will die while waiting for their transplant. As the majority of the endogenous toxins leading to organ failure are bound to albumin, albumin dialysis techniques have been developed in the hope that by removing them, prognosis may improve. Dr Faouzi Saliba presented the results of a new randomized controlled multicenter trial conducted in France comparing one such live support system, MARS, initiated within 12 hours of randomization, with conventional medical treatment in patients with fulminant or subfulminant acute hepatic failure. Importantly, 75% of the study patients underwent transplantation within 24 hours and 90% within 48 hours due to the effective transplantation system in France. Hence, although 110 patients were randomized, 7 patients in the MARS group received a liver transplantation before any MARS therapy was given, and another 7 after only limited MARS. There were no overall differences in 6-month mortality rates between groups. There was a trend to increased survival in the patients treated with MARS who had acute liver failure due to paracetamol/acetaminophen poisoning, and a significantly increased transplant-free survival in patients who underwent 3 or more MARS treatment sessions. Patients in the MARS groups also had significantly improved renal and hepatic function. In a multivariate analysis, treatment with 3 or more MARS sessions was associated with a significantly increased relative risk of 6-month transplant-free survival (RR 6.3, p<0.01).
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Participation at the 29th ISICEM
At this year’s symposium we welcomed
more than 5000 participants from over 78 countries
Which vasopressor?
Dr Daniel De Backer
Vasopressor agents are often needed to restore and maintain a minimum perfusion pressure in patients with circulatory failure. But does it make a difference which vasopressor is used? Several studies have compared dopamine with norepinephrine and Dr Daniel De Backer presented results from an international multicenter study comparing these two agents in 1679 patients with shock. Although there were no significant differences in 28-day mortality between the two groups in the whole population, in patients with cardiogenic shock and in a per protocol analysis excluding patients given open-label norepinephrine, mortality rates were lower in the norepinephrine-treated patients. Severe arrhythmias were also more common in the dopamine-treated patients. The effects of these drugs on the microcirculation may be critical to determining which is best and Dr Jacques Duranteau presented and compared the effects of the different agents on various microcirculatory indices. The use of phenylephrine, vasodilators and intrathoracic pressure regulation in patients with shock was also discussed.
Alongside the standard catecholamine vasopressors, vasopressin has been promoted as an adjunctive therapy enabling lower doses of traditional agents to be used. In a session devoted to vasopressin, Dr Karen Choong presented the results of a new randomized controlled trial of low-dose vasopressin versus placebo in 69 children with vasodilatory shock requiring inotropic support. Although there was a greater increase in mean arterial pressure in patients receiving vasopressin, there were no differences in the primary endpoint, time to vasopressor-free hemodynamic stability, between the two groups. There were also no differences in other morbidity endpoints or in the incidence of adverse events, and there was a trend to increased 30-day mortality rate (30% in the vasopressin group and 16% in the placebo group, p=0.24). Finally, Dr Keith Walley discussed some further results from the VASST study, reporting a significantly lower mortality rate in patients with less severe septic shock. He also presented post-hoc data suggesting beneficial renal effects in the vasopressin-treated patients and a beneficial interaction between vasopressin and corticosteroids. |
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