HEPATIC REGENERATION WITH COUPLED PLASMAFILTRATION AND ADSORPTION FOR LIVER EXTRACORPOREAL DETOXIFICATION (HERCOLE STUDY)

INTRODUCTION AND AIMS: CPFA (Coupled plasma filtration and adsorption) is currently used in the treatment of severe sepsis with the intention of removing the proinflammatory mediators from the systemic circulation. Some evidence exist about the bilirubin adsorbing ability of the neutral styrenic resin which is part of the extracorporeal circuit of CPFA. The aim of this study is to assess efficacy and safety of CPFA in extracorporeal detoxification of liver toxins in patients affected by acute or acute-onchronic liver failure (Figure 1). METHODS: Twelve patients (age 23 - 73 years) with acute (n ¼ 3) or acute-on-chronic (n ¼ 9) liver failure were enrolled. A total of 31 CPFA treatments were carried out. Each CPFA treatment lasted 6 hours. Unfractionated heparin was used as anticoagulation of the extracorporeal circuit in 19 CPFA sessions; citrate anticoagulation with the concomitant infusion of calcium chloride in 12 CPFA sessions. The number of treatment for each patient was established on his/her clinical status. The reduction ratios per session of bilirubin and bile acids were considered. Hemoglobin, platelets, white blood cells, coagulation tests, urea, creatinine and electrolytes were also checked on starting CPFA and at the end of CPFA, as biocompatibility measures. RESULTS: All sessions were well tolerated by the patients. Alcohol was the most common etiology of the liver injury (n ¼ 9), 1 patient was affected by acute cholangitis and Fisher-Evans syndrome, 1 had a viral etiology, and 1 patient had a postoperative jaundice. Median reduction rate per session for total bilirubin was 28.8% (range 2.2 - 40.5); for direct bilirubin was 32.7 (range 8.3 - 48.9); for indirect bilirubin was 29.5% (range 6.5 - 65.4); for bile acids was 28.9% (16.7 - 59.7); for lactic acid was 30% (range -57.2%- 55.6%). In 10 out of 12 patients was observed a recovery of liver function. At one year of follow-up 2 patients died during the hospitalization; 6 patients are followed like outpatients, recovered their basal liver function and 1 of them is no more in the waiting list for the transplant. As to the remaining 4 patients who have not yet completed the one year follow-up, 2 out of 4 are still alive after a 6-month follow-up and recovered their basal liver function, 1 patient underwent a successful liver transplantation, the last patient is still alive after a 3-month follow up. CONCLUSIONS: Although CPFA is a non-standardized technique for the liver failure, its use in patients with acute or acute-on-chronic liver failure has shown favorable effects on safety and efficacy in terms of detoxification. Thus it is considerable a “bridge technique” toward the liver transplant and the recovery of basal liver function.