Introduction
< /p>
The role of artificial liver blood purification technology in the treatment of liver failure has been affirmed, and its clinical application in other diseases has also been expanded. This technology has been carried out in many provinces and cities in my country for decades and covers a wide range. However, in various regions, the timing of treatment, the choice of treatment mode, the establishment of vascular access, the use of anticoagulants, the treatment of common machine alarms, and the process of treatment are different. Management and even the layout of artificial liver treatment rooms still have many differences in terms of practical operation.
This consensus aims to highlight the key points of the operation and application of artificial liver blood purification technology, and emphasize the standardization and clinical practicability, so as to help further standardize Clinical application of artificial liver blood purification technology.
Common treatment mode of artificial liver
The commonly used treatment modes of artificial liver includeplasma exchange/selective plasma exchange (PE/SPE), hemoperfusion (HP)/plasma perfusion (PP), dual plasma molecule adsorption system (DPMAS), plasma diafiltration (PDF), hemofiltration (HF)/hemodialysis (HD)/hemodiafiltration (HDF), paired plasma filtration adsorption (CPFA), double filtration plasma exchange (DFPP) ), Molecular Adsorption Recirculation System (MARS). The characteristics of various models of artificial liver are shown in Table 1.
Table 1 Characteristics of various models of artificial liver
Note: SIRS, Systemic Inflammatory Response Syndrome
Artificial Liver Combination Modes
The following are several commonly used combination modes.
1. DPMAS+PE
Application points: DPMAS is generally a single treatment dose of 2-3 times the plasma volume, which is different from the conventional treatment dose of PE or half dose of PE. Sequential lines. For patients with low prothrombin activity (PTA) but ≥20%, it is recommended to perform DPMAS first, followed by PE or SPE with plasma as the replacement fluid; for patients with PTA <20%, it is recommended to use plasma as the first The replacement fluid should be treated with PE or SPE, and then DPMAS; for patients with normal PTA, plasma substitutes, such as albumin solution, can be used as the replacement fluid for PE, and then DPMAS. The frequency of treatment depends on the severity of the primary disease, the effect of treatment, the molecular weight and plasma concentration of the causative factor removed, and an individualized treatment plan should be developed.
Advantages: DPMAS can not only specifically adsorb bilirubin, but also remove Inflammatory factors and other toxins, without losing autologous plasma, at the same time, combined with PE can supplement coagulation factors and albumin, improve the small consumption of coagulation substances and albumin caused by DPMAS, and alleviate the shortage of plasma resources. Compared with DPMAS or PE alone, it can increase the removal of toxins such as bilirubin and achieve better therapeutic effects.
Cons: Does not improve kidney function. Hepatic encephalopathy may be aggravated when PE is performed with plasma as the replacement fluid.
Applicable people: suitable for liver failure, liver failure caused by various reasons Patients with early stage and hyperbilirubinemia, especially those with bilirubin level >500 μmol/L.
2. PE+HDF
Application Points: Both modes can be performed simultaneously or sequentially. In sequential therapy, it is recommended to perform PE followed by HDF, which helps to correct the disturbance of water, electrolyte and acid-base balance and changes in plasma osmotic pressure that may be caused by PE. When the two modes are performed at the same time, the blood volume of extracorporeal circulation is relatively large, so HDF treatment can be performed first, and PE can be performed after ensuring that the patient’s vital signs are stable.
Advantages: The main function of PE is to remove large molecular weight toxins in the plasma. The ability to remove toxins of medium and small molecular weight such as blood ammonia and creatinine is weak, and these toxins are easily distributed widely in tissues through the blood vessel wall, and can accumulate in nerve cells through the blood-brain barrier, causing brain edema and aggravating hepatic encephalopathy. Symptoms; HDF just makes up for this deficiency. PE combined with HDF can remove toxins of various molecular weights, effectively correct water and electrolyte balance disorders, improve renal insufficiency and hepatic encephalopathy, and maintain the stability of the internal environment.
Disadvantages: PE has a large demand for plasma, and when plasma resources are tight, Mode development is limited, and SPE can be considered. HDF treatment time is relatively long, and some patients may not tolerate prolonged recumbency.
Applicable population: Liver failure, especially with renal insufficiency and water/ Electrolyte/acid-base imbalance, patients with hepatic encephalopathy.
3. HDF+DPMAS
Application Points: Both modes can be performed simultaneously or sequentially. At the same time, the blood volume of extracorporeal circulation is large, and HDF treatment can be performed first, and the DPMAS mode can be operated after the patient’s vital signs are stabilized.
Benefits: This combination The model does not require plasma, can be carried out when plasma resources are limited, and can reduce the risk of allergy and infection caused by exogenous plasma products; it has strong ability to clear bilirubin, inflammatory mediators, endotoxins, and small and medium-molecule water-soluble toxins , while rapidly improving the symptoms of jaundice, it can also effectively delay the occurrence of SIRS and multiple organ dysfunction syndrome (MODS), creating favorable conditions for the recovery of liver function.
Disadvantages: DPMAS has certain adsorption to beneficial substances such as albumin and coagulation factors , consumption, this combination mode itself cannot supplement coagulation factors. HDF treatment time is relatively long, and some patients may not tolerate prolonged recumbency.
Applicable population: Hyperbilirubinemia is the main manifestation, while Patients with severe liver disease complicated by severe infection, renal insufficiency, hepatic encephalopathy, and patients with severe drug poisoning should be used with caution in patients with severe bleeding tendency and severe hypoalbuminemia.
4. PDF+PP
Application points: PDF generally needs to be performed continuously for 4-6 hours or longer, and patients with liver failure have poor coagulation function. An appropriate anticoagulation regimen needs to be formulated to ensure the stability of blood flow and the absence of coagulation events. Both modes can be performed simultaneously or sequentially. At the same time, the blood volume of extracorporeal circulation is relatively large, and PDF treatment can be performed first, and the PP mode can be operated after the patient’s vital signs are stabilized.
Advantages: PDF can clear large, medium and small at the same time Molecular toxins, and can replenish coagulation factors; compared with PE, it can retain more coagulation factors in the body and require less plasma for treatment. PDF treatment time is longer, which enhances the removal of toxins, reduces rebound after toxin treatment, and is more conducive to maintaining hemodynamics and homeostasis. PDF combined with PP can more effectively remove bilirubin and other macromolecular toxins.
Disadvantages: Patients with severe liver disease have poor coagulation function, and this combination mode takes a long time to treat , Reasonable anticoagulation therapy and monitoring should be given to ensure the smooth progress of treatment and reduce the risk of bleeding in patients. At the same time, it should be noted that some patients may not tolerate prolonged recumbency.
Applicable population: severe liver disease with acute kidney injury, hepatorenal syndrome , SIRS or electrolyte/acid-base imbalance.
5. PE+PP+HDF
Application points: Generally, two machines are needed, one machine runs PE and PP sequentially, while the other Each machine runs HDF. In this combined mode, the volume of extracorporeal circulation is relatively large, and HDF treatment can be performed first, and the PE mode or PP mode can be operated after the patient’s vital signs are stabilized.
Advantages: This combined mode can effectively make up for the shortcomings of a single mode, , medium and small molecule toxins have good removal ability, can regulate water, electrolyte, acid-base balance disorders, and can supplement blood coagulation factors.
Disadvantages: PE has a large demand for plasma, and when plasma resources are tight, Mode development is limited, and SPE can be considered. The extracorporeal circulation circuit is complicated and the treatment time is long. A reasonable anticoagulation plan and monitoring should be given to ensure the smooth progress of the treatment and reduce the bleeding risk of patients.
Applicable population: severe liver disease with acute kidney injury , Hepatorenal syndrome, SIRS or water/electrolyte/acid-base imbalance.
The above content is taken from: Severe Liver Diseases and Artificial Liver Group of Chinese Medical Association Hepatology Branch. Expert consensus on clinical application of artificial liver blood purification technology (2022 edition) [J]. Journal of Clinical Hepatobiliary Diseases, 2022, 38(4): 767-775.
For the original text, see “Reading the original text”