Göth Daniel, Mahler Christoph F, Kälble Florian, Speer Claudius, Benning Louise, Schmitt Felix C F, Dietrich Maximilian, Krautkrämer Ellen, Zeier Martin, Merle Uta, Morath Christian, Fiedler Mascha O, Weigand Markus A, Nusshag Christian
Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany.
Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany.
J Clin Med. 2023 Jul 13;12(14):4669. doi: 10.3390/jcm12144669.
Extracorporeal liver-support therapies remain controversial in critically ill patients, as most studies have failed to show an improvement in outcomes. However, heterogeneous timing and inclusion criteria, an insufficient number of treatments, and the lack of a situation-dependent selection of available liver-support modalities may have contributed to negative study results. We retrospectively investigated the procedural characteristics and safety of the three liver-support therapies CytoSorb, Molecular Adsorbent Recirculating System (MARS) and therapeutic plasma exchange (TPE). Whereas TPE had its strengths in a shorter treatment duration, in clearing larger molecules, affecting platelet numbers less, and improving systemic coagulation and hemodynamics, CytoSorb and MARS were associated with a superior reduction in particularly small protein-bound and water-soluble substances. The clearance magnitude was concentration-dependent for all three therapies, but additionally related to the molecular weight for CytoSorb and MARS therapy. Severe complications did not appear. In conclusion, a better characterization of disease-driving as well as beneficial molecules in critically ill patients with acute liver dysfunction is crucial to improve the use of liver-support therapy in critically ill patients. TPE may be beneficial in patients at high risk for bleeding complications and impaired liver synthesis and hemodynamics, while CytoSorb and MARS may be considered for patients in whom the elimination of smaller toxic compounds is a primary objective.
体外肝脏支持疗法在重症患者中仍存在争议，因为大多数研究未能显示出预后改善。然而，治疗时机和纳入标准的异质性、治疗次数不足以及缺乏根据具体情况选择可用肝脏支持方式可能导致了研究结果为阴性。我们回顾性研究了三种肝脏支持疗法——CytoSorb、分子吸附再循环系统（MARS）和治疗性血浆置换（TPE）的操作特点和安全性。TPE的优势在于治疗时间较短、能清除较大分子、对血小板数量影响较小以及能改善全身凝血和血流动力学，而CytoSorb和MARS在降低特别是小分子结合和水溶性物质方面表现更优。所有三种疗法的清除幅度均呈浓度依赖性，但CytoSorb和MARS疗法的清除幅度还与分子量有关。未出现严重并发症。总之，更好地明确急性肝功能不全重症患者中驱动疾病以及有益的分子特征对于改善重症患者肝脏支持疗法的应用至关重要。TPE可能对有出血并发症、肝脏合成及血流动力学受损高风险的患者有益，而对于以清除较小毒性化合物为主要目标的患者，可考虑使用CytoSorb和MARS。
