Severely Hyperammonemic Acute Liver Failure due to Paracetamol Overdose: The Impact of High-intensity Continuous Renal Replacement Therapy.

IF 2.2 3区医学 Q3 HEMATOLOGY

Blood Purification Pub Date : 2024-11-19 DOI:10.1159/000542556

Anis Chaba, Stephen Joseph Warrillow, Caleb Fisher, Sofia Spano, Akinori Maeda, Atthaphong Phongphithakchai, Nuttapol Pattamin, Yukiko Hikasa, Nuanprae Kitisin, Scott Warming, Claire Michel, Glenn M Eastwood, Rinaldo Bellomo

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引用次数: 0

Abstract

Introduction: Paracetamol (acetaminophen) induced acute liver failure (ALF) with severe hyperammonemia (ammonia >100 µmol.L-1) is a life-threatening condition. A strategy based on high intensity continuous renal replacement therapy (CRRT) without early (up to day seven) transplantation may enable clinicians to safely identify which patients can recover and survive and which patients require transplantation.

Methods: We conducted a single-center, retrospective cohort study of patients with severely hyperammonemic paracetamol-induced ALF. The primary outcome was early transplant-free survival.

Results: We studied 84 patients (median age: 38; female sex: 79 [85%]) over a 12-year period (median ammonia level at ICU admission: 153 µmol.L-1; median peak aspartate aminotransferase (AST): 10,029 U.L-1, median lactate: 5.0 mmol.L-1 and median INR: 4.4) and 55 (65%) with King's College criteria for transplantation). Overall, 87% received high-intensity CRRT (92% in 2020-2023). Median CRRT intensity was 54 ml.kg-1.hr-1 within the first 48 hours and increased by 1.8 ml.kg-1.hr-1 per year during the study period (p = 0.002). Transplant-free survival to day 7 was 86% in 2011-2023 and 96% in 2020-2023. Overall, only 4 patients were transplanted and only 1 (4%) in 2020-223. On multivariable Cox analysis, factors independently associated with failure to achieve day seven transplant-free survival were higher APACHE III score (HR = 1.05, 95% CI [1.02-1.08]), higher lactate (HR = 1.27, 95% CI [1.12-1.44]) and lower platelet count at ICU admission (HR = 0.85, 95%CI [0.78-0.93]) and the median effluent dose applied within the first 48 hours of ICU admission (HR = 0.67, 95% CI [0.46-0.98]).

Conclusions: Early transplant-free survival is achievable in most patients with paracetamol-induced ALF and severe hyperammonaemia with a treatment based on high-intensity CRRT. Such transplant-free survival increased over time together with increased CRRT dose.

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扑热息痛过量导致的严重高氨急性肝衰竭：高强度连续肾脏替代疗法的影响。

简介扑热息痛（对乙酰氨基酚）诱发的急性肝衰竭（ALF）伴有严重的高氨血症（氨>100 µmol.L-1），是一种危及生命的疾病。基于高强度持续肾脏替代疗法（CRRT）而不进行早期（最多第七天）移植的策略可使临床医生安全地确定哪些患者可以康复和存活，哪些患者需要移植：我们对扑热息痛诱发的严重高氨血症 ALF 患者进行了一项单中心回顾性队列研究。主要结果是早期无移植生存率：我们对 84 名患者（中位年龄：38 岁；女性：79 [85%]）进行了为期 12 年的研究（重症监护室入院时的中位氨水平：153 µmol.L-1；天冬氨酸氨基转移酶（AST）峰值中位数：10,029 U.L-1）：10,029 U.L-1，乳酸中位数：5.0 mmol.L-1中位乳酸：5.0 mmol.L-1，中位 INR：4.4）和 55 例（65%）符合国王学院移植标准）。总体而言，87%的患者接受了高强度的 CRRT（2020-2023 年为 92%）。中位 CRRT 强度在最初 48 小时内为 54 毫升.千克-1.小时-1，在研究期间每年增加 1.8 毫升.千克-1.小时-1（p = 0.002）。2011-2023年第7天无移植生存率为86%，2020-2023年为96%。总体而言，只有 4 名患者进行了移植，2020-223 年只有 1 名（4%）。在多变量 Cox 分析中，与未能达到第 7 天无移植生存率独立相关的因素有：较高的 APACHE III 评分（HR = 1.05，95% CI [1.02-1.08]）、较高的乳酸（HR = 1.27，95% CI [1.12-1.44]）、入ICU时较低的血小板计数（HR = 0.85，95%CI [0.78-0.93]）以及入ICU后48小时内应用的中位流出剂量（HR = 0.67，95% CI [0.46-0.98]）：结论：大多数扑热息痛诱导的 ALF 和严重高血氨症患者都可以通过高强度 CRRT 治疗实现早期无移植生存。随着 CRRT 剂量的增加，这种无移植生存期也会随时间推移而延长。

本文章由计算机程序翻译，如有差异，请以英文原文为准。

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来源期刊

Blood Purification 医学-泌尿学与肾脏学

CiteScore

5.80

自引率

3.30%

发文量

审稿时长

6-12 weeks

期刊介绍： Practical information on hemodialysis, hemofiltration, peritoneal dialysis and apheresis is featured in this journal. Recognizing the critical importance of equipment and procedures, particular emphasis has been placed on reports, drawn from a wide range of fields, describing technical advances and improvements in methodology. Papers reflect the search for cost-effective solutions which increase not only patient survival but also patient comfort and disease improvement through prevention or correction of undesirable effects. Advances in vascular access and blood anticoagulation, problems associated with exposure of blood to foreign surfaces and acute-care nephrology, including continuous therapies, also receive attention. Nephrologists, internists, intensivists and hospital staff involved in dialysis, apheresis and immunoadsorption for acute and chronic solid organ failure will find this journal useful and informative. ''Blood Purification'' also serves as a platform for multidisciplinary experiences involving nephrologists, cardiologists and critical care physicians in order to expand the level of interaction between different disciplines and specialities.