Liver dialysis

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The liver dialysis is on techniques of cleaning processes in kidney failure , called dialysis , based therapy concept that patients with liver failure will help the time to transplant to bridge or the liver to relieve to a regeneration permit. Even with 90 percent damage, the liver can still heal itself in some cases, provided there is enough time. This self-healing process may help avoid liver transplants.

Procedure

There are basically two types of liver dialysis procedures: 1) the cell-based - bioartificial procedures and the 2) cell-free - artificial procedures.

The cell-free systems include the so-called MARS method , the Prometheus method , which was introduced later, and the OPAL method (all of which use human serum albumin for transport). The mother of these procedures is single pass albumin dialysis , also known as SPAD .

With regard to the application of the method, further indications have emerged, from purely acute liver failure to chronic liver failure; use in poisoning has already been proven and approved by the Food and Drug Administration (FDA).

Since 2004, the costs of liver support procedures can be offset as an additional fee (ZE2016-10) via the DRG system (Diagnosis Related Groups) of the clinics .

The bioartificial methods have not been proven in terms of their effectiveness and safety despite the use of various scientific working groups worldwide. In particular, the additional synthesis performance has not yet been sufficiently demonstrable. The costs of these organic processes are nowadays in no relation to the discussions in the healthcare sector. The Charité in Berlin has gained a lot of experience in this area with the Modular Extracorporeal Liver Support (MELS).

There are also apheresis procedures for liver support. This includes bilirubin adsorption with polyanion adsorbers, also known as liver pheresis.

Molecular Adsorbents Recirculation System (MARS)

The MARS process ( Molecular Adsorbent Recirculation System ) from Gambro Hospal GmbH is a further development of the original idea of ​​albumin dialysis, known as SPAD. The desire for a standardized system with a longer running time and low albumin consumption has led to the further development of the MARS system. Basically, the MARS system is closely based on the well-known dialysis system. The blood is conducted past a semipermeable membrane , where it can release its molecules of up to about 55 kDa. These usually include many toxins that build up in the patient's blood when the liver fails. The albumin solution (yellow circuit) transports the toxins to a so-called low-flux membrane in order to exchange the smaller molecules there ( urea , creatinine , electrolytes ). A balancing of the patient can also be carried out here. The next two cleaning steps are the release of the larger molecular substances in a carbon adsorber and an ion exchanger . The albumin, which is then almost purified, can be fed back to the MARS membrane, where it continues to absorb toxins. The MARS procedure is used 8-24 hours a day and generally 3-10 days.

Single Pass Albumin Dialysis (SPAD)

With SPAD, a method similar to MARS is attempted to remove the bilirubin from the blood. A variant of the SPAD is the Continuous Single Pass Albumin Dialysis (CSPAD).

Prometheus

The Prometheus system developed by Fresenius scientists in collaboration with Danube University Krems is one of the latest liver support systems on the market. The Prometheus system combines a typical high flux dialysis with an adsorber treatment . An albumin-permeable filter is the core of the Prometheus system. Its membrane is permeable to molecules up to a size of around 300,000 Daltons (cut-off). Cells, platelets and substances with a larger molar mass, such as. B. fibrinogen, remain in the blood. The cell-free plasma fraction with the albumin-bound harmful substances it contains is passed to an anion exchanger via a neutral resin adsorber. The adsorbers can break the albumin binding and hold back these substances. The albumin purified in this way is returned to the blood.

Liver pheresis

Another method that supports the liver is liver pheresis (previously: bilirubin adsorption). This is an apheresis procedure in which the blood plasma is separated from the cellular components in the first step by means of a plasma separator. In a second step, the plasma is cleaned of substances that are toxic to the liver such as aromatic amino acids, bile acids and bilirubin using a polyanion adsorber . The blood plasma is then combined again with the cellular components and returned. Liver pheresis is the most common method for extracorporeal liver support therapy in Japan. Liver-supporting procedures (OPS code 8-858) such as liver pheresis are billed in clinics via an additional fee (ZE2016-10).

Web links

Studies

OPAL

MARS

Prometheus

Liver pheresis

Individual evidence

  1. ↑ R. Bañares, F. Nevens, FS Larsen, R. Jalan, A. Albillos, M. Dollinger, F. Saliba, T. Sauerbruch, S. Klammt, J. Ockenga, A. Pares, J. Wendon, T. Brünnler, L. Kramer, P. Mathurin, M. de la Mata, A. Gasbarrini, B. Müllhaupt, A. Wilmer, W. Laleman, M. Eefsen, S. Sen, A. Zipprich, T. Tenorio, M. Pavesi, HH Schmidt, S. Mitzner, R. Williams, V. Arroyo, RELIEF study group: Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. In: Hepatology . tape 57 , 2013, p. 1153-1162 , PMID 23213075 .
  2. ↑ J. Stange, SR Mitzner, T. Risler, CM Erley, W. Lauchart, H. Goehl, S. Klammt, P. Peszynski, J. Freytag, H. Hickstein, M. Löhr, S. Liebe, W. Schareck , UT Hopt, R. Schmidt: Molecular adsorbent recycling system (MARS): clinical results of a new membrane-based blood purification system for bioartificial liver support. In: Artif Organs . tape 23 , 1999, p. 319-330 , PMID 10226696 .
  3. ↑ C. Sponholz, K. Matthes, D. Rupp, W. Backaus, S. Klammt, D. Karailieva, A. Bauschke, U. Settmacher, M. Kohl, MG Clemens, S. Mitzner, M. Bauer, A. Kortgen: Molecular adsorbent recirculating system and single-pass albumin dialysis in liver failure - a prospective, randomized crossover study. In: J Hepatol . tape 20 , 2016, p. 2 , PMID 26728364 .
  4. ↑ A. Kribben, G. Gerken, S. Haag, S. Herget-Rosenthal, U. Treichel, C. Betz, C. Sarrazin, E. Hoste, H. Van Vlierberghe, A. Escorsell, C. Hafer, O. Schreiner, PR Galle, E. Mancini, P. Caraceni, CJ Karvellas, H. Salmhofer, M. Knotek, P. Ginès, J. Kozik-Jaromin, K. Rifai, HELIOS Study Group .: Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure. In: Gastroenterology . tape 142 , 2012, p. 782-789 , PMID 22248661 .
  5. ↑ K. Rifai, T. Ernst, U. Kretschmer, MJ Bahr, A. Schneider, C. Hafer, H. Haller, MP Manns, D. Fliser: Prometheus - a new extracorporeal system for the treatment of liver failure. In: J Hepatol . tape 39 , 2003, p. 984-990 , PMID 14642616 .
  6. ^ R. Senf, R. Klingel, S. Kurz, S. Tullius, I. Sauer, U. Frei, RU Schindler: Bilirubin adsorption in 23 critically ill patients with liver failure. In: Int J Artif Organs . tape 27 , 2004, p. 717-722 , PMID 15478543 .
  7. ↑ GL. Adani, D. Lorenzin, G. Currò, M. Sainz-Barriga, C. Comuzzi, V. Bresadola, C. Avellini, U. Baccarani: Selective bilirubin removal by plasma treatment with Plasorba BR-350 for early cholestatic graft dysfunction. In: Transplant Proc . tape 39 , 2007, p. 1904-1906 , PMID 17692649 .
  8. ↑ R. Ott, H. Rupprecht, G. Born, V. Müller, T. Reck, W. Hohenberger, F. Köckerling: Plasma separation and bilirubin adsorption after complicated liver transplantation: a therapeutic approach to excessive hyperbilirubinemia. In: transplant . tape 65 , 1998, pp. 434-437 , PMID 9484766 .
  9. ↑ P. Esposito, T. Rampino, G. Sileno, A. Dal Canton: Selective bilirubin removal: a treatment of jaundice-related kidney injury? In: Kidney Int . tape 84 , 2013, p. 624-625 , PMID 23989367 .