1Department of Anesthesiology and Pain Medicine, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
2Research Institute of Clinical Medicine of Jeonbuk National University-Biomedical Research Institute of Jeonbuk National University Hospital, Jeonju, Korea
3Humidifier Disinfectant Health Center, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
4Division of Respiratory and Critical Care Medicine, Department of Internal Medicine, Research Center for Pulmonary Disorders, Jeonbuk National University Hospital, Jeonbuk National University Medical School, Jeonju, Korea
Copyright © 2021 The Korean Society of Critical Care Medicine
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
CONFLICT OF INTEREST
No potential conflict of interest relevant to this article was reported.
AUTHOR CONTRIBUTIONS
Conceptualization: HBL. Data curation: DK, SKK. Formal analysis: HJH. Methodology: SYP. Project administration: MJK. Visualization: MJK. Writing–original draft: SWY. Writing–review & editing: MJK, HBL.
Values are presented as number (%) or mean±standard deviation.
CTP: Child-Turcotte-Pugh; MELD: model for end-stage liver disease; SAPS: Simplified Acute Physiology Score; APACHE: Acute Physiology and Chronic Health Evaluation; CRRT: continuous renal replacement therapy; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
Values are presented as mean±standard deviation.
MARS: molecular adsorbent recirculating system; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
Values are presented as number (%) or mean±standard deviation.
MARS: molecular adsorbent recirculating system; CRRT: continuous renal replacement therapy; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
No. | Gender/age (yr) | Predisposing factor | Reason for MARS | No. of MARS | New or increased bleeding sites at the time of MARS | LT | Final outcome |
---|---|---|---|---|---|---|---|
1 | M/42 | HAV | ALF complicated by HEP and renal dysfunction | 3 | No | Yes | Expire after 3 days of LT |
2 | M/47 | Herb | ALF complicated by HEP and renal dysfunction | 3 | No | Yes | Outpatient FU |
3 | M/62 | Alcohol | AoCLF complicated by progressive jaundice and renal dysfunction | 3 | Catheter insertion site hematoma | No | Expire |
4 | M/64 | Alcohol | AoCLF complicated by progressive jaundice and renal dysfunction | 2 | No | No | Expire |
5 | F/28 | Pregnancy | ALF complicated by renal dysfunction | 1 | Vaginal bleeding, catheter insertion site hematoma | No | Outpatient FU |
6 | M/42 | Alcohol, GI bleeding | AoCLF complicated by HEP and renal dysfunction | 1 | GI bleeding, catheter insertion site hematoma | No | Expire |
7 | F/51 | HBV | AoCLF complicated by progressive jaundice and renal dysfunction | 2 | Catheter insertion site hematoma | Yes | Outpatient FU, HD |
8 | M/62 | Drug, HBV | AoCLF complicated by progressive jaundice and renal dysfunction | 2 | No | Yes | Outpatient FU, HD |
9 | F/35 | HAV | ALF complicated by HEP | 2 | No | No | Outpatient FU |
10 | F/62 | Alcohol | AoCLF complicated by progressive jaundice | 2 | Brain subdural hemorrhage | No | Expire |
11 | M/48 | Alcohol | AoCLF complicated by progressive jaundice | 1 | Oral bleeding, catheter insertion site hematoma | Yes | Outpatient FU |
12 | M/59 | HBV | AoCLF complicated by progressive jaundice and renal dysfunction | 6 | No | Yes | Outpatient FU, HD |
13 | M/66 | Alcohol | AoCLF complicated by progressive jaundice | 2 | Catheter insertion site hematoma | No | Expire |
14 | F/26 | Alcohol | AoCLF complicated by progressive jaundice | 3 | No | Yes | Expire after 5 months of LT |
15 | M/35 | Alcohol, GI bleeding | AoCLF complicated by HEP, progressive jaundice, and renal dysfunction | 3 | No | No | Expire |
16 | M/42 | HBV | AoCLF complicated by HEP, progressive jaundice | 2 | No | No | Expire |
17 | M/49 | Alcohol, herb | ALF complicated by HEP, progressive jaundice | 3 | Catheter insertion site hematoma | No | Expire |
Variable | All patients (n=17) | Bleeder (n=8) | Non-bleeder (n=9) | P-value |
---|---|---|---|---|
Male | 12 (70.6) | 5 (62.5) | 7 (77.8) | 0.490 |
Age (yr) | 50.0±13.9 | 51.3±13.5 | 46.3±14.2 | 0.673 |
Underlying liver cirrhosis | 12 (70.6) | 6 (75.0) | 6 (66.7) | 0.707 |
End stage renal disease | 0 | 0 | 0 | 1.000 |
Disease severity | ||||
CTP score | 10.9±1.4 | 10.8±1.4 | 11.0±1.6 | 0.888 |
MELD score | 38.5±6.8 | 39.9±5.7 | 37.3±7.9 | 0.481 |
SAPS III score | 62.3±10.0 | 63.0±10.7 | 61.7±10.0 | 1.000 |
APACHE II score | 16.1±6.9 | 17.5±7.3 | 14.9±6.6 | 0.481 |
Support modality | ||||
CRRT | 13 (76.5) | 7 (87.5) | 6 (66.7) | 0.312 |
Mechanical ventilation | 4 (23.5) | 3 (37.5) | 1 (11.1) | 0.079 |
Vasopressor | 6 (35.3) | 4 (50.0) | 2 (22.2) | 0.079 |
Laboratory parameter | ||||
Hemoglobin (g/dl) | 9.7±2.1 | 9.1±2.4 | 10.3±1.6 | 0.015 |
Platelet (×103/mm3) | 77.4±46.2 | 84.6±55.6 | 70.9±38.2 | 0.606 |
AST (IU/L) | 673±1,360 | 352±635 | 958±1,776 | 0.200 |
ALT (IU/L) | 600±1045 | 359±678 | 814±1,293 | 0.200 |
Total bilirubin (mg/dl) | 30.9±12.7 | 30.2±11.7 | 31.5±14.3 | 0.743 |
Direct bilirubin (mg/dl) | 18.8±8.9 | 15.4±5.9 | 21.7±10.4 | 0.139 |
Albumin (g/dl) | 3.2±0.3 | 3.3±0.3 | 3.2±0.3 | 0.236 |
Creatinine (mg/dl) | 1.9±1.1 | 1.7±0.4 | 2.1±1.5 | 0.673 |
Ammonia (µmol/L) | 89.7±46.9 | 91.5±61.8 | 88.2±32.6 | 0.541 |
LD (IU/l) | 1,491±1,692 | 1,316±1,348 | 1,647±2,019 | 0.673 |
PT-INR | 2.5±0.8 | 2.7±1.0 | 2.3±0.4 | 0.606 |
aPTT (sec) | 48.0±10.9 | 46.1±7.4 | 49.8±13.6 | 0.963 |
Fibrinogen (mg/dl) | 151.7±51.6 | 133.9±56.4 | 169.5±42.4 | 0.161 |
FDP (mg/ml) | 62.0±58.4 | 69.4±55.7 | 53.5±64.6 | 0.613 |
Anti-thrombin Ⅲ (%) | 28.0±14.5 | 25.6±13.7 | 30.4±15.9 | 0.645 |
D-dimer (mg/L FEU) | 15.3±15.7 | 14.9±13.2 | 15.9±19.3 | 0.955 |
Factor Ⅱ (%) | 31.5±7.9 | 31.3±6.9 | 31.7±9.1 | 1.000 |
Factor V (%) | 27.4±16.9 | 16.0±7.7 | 35.0±17.4 | 0.067 |
Factor Ⅶ (%) | 19.1±7.8 | 17.5±9.8 | 20.2±6.9 | 0.914 |
Factor X (%) | 39.8±15.4 | 35.5±11.1 | 42.7±18.2 | 1.000 |
Procalcitonin (ng/ml) | 2.0±1.9 | 1.3±0.8 | 2.6±2.4 | 0.321 |
Lactate (mmol/L) | 3.2±2.0 | 3.3±2.5 | 3.0±1.6 | 0.673 |
Variable | Before MARS | After MARS | P-value |
---|---|---|---|
Complete blood count | |||
Hemoglobin (g/dl) | 9.4±1.7 | 8.8±1.8 | <0.001a |
Platelet (×103/mm3) | 78.8±35.2 | 63.5±35.1 | 0.002 |
Chemistry profile | |||
AST (IU/L) | 444±924 | 389±654 | 0.586 |
ALT (IU/L) | 470±836 | 422±713 | 0.126 |
Total bilirubin (mg/dl) | 33.0±11.6 | 28.8±9.0 | <0.001 |
Direct bilirubin (mg/dl) | 19.5±7.7 | 16.1±5.7 | <0.001 |
Albumin (g/dl) | 3.3±0.4 | 3.4±0.5 | 0.119 |
Creatinine (mg/dl) | 1.8±1.0 | 1.4±0.7 | <0.001 |
Ammonia (µmol/L) | 92.2±52.5 | 87.6±45.7 | 0.133 |
LD (IU/L) | 1,320±1,157 | 1,266±787 | 0.728 |
Coagulation profile | |||
PT-INR | 2.4±0.8 | 4.6±6.0 | 0.022 |
aPTT (sec) | 48.1±14.2 | 77.6±76.4 | 0.017 |
Fibrinogen (mg/dl) | 155.4±28.1 | 98.1±64.1 | <0.001 |
FDP (mg/ml) | 107±107 | 189±121 | <0.001 |
Anti-thrombin Ⅲ (%) | 30.6±13.6 | 34.4±13.2 | 0.141 |
D-dimer (mg/L FEU) | 34.2±44.8 | 66.6±53.6 | <0.001 |
Coagulation factor | |||
Factor Ⅱ (%) | 34.7±9.3 | 32.0±10.6 | 0.014 |
Factor Ⅴ (%) | 30.1±17.6 | 21.9±17.1 | <0.001 |
Factor Ⅶ (%) | 21.2±9.8 | 19.7±9.3 | 0.008 |
Factor Ⅹ (%) | 44.4±16.0 | 41.4±16.3 | 0.003 |
Variable | Bleeding sessions (n=14) | Non-bleeding sessions (n=13) | P-value |
---|---|---|---|
Support modality | |||
CRRT | 11 (78.6) | 9 (69.2) | 0.685 |
Mechanical ventilation | 4 (28.6) | 1 (7.7) | 0.375 |
Vasopressor | 4 (28.6) | 1 (7.7) | 0.375 |
Complete blood count | |||
Hemoglobin (g/dl) | 9.4±2.2 | 10.1±1.5 | 0.054 |
Platelet (×103/mm3) | 87.2±41.3 | 89.7±30.4 | 0.616 |
Laboratory parameter | |||
AST (IU/L) | 347±499 | 857±1506 | 0.519 |
ALT (IU/L) | 350±599 | 986±1213 | 0.239 |
Total bilirubin (mg/dl) | 34.1±11.1 | 25.1±13.3 | 0.066 |
Direct bilirubin (mg/dl) | 19.6±7.7 | 16.7±9.1 | 0.379 |
Albumin (g/dl) | 3.3±0.4 | 3.4±0.4 | 0.820 |
Creatinine (mg/dl) | 1.8±0.9 | 1.5±0.8 | 0.759 |
Ammonia (µmol/L) | 95.5±72.0 | 96.0±40.9 | 0.350 |
LD (IU/L) | 1,265±1,088 | 1,534±1,690 | 0.943 |
Coagulation profile | |||
PT-INR | 2.7±1.1 | 2.0±0.3 | 0.038 |
aPTT (sec) | 46.4±5.8 | 45.5±13.5 | 0.141 |
Fibrinogen (mg/dl) | 163±84 | 159±43 | 0.859 |
FDP (mg/ml) | 106.9±106.8 | 98.4±98.7 | 0.810 |
Anti-thrombin Ⅲ (%) | 26.6±12.4 | 26.4±7.7 | 0.955 |
D-dimer (mg/L FEU) | 32.1±45.6 | 32.3±39.5 | 0.689 |
Coagulation factor | |||
Factor Ⅱ (%) | 33.5±8.8 | 39.6±10.8 | 0.270 |
Factor Ⅴ (%) | 24.8±16.8 | 45.6±21.2 | 0.023 |
Factor Ⅶ (%) | 19.3±9.2 | 25.0±8.3 | 0.222 |
Factor Ⅹ (%) | 41.5±15.2 | 52.3±18.9 | 0.212 |
Independent variable | Unstandardized coefficient |
Standardized coefficient |
P | |
---|---|---|---|---|
B | SE | β | ||
Hemoglobin (g/dl) | 2.443 | 0.994 | 0.460 | 0.020 |
Platelet (×103/mm3) | –0.072 | 0.046 | –0.281 | 0.132 |
Total bilirubin (mg/dl) | 0.153 | 0.157 | 0.198 | 0.338 |
Albumin (g/dl) | 6.657 | 3.948 | 0.280 | 0.101 |
PT (INR) | –5.227 | 2.389 | –0.462 | 0.036 |
Fibrinogen (mg/dl) | –0.030 | 0.027 | –0.185 | 0.284 |
Anti-thrombin Ⅲ (%) | –0.132 | 0.102 | –0.199 | 0.206 |
Factor V (%) | 0.281 | 0.125 | 0.434 | 0.032 |
MARS: molecular adsorbent recirculating system; LT: liver transplantation; HAV: hepatitis A virus; ALF: acute liver failure; HEP: hepatic encephalopathy; FU: follow-up; AoCLF: acute-on-chronic liver failure; GI: gastro-intestinal; HBV: hepatitis B virus; HD: hemodialysis.
Values are presented as number (%) or mean±standard deviation. CTP: Child-Turcotte-Pugh; MELD: model for end-stage liver disease; SAPS: Simplified Acute Physiology Score; APACHE: Acute Physiology and Chronic Health Evaluation; CRRT: continuous renal replacement therapy; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
Values are presented as mean±standard deviation. MARS: molecular adsorbent recirculating system; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
Values are presented as number (%) or mean±standard deviation. MARS: molecular adsorbent recirculating system; CRRT: continuous renal replacement therapy; AST: aspartate transaminase; ALT: alanine aminotransferase; LD: lactate dehydrogenase; PT-INR: international normalized ratio of prothrombin time; aPTT: activated partial thromboplastin time; FDP: fibrinogen degradation product; FEU: fibrinogen equivalent unit.
F=2.582 (P=0.027), adjR2=0.240, Durbin-Watson=2.154. MARS: molecular adsorbent recirculating system; SE: standard error; PT-INR: international normalized ratio of prothrombin time.