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
{"title":"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。","authors":"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","doi":"10.1159/000542556","DOIUrl":null,"url":null,"abstract":"<p><strong>Introduction: </strong>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.</p><p><strong>Methods: </strong>We conducted a single-center, retrospective cohort study of patients with severely hyperammonemic paracetamol-induced ALF. The primary outcome was early transplant-free survival.</p><p><strong>Results: </strong>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]).</p><p><strong>Conclusions: </strong>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.</p>","PeriodicalId":8953,"journal":{"name":"Blood Purification","volume":" ","pages":"1-18"},"PeriodicalIF":2.2000,"publicationDate":"2024-11-19","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":"0","resultStr":"{\"title\":\"Severely Hyperammonemic Acute Liver Failure due to Paracetamol Overdose: The Impact of High-intensity Continuous Renal Replacement Therapy.\",\"authors\":\"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\",\"doi\":\"10.1159/000542556\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Introduction: </strong>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.</p><p><strong>Methods: </strong>We conducted a single-center, retrospective cohort study of patients with severely hyperammonemic paracetamol-induced ALF. The primary outcome was early transplant-free survival.</p><p><strong>Results: </strong>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]).</p><p><strong>Conclusions: </strong>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.</p>\",\"PeriodicalId\":8953,\"journal\":{\"name\":\"Blood Purification\",\"volume\":\" \",\"pages\":\"1-18\"},\"PeriodicalIF\":2.2000,\"publicationDate\":\"2024-11-19\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Blood Purification\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1159/000542556\",\"RegionNum\":3,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"\",\"PubModel\":\"\",\"JCR\":\"Q3\",\"JCRName\":\"HEMATOLOGY\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Blood Purification","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1159/000542556","RegionNum":3,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"","PubModel":"","JCR":"Q3","JCRName":"HEMATOLOGY","Score":null,"Total":0}
Severely Hyperammonemic Acute Liver Failure due to Paracetamol Overdose: The Impact of High-intensity Continuous Renal Replacement Therapy.
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.
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.
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