Single-Pass Albumin Dialysis During Continuous Renal Replacement Therapy for Management of Liver Failure Nathan Beins1, MD ; Brooke English2, RN ; Marita Thomas2, MD ; Uttam Garg3, Ph.D. ; Darcy Weidemann1, MD ; Vimal Chadha1, MD Section of Nephrology1, Critical Care Medicine2, Pathology and Laboratory Medicine3, Children’s Mercy, Kansas City, MO, United States

Background Acute Kidney Injury (AKI) is a relatively common occurrence in critically ill children and many require renal replacement therapy Most critically ill children with AKI requiring CRRT will also have multi-organ dysfunction Multiorgan dysfunction syndrome (MODS) occurs in ~20% of critically ill children with an associated ~10% mortality1

Background II Liver dysfunction is commonly seen in MODS while fulminant hepatic failure is rare2 Rarely, severe hyperbilirubinemia (SHB) occurs and is associated with increased mortality SHB also interferes with laboratory analyses (creatinine, alkaline phosphatase, etc.) and near-infrared spectroscopic (NIRS) monitoring

Methods Our aim was to evaluate the effectiveness of single-pass albumin dialysis in conjunction with CRRT for bilirubin clearance Single pass albumin dialysis (SPAD) was performed for severe hyperbilirubinemia in four sequential patients already receiving CVVHDF therapy for severe AKI/fluid overload Serum and effluent total bilirubin levels were monitored during SPAD therapy

Single-Pass Albumin Dialysis Single pass albumin dialysis (SPAD) was performed in conjunction with the standard CVVHDF system at our institution SPAD was performed via the addition of 400 mL of 25% albumin to the dialysis fluid (5L) thereby achieving a 1.85% albumin solution

First Experience

Serum Bilirubin during SPAD SPAD discontinued Colored lines represent four individual patients

% decrease in bilirubin during SPAD Results Patient Age (yrs) Sex Diagnosis Max. bilirubin (mg/dL) Length of SPAD (hrs) % decrease in bilirubin during SPAD Outcome 1 0.6 M Hemophagocytic histiolymphocytosis 51.5 35 56% Expired 2 7 Cystic fibrosis, sepsis, acute on chronic liver failure 32.6 96 42% Recovered, expired 3 weeks. later 3 5 Fulminant acute liver failure with encephalopathy 23.9 26 21% Received liver transplant 4 Neuroblastoma, post-HCT with VOD 32 240 73% Recovered, expired 1.5 years later

Conclusions Caveats & Future Questions Single pass albumin dialysis can effectively clear severe hyperbilirubinemia Caveats & Future Questions - Small sample size - No hard outcomes - Uncertain removal of nutrients & medications - Expense and limits of albumin supply - Effectiveness in comparison to other modalities (e.g. plasmapharesis, MARS)

Questions

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