1. Continuous Veno-Venous `Single Pass ´ Albumin Haemodiafiltration (SPAD) in Acute Liver Failure (ALF) in Childhood H. I. G. Ringe, V.Varnholt, M. Zimmering*,W. Luck**, I.. M.Sauer *** Pediatric Interdisciplinary Intensive Care Unit * Department of Pediatric Nephrology, ** Department Pediatric Gastroenterology,*** Department of Experimental Transplant Surgery Charité Campus Virchow Berlin Germany

2. Albumin dialysis membrane 50 K Da

4. Substitute Albumin 20% Roler pump Subsitute pump Blood pump

6. Indication for SPAD and LTX PatientINR >4Bilirubin >20 mg/dl OthersEncephalopathy grade (1-4°) Dyes NH33° ByesnoNH33-4° Ryes -2-3° Hnoyes2nd LTx unsuitable for re-LTX1-2° ÜnoyesCVVH for hepato-renal-failure 3-4° Kyesno MOF CVVH elemination of endotoxin and TNF -α etc intubated sedated paralized M1+23,6 + >4yes NH3, Wilson crisis haemolysis, M2 post -tx hepatorenal failure 1-2° F2,5yesNH3 1

7. Goals Reduction of toxins Laboratory results: bilirubin, bile-acid, NH3 Encephalopathy score Blood pressure stabilisation Recovery of liver function : Laboratory results: fibrinogen, PTZ Cytokines ? Side effects Platelet count Cytokines (IL2-Receptor, IL6, IL 8, IL 10, TNF-α, LPS BP) Clinical data

10. * = FFP 6 hourly

12. SPAD ceased 425

13. Patient DPatient B Follow up in auxiliary transplantation

20. 48 19 26 0 54 46 45 56 0 0.3 9.7 7 6 17 136 0 10 20 30 40 50 60 IL 8 pg/ml ml/min KOIL 10 pg/ml ml/min KOLPS b P µg/ml ml/min KO Cytokine serum levels during SPAD and urine- and SPAD-clearance ml/min 1,73m 2 Serum 0 hoursSerum 12 hoursSerum 24 hoursUrineSPAD

21. Costs: SPAD versus MARS SPADSPAD MARSMARS HA 20% 2-4 L/d. 235,40 - 470,80 Euro Filter1 Filter 43,00 Euro B Bag production 2 Bags 20,00 Euro Substiute solution 9-18 L/d 21,24 - 42,48 Euro CAVVHDSumme 338,68 - 574,08 Euro MARS system Filter 2 Adsorber 1 Filter 1840,00 Euro HA 20%600ml 70,62 Euro MARSSumme 1910,62 Euro

22. Conclusion SPAD : - lowers effectively bilirubin, bile acids und ammonium in ALF - reduces hepatic encephalopathy - is well tolerated in case of SPAD System pre-filling even in a catecholamine dependant patient - stabilizes children prior to LTX and is helpful for bridging to transplantation.

23. Conclusion Side effects Allergic reaction to human albumin Thrombocytopenia (HIT) Unclear Whether SPAD can replace liver function until liver recovery appears Role of cytokine reduction / stimulation Definition of criteria to distinguish between those who recover or not is needed (Cytokines, Coagulation, HE ?) SPAD is easy to set up and cheaper than MARS