[Extracorporeal methods of hematological correction in patients with acute liver insufficiency after cardiac surgery].

BACKGROUND & AIMS: Acute liver failure (ALF) usually develops in multiple organ dysfunction syndrome (MODS) and carries a high mortality risk in patients after cardiac surgery. Artificial liver support devices aim to remove albumin-bound and water-soluble toxins arising as a result of liver failure. The currently most used devices combine haemodialysis with albumin dialysis (MARS) or plasma separation and adsorption (Prometheus). The aim of this study was to assess safety and efficacy of use MARS or Prometheus in elderly patients with ALF have been operated for heart diseases. METHOD: We studied 26 elder patients with ALF and MODS as postoperative complication after cardiac surgery. Patients were assigned to groups, given a combination of MARS and standard medical therapy (SMT) (MARS-group, n=9) or Prometheus and SMT (Prometheus-group, n=17). Inclusion criteria were clinical and laboratory signs of ALF: serum total bilirubin level>180 mkmol/L, 2-fold increasing serum aspartate aminotransferase (AST) and alanine aminotransferase (ALT), low serum cholinesterase and high serum ammonia levels. A variety of clinical and biochemical parameters were assessed. Primary endpoint was survival probabilities at day 28. RESULTS: MARS was used to provide 1 to 2 rounds (minimum of 6 hours each) and Prometheus was used to provide 2 to 14 rounds (minimum of 6 hours each). There were amelioration of haemodinamic instability, especially in MARS-group (increase in ADmean was 17% in MARS (p=0.005) and 10% in Prometheus-group (p=0.001)), increase in P/F ratio (12% in Prometheus-group (p=0.07)), decrease in serum total bilirubin (8.6% in MARS-group (p=0.028) and 33% in Prometheus-group (p<0.001)) and unconjugated bilirubin levels (29% in Prometheus-group (p=0.003)), also we had decreasing in serum aminotransferase levels and trend to increasing in serum cholinesterase level (12% in MARS-group (p=0.87) and 8% in Prometheus-group (p=0.86)). There were no side effects of extracorporeal liver support in both patients groups. Survival of patients with ALF, treated with MARS was 22%, in Prometheus group--35%. CONCLUSIONS: MARS and Prometheus are found to be safe and effective in patients with ALF after cardiac surgery. Further studies are needed to assess whether therapy might be beneficial in specific sublets of patients.

[Albumin dialysis in complex intensive therapy].

After cardiac surgery, acute hepatic failure (AHF) is a most common component of the multiple organ dysfunction syndrome (MODS) and associated with high mortality. In the past year, A. N. Bakulev Research Center of Cardiovascular Surgery, Russian Academy of Medical Sciences, has performed 10 postoperative MARS therapy sessions in patients with MODS caused by the development of low cardiac output. The results of the study suggest that MARS therapy has no negative impact on circulatory parameters under adequate thermoregulation monitoring. During albumin dialysis, there is a reduction in bilirubin levels by the end of a session, a significant decrease in the parameters of uremic intoxication: urea and creatinine. The studies of the values of albumin in different constituents of an extracorporeal contour have indicated the preservation of a significant gradient of the protein concentrations between the patient's blood and a dialyzing solution, which is indicative of the absence of laboratory significant permeability of a MARS filter for these molecules. Thus, the first experience in using MARD therapy suggests that it may be successfully used in patients with MODS after cardiacsurgery.

[A present-day variant of intermitttent replacement renal therapy in patients with multiple organ failure after cardiovascular surgery]. / Sovremennyi variant intermittiruiushchei zamestitel'noi pochechnoi terapii u bol'nykh s sindromom poliorgannoi nedostatochnosti posle operatsii na serdtse i sosudakh.

The efficiency of "semi-prolonged" replacement renal therapy (RRT) was assessed in patients with multiple organ dysfunction (MOD) after cardiovascular surgery. The results of semiprolonged RRT are analyzed in 65 patients (36-69 years, mean age 52.4 +/- 15.7 years, body weight 57-105 kg, mean 79.4 +/- 21.6 kg) operated on at A. N. Bakulev Cardiovascular Surgery Center, Russian Academy of Medical Sciences. Bicarbonate hemodialysis (BHD) was carried out in 50 patients, on-line hemodiafiltration (HDF) in the rest patients. Interventions on the heart and vessels of different complexity were carried out. The results indicate that semiprolonged SRT in complex with intensive care measures notably reduced the mortality of patients with MOD and improved the survival rate in this category of patients. Semiprolonged RRT is an effective method, which can and should be used in critical patients. This method meets all the requirements to modern RRT and ensures adequate filtration of nitrous metabolism products, corrects water-electrolyte and acid base balance, allows infusion/transfusion therapy and parenteral nutrition, and has no negative impact on the hemodynamic values, which is particularly important after cardiovascular interventions.

[Peritoneal dialysis in the newborn and infants after radical correction of complex congenital heart defects]. / Peritoneal'nyi dializ u novorozhdennykh i grudnykh detei posle radikal'noi korrektsii slozhnykh vrozhdennykh porokov serdtsa.

The efficiency of peritoneal dialysis (PD) was evaluated in newborns and infants with multiple organ dysfunction (MOD) after cardiosurgery. In 1996-2001 at A. N. Bakulev Cardiovascular Surgery Center, Russian Academy of Medical Sciences, PD was used as permanent renal replacement therapy (RRT) in 19 newborns and infants aged under 1 year after radical correction of congenital heart diseases. The mean age of infants was 6.2 +/- 4.3 months, body weight 6.1 +/- 1.7 kg. Radical correction of congenital heart diseases was carried out in all patients. The immediate postoperative period was complicated by MOD in all patients. Pronounced cardiac, respiratory, and renal insufficiency was observed in all cases. The main indication for the beginning of PD was oligouria, hypervolemia, edematous syndrome with progressive cardiorespiratory insufficiency. Multiple-modality intensive care including PD resulted in positive changes in the clinical status of infants by days 4-5 of PD: hemodynamic values, gaseous exchange function of the lungs, and laboratory values improved. Hence, PD as an RRT method in newborns and infants subjected to radical cardiosurgery proved to be effective in the complex of intensive care measures for MOD. This sufficiently simple method, requiring no expensive equipment, adequately corrects hyperhydration and hypervolemia, metabolic and electrolyte disorders, and other MOD symptoms in newborns and infants.