Extracorporeal Elimination of Piperacillin/Tazobactam during Molecular Adsorbent Recirculating System Therapy

Artificial liver support in patients with liver failure: a modified DELPHI consensus of international experts

The present narrative review on albumin dialysis provides evidence-based and expert opinion guidelines for clinicians caring for adult patients with different types of liver failure. The review was prepared by an expert panel of 13 members with liver and ntensive care expertise in extracorporeal liver support therapies for the management of patients with liver failure. The coordinating committee developed the questions according to their importance in the management of patients with liver failure. For each indication, experts conducted a comprehensive review of the literature aiming to identify the best available evidence and assessed the quality of evidence based on the literature and their experience. Summary statements and expert's recommendations covered all indications of albumin dialysis therapy in patients with liver failure, timing and intensity of treatment, efficacy, technical issues related to the device and safety. The panel supports the data from the literature that albumin dialysis showed a beneficial effect on hepatic encephalopathy, refractory pruritus, renal function, reduction of cholestasis and jaundice. However, the trials lacked to show a clear beneficial effect on overall survival. A short-term survival benefit at 15 and 21 days respectively in acute and acute-on-chronic liver failure has been reported in recent studies. The technique should be limited to patients with a transplant project, to centers experienced in the management of advanced liver disease. The use of extracorporeal albumin dialysis could be beneficial in selected patients with advanced liver diseases listed for transplant or with a transplant project. Waiting future large randomized controlled trials, this panel experts' statements may help careful patient selection and better treatment modalities.

Therapeutic Drug Monitoring of Anti-infective Drugs: Implementation Strategies for 3 Different Scenarios

BACKGROUND

Therapeutic drug monitoring (TDM) supports personalized treatment. For successful implementation, TDM must have a turnaround time suited to the clinical needs of patients and their health care settings. Here, the authors share their views of how a TDM strategy can be tailored to specific settings and patient groups.

METHODS

The authors selected distinct scenarios for TDM: high-risk, complex, and/or critically ill patient population; outpatients; and settings with limited laboratory resources. In addition to the TDM scenario approach, they explored potential issues with the legal framework governing dose escalation.

RESULTS

The most important issues identified in the different scenarios are that critically ill patients require rapid turnaround time, outpatients require an easy sampling procedure for the sample matrix and sample collection times, settings with limited laboratory resources necessitate setting-specific analytic techniques, and all scenarios warrant a legal framework to capture the use of escalated dosages, ideally with the use of trackable dosing software.

CONCLUSIONS

To benefit patients, TDM strategies need to be tailored to the intended population. Strategies can be adapted for rapid turnaround time for critically ill patients, convenient sampling for outpatients, and feasibility for those in settings with limited laboratory resources.

MARS: Should I Use It?

Severe liver failure, including acute liver failure and acute-on-chronic liver failure, is associated with high mortality, and many patients die despite aggressive medical therapy. While liver transplantation is a viable treatment option for liver failure patients, a large proportion of these patients die given the shortage in the liver donation and the severity of illness, leading to death while waiting for a liver transplant. Extracorporeal liver support devices, including molecular adsorbent recirculating system (MARS), have been developed as bridge to transplantation (bridge for patients who are decompensating while waiting for liver transplantation) and bridge to recovery (for whom recovery is deemed reasonable). In addition to its uses in acute liver failure and acute-on-chronic liver failure, the MARS system has also been applied in various clinical settings, such as drug overdosing and poisoning and intractable cholestatic pruritus refractory to pharmacological treatment. This review aims to discuss the controversies, potential benefits, practicalities, and disadvantages of using MARS in clinical practice.

Molecular Adsorbent Recirculating System Therapy with Continuous Renal Replacement Therapy Enhanced Clearance of Piperacillin in a Pediatric Patient and Led to Failure to Attain Pharmacodynamic Targets

Molecular adsorbent recirculating system (MARS), an extracorporeal support device used in patients with liver failure, specifically removes albumin-bound molecules, including antibiotics. Case reports in adult patients showed that MARS enhances the clearance of piperacillin. However, for those patients, pharmacodynamic targets were achieved when piperacillin/tazobactam was administered as extended infusions over 3-4 hours. In contrast, piperacillin/tazobactam is typically given as short intermittent infusions in children. No reports describe the effect of MARS on piperacillin pharmacokinetics or pharmacodynamic target attainment in pediatric patients with liver failure. This case report describes the effects of MARS on piperacillin clearance and target attainment in a child with liver failure. It was noted that MARS, in conjunction with continuous renal replacement therapy (CRRT), enhanced the clearance of piperacillin when compared with CRRT alone (6.4-7.4 L/hr vs 3.0 L/hr). Pharmacodynamic targets were not attained during MARS-CRRT cycles with free piperacillin concentrations being above 64 µg/ml for < 50% of dosing intervals, the goal target. We performed simulation analysis to identify a dosing regimen to optimize target attainment. For this patient, doses 3 times what she received over 3-hour extended infusions and an additional dose within 5 hours of cycle initiation would have led to target attainment throughout the MARS-CRRT cycles.

EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure

The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.