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  • 1 Péterfy Sándor u. Hospital and Polyclinics Department of Emergency Medicine and Clinical Toxicology Budapest Hungary
  • 2 Péterfy Sándor u. Hospital and Polyclinics Fresenius Medical Care Dialysis Centre Budapest Hungary
  • 3 Fresenius Medical Care Budapest Hungary
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Despite intensive therapy, the mortality of acute hepatic failure is 60 to 90% without liver transplantation. Due to the limited number of transplantable organs, however, a significant percentage of patients die while on the waiting list. In order to reduce mortality, several attempts have been made to remove the albumin-bound and water-soluble toxic substances accumulated in hepatic failure, aimed at supporting spontaneous regeneration of the liver and maintaining patients alive until liver transplantation. Prometheus® treatment is a relatively new technique combining Fractionated Plasma Separation and Adsorption (FPSA) with high-flux dialysis. During the procedure the patient’s own separated albumin-rich plasma flows through special adsorbers, allowing elimination of toxins bound to albumin, while the water-soluble toxins are removed by haemodialysis. Objective: The authors’ intention was to demonstrate the efficacy of Prometheus® treatment in patients with acute hepatic failure due to intoxication. Patients and Method: Prometheus® treatment was administered in three patients with acute hepatic failure due to severe intoxication caused by paracetamol, potassium permanganate and Amanita phalloides , respectively, that could not be controlled by conservative therapy. Results: Ten treatments were performed in the three female patients. No serious complication was observed. Significant reduction of albumin-bound toxins (unconjugated bilirubin p = 0.048; bile acid p = 0.001) and water-soluble toxins (conjugated bilirubin p = 0.002; creatinine p = 0.007) was observed. Ammonia, urea, fibrinogen and antithrombin III levels showed no significant change. All three patients recovered without liver transplantation. Conclusion: Toxins accumulated in acute hepatic failure can be removed efficiently by Prometheus® treatment. The procedure is safe. In cases not controllable by conservative therapy it allows patients survive until their liver regenerates spontaneously or liver transplantation becomes feasible.

  • Kramer, L.: Acut liver failure. Wien. Klin. Wochenschr., 2004, 116 , 68–71.

    Kramer L. , 'Acut liver failure ' (2004 ) 116 Wien. Klin. Wochenschr. : 68 -71.

  • Polson, J., Lee, W. M.: AASLD position paper: The management of acute liver failure. Hepatology, 2005, 41 , 1179–1197.

    Lee W. M. , 'AASLD position paper: The management of acute liver failure ' (2005 ) 41 Hepatology : 1179 -1197.

    • Search Google Scholar
  • van de Kerkhove, M. D., Hoekstra, R., Chamuleau, R. A., et al.: Clinical application of bioartificial liver support systems. Ann. Surg., 2004, 240 , 216–230.

    Chamuleau R. A. , 'Clinical application of bioartificial liver support systems ' (2004 ) 240 Ann. Surg. : 216 -230.

    • Search Google Scholar
  • Schneider, A., Attaran, M., Meier, P. N. et al.: Hepatocyte transplantation in an acute liver failure due to mushroom poisoning. Transplantation, 2006, 82 , 1115–1116.

    Meier P. N. , 'Hepatocyte transplantation in an acute liver failure due to mushroom poisoning ' (2006 ) 82 Transplantation : 1115 -1116.

    • Search Google Scholar
  • Aleem Khan, A., Parveen, N., Habeeb, M. A., et al.: Journey from hepatocyte transplantation to hepatic stem cell: A novel treatment strategy for liver disease. Indian J. Med. Res., 2006, 123 , 601–614.

    Habeeb M. A. , 'Journey from hepatocyte transplantation to hepatic stem cell: A novel treatment strategy for liver disease ' (2006 ) 123 Indian J. Med. Res. : 601 -614.

    • Search Google Scholar
  • Denis, J., Opolon, P., Nusinovici, V., et al.: Treatment of encephalopathy during fulminant hepatic failure by haemodialysis with high permeability membrane. Gut, 1978, 19 , 787–793.

    Nusinovici V. , 'Treatment of encephalopathy during fulminant hepatic failure by haemodialysis with high permeability membrane ' (1978 ) 19 Gut : 787 -793.

    • Search Google Scholar
  • O’Grady, J. G., Gimson, A. E. S., O’Brien, C. J., Pucknell, A. et al.: Controlled trials of charcoal hemoperfusion and prognostic factors in fulminant hepatic failure. Gastroenterology, 1988, 94 , 1186–92.

    Pucknell A. , 'Controlled trials of charcoal hemoperfusion and prognostic factors in fulminant hepatic failure ' (1988 ) 94 Gastroenterology : 1186 -92.

    • Search Google Scholar
  • Desmet, V. J., De Groote, J., Van Damme, B.: Acut hepatocellular failure. A study of 17 patients treated with exchange transfusion. Hum. Pathol., 1972, 3 , 167, 182.

    Damme B. , 'Acut hepatocellular failure. A study of 17 patients treated with exchange transfusion ' (1972 ) 3 Hum. Pathol. : 167 -.

    • Search Google Scholar
  • Desilvestro, G., Marson, P., Brandolse, R., et al.: A single institution’s experience (1982–1999) with plasma-exchange therapy in patients with fulminant hepatic failure. Int. J. Artif. Org., 2000, 23 , 454–461.

    Brandolse R. , 'A single institution’s experience (1982–1999) with plasma-exchange therapy in patients with fulminant hepatic failure ' (2000 ) 23 Int. J. Artif. Org. : 454 -461.

    • Search Google Scholar
  • Stockmann, H., Hiemstra, C. A., Marquet, R. L., et al.: Extracorporeal perfusion for the treatment of acute liver failure. Ann. Surg., 2000, 231 , 460–470.

    Marquet R. L. , 'Extracorporeal perfusion for the treatment of acute liver failure ' (2000 ) 231 Ann. Surg. : 460 -470.

    • Search Google Scholar
  • Ho, D. W. Y., Fan, S. T., Woo, Y. H., et al.: Selective plasma filtration for treatment of fulminant hepatic failure induced by D-galactosamine in a pig model. Gut, 2002, 50 , 869–876.

    Woo Y. H. , 'Selective plasma filtration for treatment of fulminant hepatic failure induced by D-galactosamine in a pig model ' (2002 ) 50 Gut : 869 -876.

    • Search Google Scholar
  • Stange, J., Hassanein, T. I., Mehta, R., et al.: The molecular adsorbents recycling system as a liver support sytem based on albumin dialysis: a summary of preclinical investigations, prospective, randomised, controlled clinical trial, and clinical experience from 19 centers. Artif. Organs, 2002, 26 , 103–110.

    Mehta R. , 'The molecular adsorbents recycling system as a liver support sytem based on albumin dialysis: a summary of preclinical investigations, prospective, randomised, controlled clinical trial, and clinical experience from 19 centers ' (2002 ) 26 Artif. Organs : 103 -110.

    • Search Google Scholar
  • Heemann, U., Treichel, U., Loock, J., et al.: Albumin dialysis in cirrhosis with superimposed acute liver injury: A prospective, controlled study. Hepatology, 2002, 36 , 949–958.

    Loock J. , 'Albumin dialysis in cirrhosis with superimposed acute liver injury: A prospective, controlled study ' (2002 ) 36 Hepatology : 949 -958.

    • Search Google Scholar
  • Doria, C., Mandala, L., Scott, V. L., et al.: Fulminant hepatic failure bridged to liver transplantation with a molecular adsorbent recirculating system: A single-center experience. Dig. Dis. Sci., 2006, 51 , 47–53.

    Scott V. L. , 'Fulminant hepatic failure bridged to liver transplantation with a molecular adsorbent recirculating system: A single-center experience ' (2006 ) 51 Dig. Dis. Sci. : 47 -53.

    • Search Google Scholar
  • Lahdenperä, A., Koivusalo, A. M., Vakkuri, A., et al.: Value of albumin dialysis therapy in severe liver insufficiency. Transplant. Int., 2005, 17 , 717–723.

    Vakkuri A. , 'Value of albumin dialysis therapy in severe liver insufficiency ' (2005 ) 17 Transplant. Int. : 717 -723.

    • Search Google Scholar
  • Sen, S., Felldin, M., Steiner, C. et al.: Albumin Dialysis and Molecular Adsorbents Recirculating System (MARS) for acute Wilson’s Disease. Liver Transplant., 2002, 8 , 962–967.

    Steiner C. , 'Albumin Dialysis and Molecular Adsorbents Recirculating System (MARS) for acute Wilson’s Disease ' (2002 ) 8 Liver Transplant. : 962 -967.

    • Search Google Scholar
  • Falkenhagen, D., Strobl, W., Vogt, G., et al.: Fractionated plasma separation system: a novel system for blood purification to remove albumin bound substances. Artif. Organs, 1999, 23 , 81–86.

    Vogt G. , 'Fractionated plasma separation system: a novel system for blood purification to remove albumin bound substances ' (1999 ) 23 Artif. Organs : 81 -86.

    • Search Google Scholar
  • Krause, A.: Prometheus – a new extracorporeal liver support therapy. In: Arroyo, V., Forns, X., Garcia-Pagán, J. C. et al. (eds): Progress in the Treatment of Liver Diseases. Ars Medica, 2003, 437–443.

  • Rifai, K., Ernst, T., Kretschmer, U., et al.: Prometheus® – a new extracorporeal system for the treatment of liver failure. J. Hepatol., 2003, 39 , 984–990.

    Kretschmer U. , 'Prometheus® – a new extracorporeal system for the treatment of liver failure ' (2003 ) 39 J. Hepatol. : 984 -990.

    • Search Google Scholar
  • Rifai, K., Ernst, T., Kretschmer, U., et al.: Removal selectivity of Prometheus: A new extracorporeal liver support device. World J. Gastroenterol., 2006, 12 , 940–944.

    Kretschmer U. , 'Removal selectivity of Prometheus: A new extracorporeal liver support device ' (2006 ) 12 World J. Gastroenterol. : 940 -944.

    • Search Google Scholar
  • Rifai, K., Ernst, T., Kretschmer, U., et al.: The Prometheus device for extracorporeal support of combined liver and renal failure. Blood Purif., 2005, 23 , 298–302.

    Kretschmer U. , 'The Prometheus device for extracorporeal support of combined liver and renal failure ' (2005 ) 23 Blood Purif. : 298 -302.

    • Search Google Scholar
  • Evenepoel, P., Laleman, W., Wilmer, A., et al.: Detoxifying capacity and kinetics of Prometheus – a new extracorporeal liver support system for the treatment of liver failure. Blood Purif., 2005, 23 , 349–358.

    Wilmer A. , 'Detoxifying capacity and kinetics of Prometheus – a new extracorporeal liver support system for the treatment of liver failure ' (2005 ) 23 Blood Purif. : 349 -358.

    • Search Google Scholar
  • Krisper, P., Haditsch, B., Stauber, R., et al.: In vivo quantification of liver dialysis: Comparison of albumin dialysis and fractionated plasma separation. J. Hepat., 2005, 43 , 451–457.

    Stauber R. , 'In vivo quantification of liver dialysis: Comparison of albumin dialysis and fractionated plasma separation ' (2005 ) 43 J. Hepat. : 451 -457.

    • Search Google Scholar
  • Kramer, L., Bauer, E., Schenk, P., et al.: Successful treatment of refractory cerebral oedema in ecstasy/cocaine-induced fulminant hepatic failure using a new high-efficacy liver detoxification device (FPSA-Prometheus). Wien. Klin. Wochenschr., 2003, 115 , 599–603.

    Schenk P. , 'Successful treatment of refractory cerebral oedema in ecstasy/cocaine-induced fulminant hepatic failure using a new high-efficacy liver detoxification device (FPSA-Prometheus) ' (2003 ) 115 Wien. Klin. Wochenschr. : 599 -603.

    • Search Google Scholar
  • Skwarek, A., Grodzicki, M., Nyckow, P., et al.: The use of Prometheus FPSA system in the treatment of acute liver failure: Preliminary result. Transplant. Proc., 2006, 38 , 209–211.

    Nyckow P. , 'The use of Prometheus FPSA system in the treatment of acute liver failure: Preliminary result ' (2006 ) 38 Transplant. Proc. : 209 -211.

    • Search Google Scholar