Role of CRRT and PLEx in Acute Liver Cell Failure

CRRT in Acute Liver Failure

The European Association for the Study of the Liver recommends CRRT in acute liver failure patients with acute kidney injury (AKI), regardless of the type of kidney injury 1, 2
CRRT is particularly indicated in patients with severe and/or refractory electrolyte or acid-base imbalances, volume overload, and symptomatic azotemia, according to the European Society of Intensive Care Medicine 1, 2
CRRT provides better hemodynamic stability compared to intermittent hemodialysis in critically ill patients with liver failure, who are often hemodynamically unstable, as stated by the Society of Critical Care Medicine 1, 3
CRRT allows for slower correction of severe or refractory hyponatremia than hemodialysis, reducing neurological complications, as recommended by the American College of Physicians 1
CRRT facilitates management of fluid balance in hemodynamically unstable patients with liver failure, according to the European Society of Intensive Care Medicine 3

A typical dose for CRRT in liver failure would be 20-25 mL/kg/hr of effluent generation, as suggested by the Society of Critical Care Medicine 3
CRRT causes significant loss of water-soluble nutrients (approximately 10-15g amino acids/day) and electrolytes, requiring careful monitoring and replacement, as stated by the European Society for Clinical Nutrition 4
Continuous venovenous hemofiltration (CVVH) and venovenous hemodiafiltration (CVVHD-F) are preferred modalities in critically ill patients with acute liver failure, according to the American Society of Nephrology 4

The European Association for the Study of the Liver states that liver transplantation remains the best therapeutic option for patients with hepatorenal syndrome 1
Avoid delaying CRRT initiation in acute liver failure patients with AKI, as early RRT may improve survival, as recommended by the European Society of Intensive Care Medicine 1
Be cautious with regional citrate anticoagulation in liver failure patients; while not absolutely contraindicated, it requires careful monitoring of ionized calcium levels and total calcium to ionized calcium ratio, as stated by the National Kidney Foundation 5
Monitor for significant nutrient losses during CRRT, particularly amino acids, water-soluble vitamins, and electrolytes (phosphate, magnesium), as suggested by the European Society for Clinical Nutrition 4
Despite poor prognosis in some cases, do not limit CRRT and ICU treatment only to liver transplant candidates; base decisions on individual severity of illness, using prognostic scores, clinical judgment, and patient preferences, as recommended by the European Association for the Study of the Liver 1

The American Journal of Kidney Diseases recommends using bicarbonate rather than lactate as the buffer in all dialysate and replacement fluids for liver failure patients, as patients with liver failure have impaired lactate metabolism, with a strong recommendation (1B evidence) 6
Bicarbonate provides safer acid-base correction in liver failure patients, as lactate-buffered solutions risk worsening lactic acidosis, according to the American Journal of Kidney Diseases 6

Regional citrate anticoagulation can be used cautiously in liver failure, but requires intensive monitoring, including tracking systemic ionized calcium levels and the total calcium to ionized calcium (tCa/iCa) ratio, as suggested by the American Journal of Kidney Diseases 7
Liver failure patients are often coagulopathic, making heparin-based anticoagulation potentially more hazardous than citrate, according to the American Journal of Kidney Diseases 7
If citrate is deemed too risky, consider CRRT with no anticoagulation or use intermittent modalities like sustained low-efficiency dialysis (SLED), as recommended by the American Journal of Kidney Diseases 7, 8

The American Journal of Kidney Diseases recommends the right internal jugular vein as the first choice for CRRT access, followed by the femoral vein and then the left internal jugular vein 6
The subclavian vein should be avoided due to the risk of thrombosis/stenosis, according to the American Journal of Kidney Diseases 6