salon a 17 kasim 2011 14.10 14.30 ender egedik
TRANSCRIPT
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Karaciğer Yetmezliğinde Ekstrakorporeal Tedavi
Yrd. Doç. Dr. Ender GEDİKİnönü Ü. T. F.
Anesteziyoloji ve Reanimasyon ADYoğun Bakım BD
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Laboratuar ve genel durum
Parametre 23 y erkek 48 y kadın
INR 7.50 6.40
AST / ALT [U/L] 825 / 2512 314 / 309
Amonyak / Laktat 544 / 25 163 / 64
Bilirubin (mg/dL) 23.6 17.1
Kreatinin (mg/dL) 0.6 0.6
MELD skoru 30 27
Hepatik ensefalopati III° II°
Seroloji HBV HBV
GKSSolunum
7Entübe, IV
11NIV
Akut bulgular 2 gün 3 gün
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Tedavi seçenekleri ???
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King’s College Kriterleri Artmış Mortalite
Parasetamol Diğer nedenler
Hepatik koma (evre 3-4)
Arteriyel pH < 7.3
PT > 100 sn
Kreatinin > 3.4 mg/dL
PT > 100 sn
YA DA BEŞ ÖLÇÜTÜN ÜÇÜ
Yaş < 10 ya da > 40 yıl
Non A/B/C hepatiti
Halotan hepatiti
İdiyosinkratik ilaç reaksiyonu
Ensefalopati öncesi > 1 hft sarılık
PT > 50 sn
Bilirubin > 17.5 mg/dL
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Ekstrakorporeal Tedavi
• İlk kez 1865’de kullanılmış
• Yaşayan bir organizma (vücut) dışı tedaviler
• Gustave KLIMT
• Death and Life
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KARACİĞER DESTEK TEDAVİLERİ
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KC naklinde monitorizasyon ve EKT
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KC Destek Tedavileri
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Amaçları
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Karaciğer Destek Sistemleri
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Biyolojik olmayan sistemler
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Sürekli renal replasman tedavileri
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Sürekli renal replasman tedavileri
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Plazmaferez ve plazma exchange (değişimi)
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SVVHDF Plazma değişimi
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Single Pass Albumin Dialysis-SPAD
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Selective plasma filtration therapy-SEPET
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MARSMolecular Adsorbent Recirculating System
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Biyokimyasal değişimler
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Prometheus : Fractionated plasma separation and adsorption (FPSA, SEPAD)
Prometheus Desmotes
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Biyolojik olmayan sistemlerKardiyovasküler komplikasyonlar
Topaloğlu S, Yoğun Bakım Dergisi 2010
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Diğer komplikasyonlar
Topaloğlu S, Yoğun Bakım Dergisi 2010
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Diğer komplikasyonlar
Topaloğlu S, Yoğun Bakım Dergisi 2010
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BİYOLOJİK SİSTEMLER
• Biyolojik
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HepatAssist
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ELADExtracorporeal liver assist device
Insan hepatositi, J . O’GRADY, 2006
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BLSSBioartificial liver support system
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AMC-BALAcademic medical center-Bioartificial liver
R. Idilman 2008
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MELS-Modular extracorporeal liver support, dual hepatosit
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Ekstrakorporeal Tedavi Uniteleri
• Santral bir venden alınan kan tedavi ünitelerinden geçtikten sonra tekrar hastaya verilir.
• En az 3 ünite paralel ya da seri olarak bağlanır
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Plazmaferez
• HepatAssist• MELS• AMC-BAL
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Plazma fraksiyonasyonu
• Prometheus
• Molekül ağırlığı > 70-100 kDa
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Hemofiltrasyon
• ELAD• BLSS
• Molekül ağırlığı 15-70 kDa
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Hemodiyaliz
• Liver dialysis• MARS• Prometheus• MELS
• Düşük-orta geçirgenlikte membran
• Difüzyon• Tamponlanmış diyalizat
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Albumin diyalizi
• Prometheus• MELS
• Hemodiyaliz ile aynı• Albumin diyalizat
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Destekli transfer
• MARS
• Albumin diyalizi ile aynı• Albumin bağlı toksinler
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Adsorbsiyon• Liver dialysis• MARS• Prometheus
• HepatAssist• ELAD• MELS
• Proteine bağlı toksinler• Bilirubin ve safra asitleri
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Biyotransformasyon ve sentez
• HepatAssist• ELAD• BLSS• MELS• AMC-BAL
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Oksijen sunumu
• HepatAssist• ELAD• BLSS• MELS• AMC-BAL
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• EXTRACORPOREAL LIVER SUPPORT WITH THE MOLECULAR ADSORBENT RECIRCULATING SYSTEM (MARS) IN PATIENTS WITH ACUTE-ON-CHRONIC LIVER FAILURE (AOCLF). THE RELIEF TRIAL
• Relief Study Group, 189 patients• MARS at low dosage is a safe procedure, has
significant dialysis effect and improves severe HE in AoCLF. A significant beneficial effect on survival could not be demonstrated.
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• EXTRACORPOREAL LIVER SUPPORT BY FRACTIONATED PLASMA SEPARATION AND ADSORPTION (PROMETHEUS®) IN PATIENTS WITH ACUTE-ON-CHRONIC LIVER FAILURE (HELIOS STUDY): A PROSPECTIVE RANDOMIZED CONTROLLED MULTICENTER STUDY
• HELIOS Study Group, 145 patients • Conclusions: Extracorporeal liver support therapy by FPSA
(Prometheus®) was not associated with an improved survival in all patients with AOC compared to standard medical therapy alone. However, a survival advantage was observed in patients with hepatorenal syndrome type I or severe AOC with MELD score >30
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• Use of any form of advanced liver supporting system is not indicated unless studied in a randomized controlled trial.
• High-volume plasma exchange, however, seems to improve the transplant-free survival in patients with ALF.
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Tedavi AlgoritmasıTopaloğlu S, Yoğun Bakım Dergisi 2010
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Karaciğer Destek Tedavileri -SONUÇÇalışmaların çoğu randomize değil Çok merkezli → sonuç
ELAD (insan hücreleri) / HepatAssist (domuz hücreleri)MARS / SEPAD-Prometheus
Sağkalım üzerine etkisi ? / HE üzerine olumlu / bilirubin ↓↓
Koagülasyon / glukoz düzeyi / antibiyotik düzeyi
1
2
3
4
5
Biyolojik yapay sistemler → karaciğer hücreleriBiyolojik olmayan yapay sistemler → hücresiz
Nakil için köprü / karaciğer iyileşmesi / bilinen ve bilinmeyen toksinler
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Laboratuar ve genel durum
Parametre 23 y erkek 48 y kadın
INR 7.50 6.40
AST / ALT [U/L] 825 / 2512 314 / 309
Amonyak / Laktat 544 / 25 163 / 64
Bilirubin (mg/dL) 23.6 17.1
Kreatinin (mg/dL) 0.6 0.6
MELD skoru 30 27
Hepatik ensefalopati III° II°
Seroloji HBV HBV
GKSSolunum
7Entübe
11NIV
Akut bulgular 2 gün 3 gün
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23 y erkek, 6 saat içinde CVKN, 12. günde kaybedildi
48 y kadın, 12 saat içinde CVKN, 18. günde taburcu edildi
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Karaciğer Nakli – İnönü Ü.
Liver Transplantation
n: 651
LLS LDLTn: 39
LL LDLTn: 19
LDLTn: 501
RL LDLTn: 443
DDLT n: 150
Whole LT
n: 105
Split LTn: 46
RLn: 8
LLSn: 19
LLn: 5
Ext RLn:14
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Endikasyonlar
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İnönü Ü. Karaciğer Nakli Ens. Md. Prof. Dr. Sezai Yılmaz
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İLGİNİZ İÇİN TEŞEKKÜRLER