The Effect of Prometheus (R) Liver Support Dialysis on Cerebral Metabolism in Acute Liver Failure

Study Overview
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Brief Summary
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The main objective of this study is to investigate the effect of Prometheus liver support dialysis on intracranial pressure, cerebral metabolism and circulation in patients with acute liver failure.

Detailed Description
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Acute liver failure (ALF) is a highly mortal medical condition often complicated by multiorgan failure. Apart from severe coagulopathy ALF is characterized by onset of hepatic encephalopathy and in many cases intracranial hypertension (ICH) with the risk of cerebral incarceration. The pathogenesis behind ICH is incompletely understood and the therapeutic options are limited. Prometheus (R) liver support dialysis offers a system that apart from regular high-flux hemodialysis to a certain extent is able of removing albumin-bound substances from the patient - a feature that theoretically could benefit patients with ALF. In this study we intend to investigate the effect of 6-8 hours of Prometheus (R) liver support dialysis on cerebral metabolism, ICH and cerebral bloodflow (CBF) in patients with ALF. The study is designed as a open, prospective and randomized study, where a control-group treated with 6-8 hours of continuously veno-venous hemodiafiltration (CVVHDF) and standard medical treatment (SMT) is compared to the intervention group treated with Prometheus (R) liver support dialysis and SMT. The study is designed as a cross-over study so that included patients will be treated in both groups in a randomized order. The primary end-points are treatment effect on intracranial pressure, CBF and cerebral oxidative metabolism (lactate/pyruvate-ratio). We use a intracranial monitoring system from Integra/Camino (R) (United States) in combination with CMA microdialysis system and bedside analyzer (CMA-600) (Stockholm, Sweden).

Official Title
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The Effect of Prometheus (R) Liver Support Dialysis on Intracranial Pressure, Cerebral Oxidative Metabolism and Hemodynamics in Patients With Acute Liver Failure

Conditions
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Acute Liver Failure, Hepatic Encephalopathy, Intracranial Hypertension

Intervention / Treatment
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* Device: Prometheus (R) liver support dialysis
* Device: CVVHDF (Continuously Veno-Venous Hemodiafiltration)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: acute liver failure and grade II-IV encephalopathy and persistent raised arterial ammonia-concentration above 150 micromol/L and informed consent from closest relative and general practitioner Exclusion Criteria: withdrawal of informed consent severe untreated infection active bleeding within 48 hours suspicion of malignant liver disease severe heart insufficiency or middle artery pressure below 60 mmHg in spite of vasoactive therapy pregnant or lactating women disseminated intravascular coagulation clinical suspicion of cerebral damage

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Crossover Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Active Comparator: 1<br>Treatment with 6-8 hours of Prometheus (R) liver support dialysis | Device: Prometheus (R) liver support dialysis<br>* 6-8 hours of dialysis<br>|
| Active Comparator: 2<br>Treatment with 6-8 hours of CVVHDF | Device: CVVHDF (Continuously Veno-Venous Hemodiafiltration)<br>* 6-8 hours of dialysis with the CVVHDF system PrismaFlex offered by Gambro (Sweden).<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| treatment effect on cerebral oxidative metabolism (lactate/pyruvate-ratio) |  | 24 hours | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| treatment effect on intracranial pressure |  | 24 hours |