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[Dr. Sinn's LiverTODAY 004 - High-volume plasma exchange (HVP) in acute liver failure]

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Acute liver failure ´Â »ç¸Á·üÀÌ ³ôÀº ÁúȯÀÔ´Ï´Ù. À̶§ º¸Á¶ÀûÀ¸·Î »ç¿ëÇÒ ¼ö ÀÖ´Â ¹æ¹ýÀÌ high-volume plasma exchange (HVP) ÀÔ´Ï´Ù. À̹ø¿¡ ¼Ò°³µå¸± ³í¹®Àº Journal of Hepatology¿¡ ½Ç¸° RCT °á°úÀÔ´Ï´Ù (Larsen FS. J Hepatol 2016).

BACKGROUND & AIMS: Acute liver failure (ALF) often results in cardiovascular instability, renal failure, brain oedema and death either due to irreversible shock, cerebral herniation or development of multiple organ failure. High-volume plasma exchange (HVP), defined as exchange of 8-12 or 15% of ideal body weight with fresh frozen plasma in case series improves systemic, cerebral and splanchnic parameters.

METHODS: In this prospective, randomised, controlled, multicentre trial we randomly assigned 182 patients with ALF to receive either standard medical therapy (SMT; 90 patients) or SMT plus HVP for three days (92 patients). The baseline characteristics of the groups were similar. The primary endpoint was liver transplantation-free survival during hospital stay. Secondary-endpoints included survival after liver transplantation with or without HVP with intention-to-treat analysis. A proof-of-principle study evaluating the effect of HVP on the immune cell function was also undertaken.

RESULTS: For the entire patient population, overall hospital survival was 58.7% for patients treated with HVP vs. 47.8% for the control group (hazard ratio (HR), with stratification for liver transplantation: 0.56; 95% confidence interval (CI), 0.36-0.86; p=0.0083). HVP prior to transplantation did not improve survival compared with patients who received SMT alone (CI 0.37 to 3.98; p=0.75). The incidence of severe adverse events was similar in the two groups. Systemic inflammatory response syndrome (SIRS) and sequential organ failure assessment (SOFA) scores fell in the treated group compared to control group, over the study period (p<0.001).

CONCLUSIONS: Treatment with HVP improves outcome in patients with ALF by increasing liver transplant-free survival. This is attributable to attenuation of innate immune activation and amelioration of multi-organ dysfunction.

±Þ¼º °£ºÎÀü ȯÀÚ 182¸íÀ» standard medical therapy (90¸í)°ú standard medical therapy plus high volume plasma exchange (HVP) (92¸í)À¸·Î ¹«ÀÛÀ§ ´ëÁ¶±º ºñ±³ ¿¬±¸¸¦ ½ÃÇàÇÑ °á°úÀÔ´Ï´Ù. HVP ¸¦ ½ÃÇà¹ÞÀº »ç¶÷µéÀº ±×·¸Áö ¾ÊÀº »ç¶÷µé¿¡ ºñÇØ »ýÁ¸À²ÀÌ À¯ÀÇÇÏ°Ô ³ô¾Ò½À´Ï´Ù. ¹°·Ð À̽Ä(LTx)À» ¹ÞÀº ºÐµéÀÌ ¼ºÀûÀÌ °¡Àå ÁÁ¾Ò½À´Ï´Ù¸¸..

±Þ¼º °£ºÎÀüÀº ºñ±³Àû µå¹® ÁúȯÀÔ´Ï´Ù. ÀÌ ¿¬±¸¿¡ ȯÀÚ¸¦ µî·ÏÇϴµ¥ 12³âÀÌ °É·È½À´Ï´Ù (1998-2010³â). ¿¬±¸ÀÚµéÀÇ ¿­Á¤¿¡ Á¸°æ½ÉÀÌ µé¾ú½À´Ï´Ù. ÀÌ ÀÚ·á µîÀ» ±Ù°Å·Î 2016³â American Society for Apheresis¿¡¼­´Â acute liver failureµ¥ HVP¸¦ category I, grade 1A·Î ±Ç°íÇÏ°í ÀÖ½À´Ï´Ù (Schwartz J. J Clin Apher 2016).

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HVP´Â ±¹³»¿¡¼­´Â ±Þ¿© ÀÎÁ¤µÇÁö ¾Ê´Â Ä¡·áÀÔ´Ï´Ù. ºñ±Þ¿© ¶Ç´Â 100/100À¸·Îµµ ÇÒ ¼ö ¾ø´Ù°í ÇÕ´Ï´Ù. SMC¿¡¼­´Â HVP°¡ ±â¼úÀûÀ¸·Î´Â °¡´ÉÇѵ¥, ¿ì¸®³ª¶ó ±Þ¿©Á¤Ã¥ ¹®Á¦·Î HVP¸¦ ½ÃÇàÇÏÁö ¸øÇÏ°í ÀÖ¾ú½À´Ï´Ù. Çѹø HVPÀ» ÇÒ ¶§¸¶´Ù ¸ðµÎ »è°¨À̱⠶§¹®¿¡ º´¿ø¿¡ 350¸¸¿ø ÀÌ»óÀÇ ¼ÕÇØ°¡ ¹ß»ýÇÑ´Ù°í ÇÕ´Ï´Ù.

±×·¡¼­ ¾ÆÀÌ·¯´ÏÇÏ°Ô Á¦ ù HVP ȯÀÚ´Â acute liver failure (r/o drug-induced) ·Î coma»óÅ·ΠÀü¿ø¿Â ¿Ü±¹ÀΠȯÀÚ¿´½À´Ï´Ù. °£À̽ÄÀ» ÁøÇàÇÏ·Á°í ³»¿øÇÏ¿´´Âµ¥, donor°¡ fatty liver°¡ ½ÉÇؼ­ ÀÌ½Ä ÁøÇàÀÌ ¾î·Á¿ü½À´Ï´Ù. ´Ù¸¥ »ýü °£ ±âÁõÀÚ°¡ °Ë»ç°¡ ÁøÇàµÇ´Â µ¿¾È ¿Ü±¹ÀÎÀº ±Þ¿©¿Í ¹«°üÇϹǷΠµÎ Â÷·Ê HVP¸¦ ½ÃÇàÇÏ¿´°í, HVP ½ÃÇà ÈÄ ÀǽÄÀÌ È£ÀüµÇ¾î À̽ÄÀÌ Ãë¼ÒµÇ°í ȯÀÚºÐÀº spontaneous recoverµÇ¾î Åð¿ø, º»±¹À¸·Î ±Í±¹ÇÏ¿´½À´Ï´Ù.

ù ȯÀÚÀÇ °æ°ú°¡ ÁÁ¾Æ¼­ ÀÌÈĺÎÅÍ´Â ±Þ¿© Á¤Ã¥°ú »ó°ü ¾øÀÌ »è°¨µÇ¸é ÀÌÀÇ ½ÅûÀ» ÇÏ°Ú´Ù°í ¸¶À½¸Ô°í Çѱ¹ÀΠȯÀÚ¿¡¼­µµ HVP¸¦ ½ÃÇàÇÏ°í ÀÖ½À´Ï´Ù. »è°¨Å뺸°¡ ¿À¸é °­·ÂÈ÷ ÀÇÀǽÅûÀ» ÇØ º¸·Á°í^^ Áغñ ÁßÀε¥ ¾ÆÁ÷ ¼­·ù¸¦ ¹ÞÁö´Â ¸øÇß½À´Ï´Ù. ÀÌÈÄ Çѱ¹ÀÎ µÎ ºÐ¿¡°Ô¼­ HVP°¡ ÁøÇàµÇ¾ú°í, µÎ ºÐ ¸ðµÎ °£À̽ÄÀ» ¹Þ°í ȸº¹ÇÏ¿´½À´Ï´Ù.


[References]

1) EsoTODAY - Esophageal diseases

2) SmallTODAY - Small bowel diseases

3) ColonTODAY - Colorectal diseases

4) Dr. Sinn's LiverTODAY - Liver diseases

© ¼º±Õ°ü´ëÇб³ ÀÇ°ú´ëÇÐ »ï¼º¼­¿ïº´¿ø ¼ÒÈ­±â³»°ú ½Åµ¿Çö (2016-8-10)