Abstract
Fulminant hepatitis is an intractable disease caused by various etiological agents. Artificial liver support (ALS) is a symptomatic treatment to control the bleeding tendency, hepatic coma and brain edema. Several attempted ALS treatments have not been sufficient for the patients to regain consciousness, and randomized control trials (RCTs) have failed to show any beneficial effect on the patient survival rate. Plasma exchange has been the prevailing ALS method in Japan since the mid 1980's. It can supply an adequate amount of coagulation factors, however its capability to remove water-soluble substances with a large distribution volume is poor. We thus tried to combine plasma exchange with hemodiafiltration to compensate for the faults of plasma exchange. Plasma exchange in combination with hemodiafiltration using a high-volume buffer and high performance membrane can remove water-soluble toxic substances with a large distribution volume such as glutamine, resulting in a recovery rate of more than 90% from hepatic coma. This combination It can also sustain favorable conditions in patients with severe fulminant hepatic failure (FHF) with favorable comparison to an ahepatic state. ALS is a symptomatic treatment ; therefore the recovery rate from hepatic coma is a suitable primary endpoint of any clinical trial that evaluates the efficacy of ALS. This combination ALS has become a reliable and standard method for Japanese clinicians, although its efficacy has not been ascertained by an RCT.
