This case reports on a 55-year-old man with hepatocellular carcinoma in the context of a hepatitis C virus (HCV)-infection, who was hospitalized and scheduled for an elective orthotopic liver transplantation. During the first postoperative day (POD), the patient continued to have severe hemodynamic instability, requiring high doses of norepinephrine (0.6 µg/kg/min), epinephrine (0.5 µg/kg/min) as well as vasopressin. In the first hours after liver transplantation, ischemia-reperfusion injury was detected. The patient exhibited severe metabolic acidosis (pH 7.19, base excess -12 mmol/l, lactate 20.3 mmol/l), hypotension for several hours and acute anuric renal failure (creatinine 2.9 mg/dL, urea 51 mg/dL). Additionally, he showed signs of severe liver dysfunction as evidenced by clearly elevated alanine aminotransferase (ALT, 2486 U/l), aspartate aminotransferase (AST, 8852 U/l), and bilirubin serum levels (5.5 mg/dl). With the rationale to stabilize the deteriorating clinical condition in the context of the underlying ischemia-reperfusion injury accompanied by hemodynamic instability, hyperlactatemia and severe liver failure, the decision was made to initiate combined continuous veno-venous hemodiafiltration (CVVHDF) and CytoSorb therapy on POD 1. Due to reoccurrence of progressive hyperbilirubinemia after resolution of the initial shock, a second treatment interval with CytoSorb was started. During the first treatment interval, a total of 4 CytoSorb therapy days were performed, with a change of cartridge every 12 hours. The second treatment interval included 3 CytoSorb therapy sessions with 24 hours of run time per adsorber.
The combined usage of CVVHDF and CytoSorb hemoadsorption therapy resulted in an improvement in hemodynamics, resolution of lactic acidosis, and an efficient and sustained reduction in plasma bilirubin. Moreover, CytoSorb constitutes a safe and easy treatment of hyperbilirubinemia and may also represent a bridging therapy before (re-)transplantation