563 - Extracorporeal Support in Pediatric Acute and Acute-on-Chronic Liver Failure

Publication Number: 4551.563

Samantha Krieger, Stanford University School of Medicine, Palo Alto, CA, United States; Ke-You Zhang, Stanford University School of Medicine, Palo Alto, CA, United States; Saraswati Kache, Lucile Packard Children's Hospital Stanford, Palo Alto, CA, United States; Scott Sutherland, Stanford University School of Medicine, Palo Alto, CA, United States; Shina Menon, Stanford University School of Medicine, Palo Alto, CA, United States

Background: Pediatric acute liver failure (PALF) and acute-on-chronic liver failure (ACLF) are complex conditions associated with significant morbidity and mortality. Treatment for PALF focuses on supportive measures including continuous renal replacement therapy (CRRT) and/or therapeutic plasma exchange (TPE), until liver function recovers or liver transplantation. As no specific guidelines exist for ACLF, it is typically managed similarly to PALF.

Objective: We aimed to characterize the clinical features, extracorporeal treatment patterns, and outcomes of children with PALF and ACLF receiving continuous renal replacement therapy.

Design/Methods: Single center retrospective cohort of patients from birth to 25 years old admitted to Lucile Packard Children’s Hospital from 2018–2024 with PALF or ACLF who received CRRT. Demographic, clinical, and lab data were compared by liver failure type and Intensive Care Unit (ICU) survival.

Results: In this preliminary report, fifty-five patients were analyzed (PALF=29, ACLF=26) with a median age of 42 months [IQR 5.5–167.5] (Table 1). In PALF, the most indication for CRRT was hyperammonemia (n=21, 72%) and 20 (69%) survived to ICU discharge. TPE was done in 9 (31%). The median (IQR) age PALF survivors was 37 months [9.2, 171.8] compared to 7 months [0, 109] for non survivors. CRRT was initiated at a median of 1.2 days [0.9, 6.1] after ICU admission in survivors compared to 3.4 days in non survivors [0.8, 15]. Ammonia declined from a median of 126 to 78 µmol/L by 24 hours in survivors compared to no decline (166.5 to 202 µmol/L by 24 hours) in non-survivors despite an increase in CRRT dose from 40 to 97 mL/kg/hr. Of the survivors with PALF, 11 (55%) recovered native liver function and 9 (45%) underwent transplant.
In ACLF, the most common indication was fluid overload (n=13, 50%) and 14 (54%) survived to ICU discharge. Survivors were older (median age of 52.5 months compared to 21.5 months) and started CRRT at a median (IQR) of 12 days [3, 23.8] after ICU admission compared to 8.3 days [2.5, 34.9]. Of the survivors, 9 (64%) underwent a liver transplant during admission, while 5 (36%) were discharged with stable chronic liver disease.

Conclusion(s): CRRT indication and survival patterns differed by liver-failure type. In PALF, survivors had early CRRT initiation and showed a decrease in ammonia levels post initiation, while non-survivors showed no decline in ammonia. In patients with ACLF, survival (54%) was lower than contemporary cohorts. Next we plan to evaluate impact of fluid status, illness severity on admission, etiologies and other factors associated with survival.

S Krieger Verification letter.pdf