Artificial liver support with CytoSorb and continuous veno- venous hemodiafiltration and advanced organ support (ADVOS) for critically ill patients with hyperbilirubinemia: a retrospective analysis

Background: As many as 30% of critically ill patients in intensive care units experience acute liver dysfunction with hyperbilirubinemia as a part of multiorgan failure that is associated with poor outcome. This retrospective cohort study was aimed at comparing CytoSorb and ADVOS in terms of bilirubin removal and overall survival among critically ill patients with hyperbilirubinemia ≥ 7 mg/dL. Methods: At the University Hospital Essen, between January 2021 and March 2024, 71 patients were treated with CytoSorb integrated in a continuous veno-venous hemodiafiltration (CVVHDF) circuit, and 71 patients were treated with ADVOS. Each therapy session lasted 24 hours. Results: The first single sessions of both CytoSorb with CVVHDF and ADVOS were associated with a statistically significant decrease in total serum bilirubin levels (Cytosorb, 20 to 14 mg/dL, p<0.0001; ADVOS, 16 to 14 mg/dL, p<0.0001), but the percentage bilirubin reduction was more pronounced for CytoSorb treatment (26% vs. 17%, p=0.0002). The number of days of treatment was similar for both groups (3 vs. 4, p=0.07). After completion of therapy, serum levels of total bilirubin had decreased significantly; 19.9 to 11.3 mg/dl (p<0.0001) in the CytoSorb group and 16.3 to 14.0 mg/dL (p=0.003) in the ADVOS group. The relative bilirubin reduction was significantly higher after application of CytoSorb than after treatment with ADVOS (35% (IQR 19,54) vs. 15% (IQR -11;54), p<0.0001). The relative removal of creatinine and urea nitrogen was significantly higher after ADVOS treatment than after CytoSorb with CVVHD treatment. Courses of treatment with CytoSorb and ADVOS reduced similarly platelet counts, hemoglobin levels, and C-reactive protein levels. CytoSorb treatment led to a significant decline in procalcitonin levels. Seven-day or in-hospital mortality rates were high among critically ill patients in both liver support groups. Conclusions: Our results showed that CytoSorb and CVVHDF treatment performed better than ADVOS in bilirubin removal among critically ill patients with hyperbilirubinemia caused by acute liver dysfunction. ADVOS was more efficient in eliminating creatinine and urea nitrogen than was CVVHDF with CytoSorb. Additional prospective randomized controlled trials are warranted to investigate the efficacy of hemoperfusion with CytoSorb for liver disease indications among critically ill patients.