Successful Bridging to Recovery Using the Prometheus Liver Support in a Critical Ill COVID-19 Patient with Acute Liver Failure: A Case Report

Case Report

Austin Crit Care Case Rep. 2021; 5(2): 1028.

Successful Bridging to Recovery Using the Prometheus® Liver Support in a Critical Ill COVID-19 Patient with Acute Liver Failure: A Case Report

Fandel S¹, Jahn M², Herbstreit F¹, Kribben A², Brenner T¹ and Schmidt K¹*

¹Department of Anesthesiology and Intensive Care Medicine, University Hospital Essen, University Duisburg-Essen, Essen, Germany

²Department of Nephrology, University Hospital Essen, University Duisburg-Essen, Essen, Germany

*Corresponding author: Schmidt K, Department of Anesthesiology and Intensive Care Medicine, Essen University Hospital, HufelandstraΒe 55, 45147 Essen, Germany

Received: May 25, 2021; Accepted: June 21, 2021; Published: June 28, 2021


Liver impairment is frequently reported in Severe Acute Respiratory Syndrome-Coronavirus-2 (SARS-CoV-2) infected patients and contributes to increased morbidity and mortality in critically ill Coronavirus disease-2019 (COVID-19) patients. We report of a 44-year-old male patient with hypoxic and cholestatic liver failure after an initially complicated course of COVID-19 pneumonia with moderate Acute Respiratory Distress Syndrome (ARDS), Acute Kidney Injury (AKI) stage 3 with Kidney Replacement Therapy (KRT), thromboembolic intestinal ischemia with subtotal colectomy and partial resection of the small intestine and septic shock. After considerable clinical improvement we initiated extracorporeal liver support due to progressive hyperbilirubinemia up to 25,3 mg/dl.

Within 17 days we conducted 11 sessions of extracorporeal liver support by Fractionated Plasma Separation and Adsorption (FPSA; Prometheus®) until stabilization of liver function occurred. After 52 days of intensive care treatment and successful weaning from ventilation and KRT, the patient was transferred to an Intermediate Care (IMC) unit.

To the best of our knowledge, this is the first report of a COVID-19 patient successfully treated with prolonged extracorporeal liver support. Extracorporeal procedures that support liver function should be considered as bridging to recovery in selected COVID-19 patients if liver failure presents a dominant organ dysfunction.

Keywords: COVID-19; Liver failure; Extracorporeal liver support; Critical care


AKI: Acute Kidney Injury; ALF: Acute Liver Failure; ARDS: Acute Respiratory Distress Syndrome; COVID-19: Coronavirus Disease-2019; CRP: C-Reactive Protein; CT: Computertomography; ECMO: Extracorporeal Membrane Oxygenation; FPSA: Fractionated Plasma Separation and Adsorption; ICU: Intensive Care Unit; IMC: Intermediate Care Unit; KRT: Kidney Replacement Therapy; MARS: Molecular Adsorbent Recirculating System; MELD: Model of End Stage Liver Disease; MODS: Multiple Organ Dysfunction Syndrome; PCR: Polymerase Chain Reaction; PCT: Procalcitonin; SARS-CoV-2: Severe Acute Respiratory Syndrome- Coronavirus- 2; SOFA Score: sepsis Related Organ Failure Assessment Score; SPAD: Single- Pass Albumin Dialysis; WBCC: White Blood Cell Count


Emerging evidence shows that COVID-19 is a multi-organ disease that can directly or indirectly induce varying degrees of liver dysfunction. Liver dysfunction has been repeatedly described in COVID-19 patients – but in most cases the degree of hepatic injury is mild and transient [1-5]. However, in critically ill COVID-19 patients liver dysfunction correlates with morbidity and mortality and liver function has been proposed to be a marker of disease progression [2,4,6,7]. Direct virus infection of hepatocytes and cholangiocytes, imbalanced immune responses, coagulation abnormalities, systemic inflammation, ischemia, hypoxia, hepatic congestion, and drug toxicity are possible mechanisms for hepatic dysfunction in COVID-19 patients [2,3,6-8].

Knowledge about extracorporeal lung support in critically ill COVID-19 patients is emerging, whereas data on extracorporeal liver support in COVID-19 patients is limited [9]. Here we report a COVID-19 patient with severe ischemic cholangiopathy successfully treated with the extracorporeal liver support system Prometheus® (Fresenius Medical Care, Bad Homburg, Germany) in terms of bridging to recovery.

Case Presentation

The 44-year-old male patient without comorbidities was admitted to hospital with fever, cough, thoracic pain, and myalgia due to SARSCoV- 2 infection. Within the next 12 days the pulmonary status deteriorated progressively, necessitating transfer to our academic referral hospital for consideration of extracorporeal membrane oxygenation (ECMO) support on a specialized ARDS ICU (intensive care unit).

On admission to our hospital the patient presented with moderate ARDS, concomitant AKI requiring KRT and a sepsis related organ failure assessment score (SOFA) of 17. Radiologic work-up showed large patchy consolidations in line with COVID-19 pneumonia but no other pathologic findings.

The laboratory on admission showed a normal serum bilirubin concentration (0.5 mg/dl) and mildly elevated liver enzymes (AST: 143 U/l, ALT: 82 U/l, GGT 60 U/l, AP: 44U/l, LDH: 527 U/l, INR: 1,09). The Model of End Stage Liver Disease Score (MELD) on admission was 21. A viral hepatitis was excluded in the standardized ARDS work-up at admission. A pulmonary bacterial co-infection was assumed because of elevated concentrations of standard inflammation biomarkers (white blood cell count (WBCC) 11/nl, C-Reactive Protein (CRP) 29.7 mg/dl, Procalcitonin (PCT) 1.8 ng/ ml) – but microbiologic work-up remained negative and the initial antibiotic therapy with piperacillin/ tazobactam and clarithromycin was stopped after 9 days and 6 days, respectively. As part of standardized therapy of COVID-19 by that time hydroxychloroquine was also given for 10 days.

Pulmonary function over the next days improved markedly due to optimized lung protective invasive ventilation and intermittent prone positioning. Vasopressor support was completely weaned, ventilatory support was gradually reduced and inflammatory biomarkers returned to normal values. Repeated spontaneous awakening trials with complete sedation interruption showed no neurologic arousal. Computertomographic (CT) diagnostic of the head showed no pathology but further work-up detected severe hyperammonia (457 μg/dl).

Measures to reduce ammonia levels were initiated (such as oral rifaximin, oral ursodeoxycholic acid, oral lactulose, and intravenous l- ornithine aspartat), resulting in a decline of ammonia levels. However, bilirubin levels showed a steady increase up to 16,8mg/ dl, resulting in a MELD score of 32 (Figure 1). The following day the patient developed acute thromboembolic mesenteric ischemia with consecutive septic shock necessitating emergency surgery. A subtotal colectomy and partial resection of the small intestine was performed with creation of a terminal ileostoma. Intraoperative liver inspection showed a severely discoloured liver, and a liver biopsy was performed. The patient’s clinical status stabilized within 36 hours following surgical focus control and standardized sepsis therapy. Hemodynamic and pulmonary function recovered completely, but severe liver dysfunction persisted (MELD: 33; SOFA: 16).

Citation:Fandel S, Jahn M, Herbstreit F, Kribben A, Brenner T and Schmidt K. Successful Bridging to Recovery Using the Prometheus® Liver Support in a Critical Ill COVID-19 Patient with Acute Liver Failure: A Case Report. Austin Crit Care Case Rep. 2021; 5(2): 1028.