Evaluation Of Molecular Absorbent Recirculating System (MARS) On Acute Mushroom Poisoning Patients With Severe Toxic Hepatitis

Objectives:Toadstool is also called poisonous mushroom,it has a wide varities and contains complex toxins.According to the main organ damage caused by mushroom poisoning,toxins are divided into:liver toxins,gastrointestinal toxins,neurotoxin,renal toxins,etc.Clinical symptoms of mushroom poisoning is very various and complex.According to poisoning manifestations,they can be divided into:gastroenteritis type,toxic hepatitis type,hemolysis type,neuropsychiatric type,etc.In China,there are a lot of patients suffering from poisoning caused by eating mushrooms every year.The early manifestations of poisoning are mainly acute gastroenteritis type,which has a slight symptom and some may show symptoms of neuropsychiatric type,which will also not cause very serious results.With the development of disease course,some patients may progress to toxic hepatitis type,among which,severe toxic hepatitis type is the main cause of death among patients with mushroom poisoning.Acute liver failure may induce coagulation and serious damage of the nervous system,resulting in blood coagulation dysfunction,hepatic encephalopathy,etc.,and patients may die due to multiple organ failure.Because there is no specific antidote and effective treatments,once patients suffering from mushroom poisoning got acute liver failure,the death rate may is as high as 80%or above.Currently,there is no standardizedtherapeutic regimen for the treatment of mushroom poisoning.The early clinical treatment of viral hepatitis type-mushroom poisoning is mainly drug treatment,including corticosteroids?relief liver injury?and liver protection drugs while the effect of high dose of penicillin,silymarin inhibiting toxicity of poisonousmushroom is still not being made clear.The development of blood purification has brought hopes for the treatment of severe mushroom poisoning.But from the view of eliminating toxicant,because the molecular weight of amanita toxicant is very large and it willrapidly enter into the whole body parts after being taken,the curative effect ofhemodialysis?HD?,hemoperfusion?HP?,plasma exchange?PE?and continuous veno venous hemofiltration?CVVH?is very limited.PE is mainly used for the treatment of acute liver injury caused by mushroom poisoning and its mechanism is to replace the detoxification and synthetic function of livers.PE also achieves a good clinical effect,but has a poor effect on preventing and treating hepatic encephalopathy caused by mushroom poisoning.Molecular absorbent recirculating system?MARS?is a new kind of improved artificial liver support technique,which has achieved a significant curative effect in treating acute liver failure caused by other reasons.It cannot only eliminate toxic and harmful substance in the body,but can also correct water,electrolyte and acid-base disorders,avoid deficiencies of plasmapheresis and avoid absorption and damage of visible blood components.Currently,there are already case reports about successful application of MARS in rescuing acute mushroom poisoning.Recently,in our hospital,physicians applied MARS in clinical rescue of viral hepatitis type-mushroom poisoning and also got a good curative effect.In order to explore the curative effect of MARS in the rescue of severe viral hepatitis type-mushroom poisoning,a retrospective analysis was madeon curative effect and prognosis of patients with severe viral hepatitis type-mushroom poisoning treated by PE and MARS to analyze which kind of blood purification has a better curative effect,so as to provide a reference for improving the rescuing successful rate of this type of mushroom poisoning.Methods:A retrospective analysis was made on clinical materials of 277 patients with confirmed and suspected mushroom poisoning that had been admitted by the Hospital from July 2006 to December 2015 and patients with severe toxic hepatitis type-mushroom poisoning were screened out according to diagnosis standards of severe liver damage.Based on treatment methods,patients were divided into PE group?conventional treatment+PE?and MARS group?conventional treatment+MARS+PE?.Alanine aminotransferase?ALT?,direct bilirubin?DBIL?,total bilirubin?TBIL?,platelet?PLT?,prothrombin time?PT?,international standardization ratio?INR?,and other indicators of patients were monitored every day after admission.Changing condition of ALT,TBIL,DBIL,PT,PLT,INR of patients from two groups at different stages of treatment were compared and the occurrence condition of hepatic encephalopathy and death rate during the treatment period were analyzed to evaluate clinical curative efficiency of PE group and MARS group in treating severe toxic hepatitistype-mushroom poisoning.Comparison between two groups was carried out by using single factor variance analysis;enumeration data were shown in frequency or rate;?2 test or Fisher exact test method were used and p<0.05 was considered to be statistically significant.Results:A total of 246 patients were diagnosed withmushroom poisoning,with 240cases of viral hepatitis type,5 cases of neuropsychosis type and 1 case of renal damage type.Among patients with viral hepatitis type,there were 192 cases with mild liver damage,14cases with moderate liver damage and 34 cases withsevere liver damage.Among 34 cases with severe liver damage,there were 28 cases in PE group,6 cases in MARS group and patients from two groups had no evident difference in gender,age,interval from taking poison to the appearance of symptoms and the treatment time.Patients from both groups got severe injury in liver function and coagulation function and some patients died of multiple organ dysfunction syndrome?MODS?due to hepatic encephalopathy caused by continuous development of liver injury.1.Comparison of liver function changes of patients from two groups ALT of patients from two groups both decreased rapidly.From the 6^thh day,ALT of MARS group decreased more significantly and compared to PE group,it had statistical difference?p<0.05?.TBIL and DBIL of patients from MARS group first increased slightly and later decreased gradually while that of PE group first decreased and then increased continuously;the difference between two groups had statistical difference?p<0.05?.Combining with the changing trend of ALT,patients from PE group got enzyme-jaundice separation.2.Comparison of coagulation function changes of patients from two groups The coagulation indicators PT,INR of patients from two groups decreased slowly and there was no significant statistical difference between two groups?p>0.05?.3.Comparison of blood platelet changes of patients from two groups PLT of patients from two groups both increased slowly and the statistical results showed that from the 8^thday,PLT recovery speed of MARS was faster than PE group?p<0.05?.4.Comparison of machine-gathered blood plateletfresh frozen plasma infusion times There was no evident statistical difference?P>0.05?,consistent with the slow recovery of PT values of patients from two groups and it reflects that the disease severe degree and blood transfusion therapy of two groups are similar.5.Comparison of incidence and mortality of hepatic encephalopathyAmong 28 patients from PE group,11 cases got hepatic encephalopathy,9 cases died and the mortality rate of hepatic encephalopathy was 82%;among 6 patients from MARS group,3cases got hepatic encephalopathy,1 case died and the mortality rate of hepatic encephalopathy was 50%.There was no evident difference in the incidence of hepatic encephalopathy;the mortality,and overall mortality rate of hepatic encephalopathy among patients from MARS group were lower than that of PE group,there was statistical difference.Conclusions:The disease condition ofpatients with severe toxic hepatitis type-mushroom poisoning progresses rapidly.The severe injury of livers leads to multiple organ dysfunction and may result in hepatic encephalopathy in a short period of time and patients may die of multiple organ failure.Both of PE and MARS have therapeutic effect on severe mushroom poisoning,which is manifested as improvement of liver function,recovery of coagulation indicator and blood platelet.In the improvement of liver functions and recovering degree of blood platelet,the curative effect of MARS group is evidently better than PE group.Patients from PE group got enzyme-jaundice separation in the later stage of treatment.The incidence,mortality,and overall mortality rate of hepatic encephalopathy among patients from MARS group were lower than that of PE group.Suggestion:MARS+PE should be in the first place for rescuing mushroom poisoning patients with severe toxic hepatitis.