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WO2024241060A1 - Méthode de dialyse - Google Patents

Méthode de dialyse Download PDF

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Publication number
WO2024241060A1
WO2024241060A1 PCT/GB2024/051341 GB2024051341W WO2024241060A1 WO 2024241060 A1 WO2024241060 A1 WO 2024241060A1 GB 2024051341 W GB2024051341 W GB 2024051341W WO 2024241060 A1 WO2024241060 A1 WO 2024241060A1
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WIPO (PCT)
Prior art keywords
albumin
blood
individual
endotoxin
dialive
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Pending
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PCT/GB2024/051341
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English (en)
Inventor
Rajiv Jalan
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Yaqrit Ltd
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Yaqrit Ltd
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Filing date
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Publication of WO2024241060A1 publication Critical patent/WO2024241060A1/fr
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Classifications

    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M1/00—Suction or pumping devices for medical purposes; Devices for carrying-off, for treatment of, or for carrying-over, body-liquids; Drainage systems
    • A61M1/14—Dialysis systems; Artificial kidneys; Blood oxygenators ; Reciprocating systems for treatment of body fluids, e.g. single needle systems for hemofiltration or pheresis
    • A61M1/16—Dialysis systems; Artificial kidneys; Blood oxygenators ; Reciprocating systems for treatment of body fluids, e.g. single needle systems for hemofiltration or pheresis with membranes
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61K—PREPARATIONS FOR MEDICAL, DENTAL OR TOILETRY PURPOSES
    • A61K38/00—Medicinal preparations containing peptides
    • A61K38/16—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof
    • A61K38/17—Peptides having more than 20 amino acids; Gastrins; Somatostatins; Melanotropins; Derivatives thereof from animals; from humans
    • A61K38/38—Albumins
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M1/00—Suction or pumping devices for medical purposes; Devices for carrying-off, for treatment of, or for carrying-over, body-liquids; Drainage systems
    • A61M1/36—Other treatment of blood in a by-pass of the natural circulatory system, e.g. temperature adaptation, irradiation ; Extra-corporeal blood circuits
    • A61M1/3679—Other treatment of blood in a by-pass of the natural circulatory system, e.g. temperature adaptation, irradiation ; Extra-corporeal blood circuits by absorption
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M2202/00—Special media to be introduced, removed or treated
    • A61M2202/04—Liquids
    • A61M2202/0413—Blood
    • A61M2202/0445—Proteins
    • A—HUMAN NECESSITIES
    • A61—MEDICAL OR VETERINARY SCIENCE; HYGIENE
    • A61M—DEVICES FOR INTRODUCING MEDIA INTO, OR ONTO, THE BODY; DEVICES FOR TRANSDUCING BODY MEDIA OR FOR TAKING MEDIA FROM THE BODY; DEVICES FOR PRODUCING OR ENDING SLEEP OR STUPOR
    • A61M2210/00—Anatomical parts of the body
    • A61M2210/10—Trunk
    • A61M2210/1042—Alimentary tract
    • A61M2210/1071—Liver; Hepar

Definitions

  • the invention relates to the treatment of an individual suffering from liver disease. It relates to methods for safely treating such an individual and to in vitro methods of cleaning blood extracorporeally.
  • ACLF Acute-on-chronic liver failure
  • EASL-CLIF European Association for the Study of Liver diseases - Chronic Liver Failure
  • CLIF-C CLIF-Consortium
  • DIALIVE is an extracorporeal liver dialysis device that has been built to specifically address the pathophysiological sequelae responsible for the development of ACLF. DIALIVE incorporates a renal dialysis machine (e.g., Prismaflex, Baxter) and uses a dual filtration system connected in series.
  • a renal dialysis machine e.g., Prismaflex, Baxter
  • the first filter is comprised of a membrane that allows ultrafiltration of albumin and cytokines (Septex, Baxter, USA) and the second filter adsorbs PAMPs such as endotoxins and DAMPs such as genomic DNA (Oxiris, Baxter, USA).
  • the removed albumin is replaced in similar quantities with bottled, 20% albumin.
  • the rationale underlying DIALIVE are the following. First, the circulating albumin in ACLF is not only dysfunctional but can itself induce an inflammatory response. Second, systemic inflammation is the result of accumulation of DAMPs and PAMPs which leads to organ dysfunction and increased risk of infections. Therefore, DIALIVE aims to safely remove dysfunctional albumin and replace it with functional albumin and remove DAMPs and PAMPs from circulation. In large animal models of liver failure DIALIVE was shown to be safe, gave evidence of device performance and reduced short term mortality.
  • WO 2008/050148 and WO 2021/198674 describe uses of the DIALIVE device.
  • the present inventors have investigated use of the DIALIVE extracorporeal liver dialysis device in the treatment of patients with liver failure, such as patients with ACLF in a controlled randomized study. Through the conduct of this study the inventors discovered critical improvements in the methods of using the DIALIVE machine, from what was tested in the animal studies, that are needed to achieve substantial improvements in the safety and efficacy of DIALIVE. Changes to the methods that significantly enhance the safety include, but are not limited to, in-treatment interventions that prevent hypotensive, coagulation and bleeding events. Other changes to the method that enhance safety include pre-treatment interventions that prevent hypotensive, coagulation and bleeding events and continuous monitoring of blood pressure and markers of tissue hypoperfusion. Furthermore, it is beneficial that these methods are implemented under the continuous oversight of a healthcare professional familiar with extracorporeal interventions, monitoring and troubleshooting in a high dependency environment such as an Intensive Care or High Dependency Unit (ICU/HDU).
  • ICU/HDU Intensive Care or High Dependency Unit
  • a method of treating an individual with liver disease comprising treating said individual’s blood by:
  • step (c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets/mm 3 and the fibrinogen level is about >1.0 g/L.
  • the present invention relates to:
  • a method of treating an individual with liver disease comprising treating said individual’s blood by:
  • step (c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets/mm 3 or lower and the fibrinogen level is about 1.0 g/L or lower.
  • the present invention relates to: An ex vivo method of treating blood extracorporeally by removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease, the method comprising:
  • step (c) simultaneously adding to the blood albumin that does not derive from the same individual as the blood; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the blood has a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L.
  • the present invention relates to:
  • Albumin that does not derive from the blood of an individual to be treated for use in a method of liver disease, said method comprising the steps of:
  • step (c) introducing said albumin that does not derive from the individual to be treated into the blood of the individual; wherein step (a) is carried out by dialysis using means comprising a membrane having a pore size of greater than 45kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets/ mm 3 and the fibrinogen level is about >1.0 g/L.
  • FIG. 1 Biomarkers of the device performance in patients treated with DIALIVE or Standard of Care (SOC).
  • SOC Standard of Care
  • Ischemia modified albumin ratio (IMAR) was significantly reduced in the DIALIVE group compared with the SOC group at both Days-5 and 10.
  • MMRM Mixed Models for Repeated Measurements
  • Kaplan-Meier curve was constructed to determine differences between groups in the resolution of ACLF and logrank test was used for survival comparison. * Describes statistically significant difference with the groups and between groups at specified time points [*p ⁇ 0.05; **p ⁇ 0.01; ***p ⁇ 0.001], # Describes overall treatment effect [#p ⁇ 0.05; ##p ⁇ 0.01 ] .
  • the first two panel show the effect of incubation of the patient’s plasma with reporter cell lines that would become activated by toll-like 4 receptor (TLR4) or inflammasome ligands.
  • TLR4 toll-like 4 receptor
  • the third and fourth panels show biomarkers of endothelial dysfunction.
  • ADMA asymmetric dimethylarginine
  • Factor VIII there was a significant treatment effect overall in favour of DIALIVE with a significant reduction observed at Day 5.
  • MMRM Mixed Models for Repeated Measurements
  • Acute-on-chronic liver failure ACLF
  • Acute Kidney Injury AKI
  • adverse events AEs
  • Alcohol Abuse and Alcoholism NIAAA
  • asymmetric dimethylarginine ADMA
  • Chronic Liver Failure Consortium CLIF-C
  • CLIF-OF CLIF-C organ failure
  • DSMB Data Safety Monitoring Board
  • EAA Endotoxin activity assay
  • EAA European Association for the Study of Liver diseases - Chronic Liver Failure
  • EASL-CLIF Human mercaptalbumin
  • HNA human non- mercapt albumin
  • ICU International Normalized Ratio
  • ILR limulus amebocyte lysate
  • LBP lipoprotein binding protein
  • MAP mean arterial pressure
  • MELD model for end-stage liver disease
  • NIAAA National Institute on Alcohol Abuse and Alcoholism
  • MIAE serious adverse events
  • SOC standard of care
  • the present inventors have additionally shown that in patients having liver disease, a proportion of the albumin in the blood circulation is structurally abnormal.
  • the inventors have also found that the amount of ischaemia modified albumin (IMA) is increased in patients with liver disease compared with healthy control subjects.
  • IMA ischaemia modified albumin
  • the invention relates to the removal of albumin from the blood of an individual having liver disease.
  • Removal of albumin in this context refers to the removal of structurally normal albumin, and also to the removal of any structurally or functionally modified forms of albumin present in the blood of the individual. That is, preferably, the means for removing albumin used in accordance with the present invention will be capable of removing not only normal, naturally occurring albumin, but also albumin which may have an abnormal structure or albumin which has been modified. Removal of any damaged or abnormal albumin may also be therapeutically useful because damaged albumin has poor functionality and may be associated with damaging side reactions. For example, the means for removing albumin may also remove albumin having reduced molecular flexibility, reduced fatty acid binding affinity, reduced transport quality, reduced transport efficiency and/or reduced detoxification ability compared with normal, unmodified albumin.
  • the means for removing albumin may also remove particular modified forms of albumin, such as ischaemia modified albumin (IMA).
  • IMA ischaemia modified albumin
  • Such structural and functional modifications may be detected using conventional techniques, for example as described in Example 1.
  • albumin functionality may be assessed using a spin label and electron paramagnetic resonance spectroscopy.
  • the presence of IMA may be detected by examining the ability of the albumin to bind metal atoms.
  • Removal of albumin may also detoxify the blood by removing any associated albumin-bound toxins. That is, the means for removing albumin may also consequently remove toxins in the blood that are bound to the albumin.
  • the means for removing albumin from the blood removes albumin selectively. That is, albumin is removed in preference to other substances in the blood, such as other proteins.
  • the amount of albumin removed from the blood is significantly greater than that of other blood components removed. For example, more than 99% by weight of the component removed in this aspect may be albumin. More than 98%, more than 95%, more than 90%, more than 80%, more than 70%, more than 60% or more than 50% of the component removed in this aspect may be albumin. Removal of albumin here includes the removal of the various modified forms of albumin described herein.
  • the means for removing albumin may be any means capable of selectively removing albumin from blood.
  • albumin is selectively removed using a ligand that binds the albumin.
  • the ligand may be any molecule that binds albumin.
  • the ligand may be an antibody or other affinity ligand that specifically binds albumin.
  • a ligand that specifically binds albumin is a ligand capable of selectively removing albumin from blood as explained above.
  • the ligand may be capable of binding albumin more strongly than other components of blood.
  • the ligand may be an antibody that specifically binds human albumin.
  • the ligand may be an antibody that binds an epitope that is specific to albumin.
  • the ligand may be a combination of molecules which each bind albumin, such as a combination of molecules which bind different parts of the albumin molecule.
  • the ligand may be a polyclonal antibody or mixture of antibodies which bind to multiple epitopes on the albumin protein. Such a combination approach may be useful in the removal of modified forms of albumin as different antibodies may target different parts of the albumin molecule.
  • Antibodies may be raised against specific epitopes of the albumin molecule. For example, antibodies may be raised specifically against those regions, which are expected to be structurally similar in unmodified and particular modified forms of albumin.
  • the term “antibody”, unless specified to the contrary, includes fragments which bind albumin. Such fragments include Fv, F(ab’) and F(ab’)2 fragments, as well as single chain antibodies.
  • the antibodies and fragment thereof may be chimeric antibodies, CDR-grafted antibodies or humanised antibodies.
  • Antibodies for use in the present invention can be produced by any suitable method.
  • an antibody may be produced by raising antibody in a host animal against the whole polypeptide or a fragment thereof, for example an antigenic epitope thereof, herein after the “immunogen”.
  • a method for producing a polyclonal antibody comprises immunising a suitable host animal, for example an experimental animal, with the immunogen and isolating immunoglobulins from the animal’s serum.
  • the animal may therefore be inoculated with the immunogen, blood subsequently removed from the animal and the IgG fraction purified.
  • a method for producing a monoclonal antibody comprises immortalising cells which produce the desired antibody.
  • Hybridoma cells may be produced by fusing spleen cells from an inoculated experimental animal with tumour cells (Kohler and Milstein (1975) Nature 256, 495-497).
  • An immortalized cell producing the desired antibody may be selected by a conventional procedure.
  • the hybridomas may be grown in culture or injected intraperitoneally for formation of ascites fluid or into the blood stream of an allogenic host or immunocompromised host.
  • Human antibody may be prepared by in vitro immunisation of human lymphocytes, followed by transformation of the lymphocytes with Epstein-Barr virus.
  • the experimental animal is suitably a goat, rabbit, rat or mouse.
  • the immunogen may be administered as a conjugate in which the immunogen is coupled, for example via a side chain of one of the amino acid residues, to a suitable carrier.
  • the carrier molecule is typically a physiologically acceptable carrier.
  • the antibody obtained may be isolated and, if desired, purified.
  • an antibody “specifically binds” to a protein when it binds with preferential or high affinity to the protein for which it is specific but does substantially bind not bind or binds with only low affinity to other proteins. That is, an antibody specifically binds albumin if it binds to albumin more strongly than it binds to other blood components, such as other proteins in the blood. As explained above, the specificity of binding may be such that it binds structurally or functionally altered forms of albumin as well as unmodified albumin. Preferably it binds structurally or functionally altered forms of albumin with the same or substantially the same binding affinity as unmodified albumin.
  • a variety of protocols for competitive binding or immunoradiometric assays to determine the specific binding capability of an antibody are well known in the art (see for example Maddox et al, J. Exp. Med. 158, 1211-1226, 1993). Such immunoassays typically involve the formation of complexes between the specific protein and its antibody and the measurement of complex formation.
  • the ligand may be provided attached to a solid support.
  • the ligand may be immobilised on such a solid support.
  • a suitable solid support may be in the form of a column through which the blood may be passed.
  • a suitable solid support may be, for example, a porous material such as a membrane, particle bed or filter which is sufficiently porous to allow blood cells to pass through it.
  • a suitable solid support may alternatively be a solid substrate across the surface of which blood may be passed.
  • the solid support has a large surface area to maximise the area of contact between the blood of the individual and the ligand attached to the support.
  • the solid support may be in the form of beads, which can be filled into a container into which the blood can be inserted, or through which the blood can be passed.
  • the beads will preferably have a size sufficient to allow sufficient porosity when packed into a column or filter bed.
  • Various bead materials are known in the art.
  • the means for removing albumin may comprise or consist of such a solid support on which is attached or immobilised a ligand capable of binding albumin.
  • the means for removing albumin may comprise or consist of a container through which blood is passed.
  • the container may thus comprise an inlet and an outlet.
  • the inlet and outlet are positioned so that blood passing through the container comes into contact with a solid support as described herein.
  • the means for removing albumin is designed or selected to maximise the area of contact between the blood and the solid support.
  • the means for removing albumin may be a column or filter bed packed with beads, wherein a ligand for albumin is immobilised on the beads.
  • removal of albumin may be achieved via dialysis. Such an approach may also lead to the removal of other blood components that are dialysed together with the albumin. Typically, albumin should be the predominant component removed.
  • This dialysis step can use any albumin dialysis system.
  • a variety of such systems are known in the art.
  • One such system is the molecular absorbance recirculating system (MARS).
  • MERS molecular absorbance recirculating system
  • An alternate is a generic single pass albumin dialysis (SPAD) system. These systems use a 50kDa pore membrane to dialyse albumin in blood. This system is designed particularly to remove albumin-bound toxins from the blood of patients.
  • a larger pore membrane can be utilised so that albumin from the patient’s blood is actively exchanged with fresh albumin via dialysis. This permits the removal of toxins and abnormal forms of albumin in the same step. This also allows the introduction into the blood of new albumin, not from the individual, as discussed further below.
  • a membrane having a pore size of greater than 50 kDa, greater than 60 kDa, greater than 70 kDa, greater than 80 kDa, greater than 90 kDa or greater than 100 kDa may be used.
  • the membrane may have a pore size of less than 60 kDa, less than 75 kDa, less than 100 kDa or less than 150 kDa.
  • the membrane may have a pore size of greater than 45 kDa and less than 100 kDa.
  • the membrane may have a pore size of greater than 50 kDa and less than 100 kDa.
  • Other blood components may be removed together with albumin depending on the particular means used to remove the albumin.
  • other components which are removed with the albumin may be returned to the blood of the individual.
  • the components to be returned may be purified from the albumin mixture that has been removed from the blood, or may be replaced by fresh equivalent components not deriving from the individual.
  • US Patent No. 4,093,612 discloses reactive dye compositions that can be used to remove albumin from a fluid.
  • such compositions may be used for the removal of albumin from the blood of the individual.
  • This may therefore be a selective albumin trapping system based on compounds which specifically bind albumin.
  • These may be, for example reactive dyes as described in US Patent No. 4,093,612 such as cibacron-blue, or may be other molecules capable of binding albumin, such as albumin-specific antibodies.
  • albumin is removed from the blood of an individual with liver disease.
  • this albumin is replaced simultaneously with new albumin which does not derive from the individual.
  • the new albumin is preferably structurally and functionally normal. That is, the new albumin may comprise no, or substantially no, structurally or functionally modified forms of albumin. Where albumin removed from the blood of an individual comprises one or more modified forms of albumin, the albumin returned to the blood of that individual preferably comprises less modified albumin than has been removed. For example, the albumin returned to the blood of the individual may comprise less than 50%, less than 30%, less than 20%, less than 10%, less than 5% or less than 1% of the amount of modified albumin removed from that individual. Preferably, the albumin returned to the individual will comprise no modified albumin or no modified albumin of one or more of the types that were removed from the individual, such as no ischaemia modified albumin (IMA).
  • IMA no ischaemia modified albumin
  • the new albumin may derive from another individual, such as an individual that does not have liver disease, an individual that does not have liver failure or an individual that has normal liver function.
  • the new albumin will typically have a higher proportion of structurally and functionally normal albumin than the albumin removed from the individual.
  • the new albumin can be pharmaceutical grade albumin.
  • This new albumin is introduced into the blood of the individual to ensure that the individual has a suitable level of circulating albumin.
  • This can be a direct replacement for the albumin removed, for example, the same or an equivalent amount of albumin to that that is removed can be returned to the blood.
  • the individual’s albumin is effectively exchanged with new albumin.
  • the overall albumin concentration in the blood can be increased or decreased if necessary.
  • the amount of albumin that is introduced to the blood may thus be greater than or less than the amount that is removed. For example, liver disease can lead to a decrease in the level of circulating albumin. This can result in a low functional capacity.
  • the amount of new albumin introduced to the blood of the patient may be greater than the amount of albumin removed. This may supplement the level of albumin in the circulation of the individual. For example, an amount of new albumin may be introduced which raises the overall albumin level in the blood to a level the same as, or similar to, that seen in an individual not having liver disease.
  • the new albumin is introduced to the blood of the individual simultaneously with the removal of the individual’s albumin.
  • an exchange of albumin may be achieved by dialysis.
  • Simultaneous albumin removal and albumin return may also comprise sequentially or separate steps.
  • the blood of the individual may be passed through means for removing albumin and then subsequently have fresh albumin added to it. This may be achieved by different parts of the same apparatus.
  • endotoxin is a component in the blood of individuals with liver disease which may be associated with the prognosis of those patients, for example their susceptibility to infection or organ failure, their risk of mortality and their potential responsiveness to some therapies such as immunosuppression.
  • prognosis factors are linked to activation of neutrophils in the blood of an individual having liver disease, and that such activation may be related to the presence of a transmissible factor in the plasma of those individuals.
  • plasma from an individual having a high degree of neutrophil activation is capable of increasing the level of activation of normal neutrophils.
  • the inventors have further found that a similar effect may be achieved by contacting normal neutrophils with endotoxin, and that removal of endotoxin from the blood of patients having a high degree of neutrophil activation can reduce the activation levels of neutrophils in that blood. Removal of endotoxin is therefore believed to be useful in the treatment of patients having liver disease whose neutrophils are in an activated state. By restoring normal neutrophil function, the ability of those individuals to combat infection may be improved.
  • the present invention also relates to the removal of endotoxin from the blood of the patients.
  • Removal of albumin addresses one issue of detoxification, removal of endotoxin relates to a further issue of reduced immune response.
  • the means for removing endotoxin from the blood removes endotoxin selectively. That is, endotoxin is removed in preference to other substances in the blood.
  • the amount of endotoxin removed from the blood is significantly greater than that of other blood components removed. For example, more than 99% by weight of the component removed in this aspect may be endotoxin. More than 98%, more than 95%, more than 90%, more than 80%, more than 70%, more than 60% or more than 50% of the component removed in this aspect may be endotoxin.
  • the means for removing endotoxin may be any means capable of selectively removing endotoxin from blood.
  • endotoxin may be selectively removed using a ligand that binds the endotoxin.
  • the ligand may be any molecule that binds endotoxin.
  • antiendotoxin antibodies, LPS binding proteins, Polymyxin B, polyethyleneimine, an arginine ligand and various peptides are known to bind endotoxin.
  • the ligand may be an antibody or other affinity ligand that specifically bind endotoxin.
  • the ligand may be an antibody that specifically binds endotoxin.
  • a ligand that specifically binds endotoxin is a ligand capable of selectively removing endotoxin from blood as explained above.
  • the ligand is capable of binding endotoxin more strongly than other components of blood.
  • the ligand may be an antibody that binds an epitope that is specific to endotoxin.
  • the ligand may be a combination of molecules which each bind endotoxin, such as a combination of molecules which bind different parts of the endotoxin molecule or different endotoxins.
  • the ligand may be a polyclonal antibody or mixture of antibodies which bind to multiple epitopes on the endotoxin molecule or different endotoxins.
  • Antibodies may be raised against specific epitopes of the endotoxin molecule.
  • Suitable antibody types may be any antibody type, as described above in relation to albumin, such as an antibody fragment.
  • Antibodies that bind endotoxin may be prepared by any means, for example as described above in relation to albumin-binding antibodies.
  • the antibody obtained may be isolated and, if desired, purified.
  • An antibody, or other ligand “specifically binds” to a protein when it binds with preferential or high affinity to the protein for which it is specific but does substantially bind not bind or binds with only low affinity to other proteins. That is, it binds to endotoxin more strongly than it binds to other blood components, such as other proteins in the blood.
  • the specificity of binding may be such that it binds different forms of endotoxin. Preferably, it binds a variety of forms of endotoxin with a greater affinity than other blood components.
  • the ligand may be provided attached to a solid support.
  • the ligand may be immobilised on such a solid support. Suitable solid supports are as discussed above in relation to albumin-binding ligands.
  • the means for removing endotoxin may comprise or consist of such a solid support on which is attached or immobilised a ligand capable of binding endotoxin.
  • the means for removing endotoxin may comprise or consist of a container through which blood is passed.
  • the container may thus comprise an inlet and an outlet.
  • the inlet and outlet are positioned so that blood passing through the container comes into contact with a solid support as described herein.
  • the means is designed or selected to maximise the area of contact between the blood and the solid support.
  • the means may be a column or filter bed packed with beads, wherein a ligand for albumin is immobilised on the beads.
  • an agent may be administered to the individual to reduce endotoxin levels.
  • the endotoxin in the blood may be functionally neutralised rather than removed.
  • Various methods for neutralising endotoxin are known in the art. This may comprise administering an agent to the individual, which agent is capable of selectively removing or neutralising the activity of the endotoxin. This may rely on the host immune system to aid removal of endotoxin.
  • a suitable agent may bind endotoxin and allow the immune system of the individual to clear the endotoxin-agent complexes from the blood.
  • agents for decreasing circulating endotoxin levels are known, for example anti-endotoxin antibodies, albumin and LPS-binding proteins, LPS neutralising CD-14 antibodies.
  • blood components may be removed together with endotoxin depending on the particular means used to remove the endotoxin. For example, some methods for removing endotoxin may also remove other toxins from the blood. This may be beneficial to the patient. Some methods for removing endotoxin may also remove other blood components which it is desired to maintain in the blood. In this case, blood components which are removed with the endotoxin may be returned to the blood of the individual. The components to be returned may be purified from the endotoxin mixture removed, or may be replaced by fresh equivalent components that do not derive from the individual.
  • EP-A-0 129 786 describes the use of Polymyxin B covalently immobilized on polystyrene fibres for the removal of endotoxins from blood.
  • Falkenhagen et al (Artificial Organs (1996) 20:420) described the removal of endotoxin from plasma using polyethyleneimine coated beads.
  • WO 01/23413 describes oligopeptides having a high degree of dispersity which are used to selectively remove endotoxin from blood or plasma.
  • the apparatus or method of the invention will preferably be effective in achieving a significant reduction in circulating blood endotoxin levels.
  • the apparatus or method may lead to a reduction by at least 25%, at least 50%, at least 70%, at least 80%, at least 90%, at least 95%, at least 99% or more in the level of endotoxin in the blood of the individual.
  • albumin is capable of binding endotoxin in the blood.
  • the removal of albumin may also lead to the removal of some endotoxin which is bound to albumin.
  • albumin in the blood can bind to circulating endotoxin and the levels of free endotoxin in the blood may be decreased.
  • the present invention preferably utilises separate means for (a) removing albumin and (b) reducing endotoxin levels. This effect of albumin removal and/or replacement may supplement other means for reducing endotoxin and may help to “mop up” endotoxin remaining in the blood of the individual.
  • the inventors have developed a new method for use in the treatment of individuals having liver disease. These comprise a combination of components which act to remove both albumin and endotoxin from the blood of an individual having liver disease.
  • the inventors have developed an apparatus for use in the treatment of an individual having liver disease, the apparatus comprising means for removing albumin from the blood of the individual, removing albumin from the blood of the individual, and means for selectively removing endotoxin from the blood of the individual.
  • the apparatus also comprises means for supplying new albumin, that does not derive from the individual, to the blood of the individual.
  • the apparatus may also comprise means for supplying new fully functional albumin, that does not derive from the individual, to the blood of the individual.
  • the addition of fresh albumin to the blood can also be used to supplement endogenous albumin levels where these are reduced as a result of liver disease.
  • the removal of endotoxin from the blood of an individual having liver disease can help to reduce the level of activation of neutrophils in the blood of the individual. This reduction in neutrophil activation can lead to decreased risk of infection, organ failure and mortality, and can improve the responsiveness of the individual to immunosuppressive therapy and steroid or antibiotic treatment.
  • the methods of the invention thus provide a targeted approach to the treatment of liver disease, addressing multiple factors linked to such disease and benefiting the individual in multiple ways.
  • the invention relates to an apparatus for use in the treatment of an individual with liver disease.
  • the apparatus may comprise a number of components, which may be used in combination or separately.
  • An apparatus of the invention will comprise or consist essentially of means for removing albumin from the blood of an individual, means for selectively removing endotoxin from the blood of the individual and means for the simultaneous supply of albumin that does not derive from the individual to the blood of the individual.
  • a single component of the apparatus may be used for the removal of both albumin and endotoxin.
  • a component of the apparatus will comprise both means for removing albumin and means for removing endotoxin.
  • albumin and endotoxin are both to be removed by binding to specific ligands, then one or more ligands specific for albumin and one or more ligands specific for endotoxin may be used together in the same component of the apparatus.
  • the apparatus may comprise a single container, such as a column or filter bed, which comprises solid support(s) onto which the two ligands are immobilised. The ligands may be immobilised onto different supports or onto the same support. The albumin and endotoxin may thus be removed simultaneously from the blood of the individual.
  • the apparatus may include separate means for removal of albumin and endotoxin.
  • the apparatus may include more than one means capable of removing albumin and/or more than one means capable of removing albumin.
  • the apparatus also comprises means for supplying new albumin, i.e. albumin that does not derive from the individual, to the blood.
  • the apparatus may be for use ex vivo.
  • the apparatus may be designed such that blood from the individual passes through it so as to achieve albumin removal and endotoxin removal before returning to the body of the individual.
  • the albumin trap selectively removes albumin from the blood of the patient.
  • Means for carrying out albumin dialysis to remove toxins For example, the use of a large pore membrane (greater than 45 kDa) to allow albumin exchange permits improved toxin removal by allowing patient albumin to interact with the “cleaning” filters. This also permits the removal of patient albumin as it is exchanged across the filter with the albumin dialysate.
  • the invention also relates to a method of treating liver disease by using the apparatus of the invention.
  • blood from the individual may be contacted with an apparatus of the invention such that albumin and endotoxin are removed from the blood and albumin that does not derive from the individual may optionally be supplied to the blood.
  • This method may be carried out ex vivo and the blood may be subsequently returned to the individual.
  • the invention relates to a method of treating an individual having liver disease.
  • the method comprises or consists essentially of the following steps: (a) removing albumin from the blood of the individual; (b) reducing the level of endotoxin in the blood of the individual, and (c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual.
  • This may be achieved by any method or means as described herein. This method may be carried out ex vivo.
  • Steps (a) and (c) may be achieved using dialysis.
  • Step (a) may be achieved using a ligand capable of specifically binding albumin.
  • Step (b) may be achieved by directly removing endotoxin from the blood.
  • Step (b) may be achieved using a ligand that specifically binds endotoxin.
  • Step (b) may be achieved by administering to the individual a therapeutically effective amount of an agent capable of reducing the level of endotoxin in the blood. Any combination of step (a), step (b) and step (c) methods described herein may be used.
  • the method of treating a subject having liver failure as described herein comprises further steps.
  • the method comprising treatment of said individual’s blood comprises measurement of levels of various chemicals and/or biomarkers in the blood.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets/ mm 3 .
  • the platelet count is more than about 30,000 platelets/ mm 3 .
  • the method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g/L.
  • the fibrinogen level more than about 1.0 g/L.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L maximises the safety of the method and reduces the risk of hypotension.
  • platelet count and fibrinogen levels are monitored during the method.
  • the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets/ mm 3 or lower and the fibrinogen level is l.Og/L or lower.
  • the method comprises measurement of blood gas analysis.
  • Blood gas analysis comprises of measurements of Oxygen (O2) and Carbon dioxide (CO2) levels in the blood. These are important markers of respiratory function such as oxygenation level and adequate removal of CO2 from the body. These are essential elements of monitoring a sick patient such as patients with liver failure, they provide early signs of deterioration of respiratory function e.g. fluid accumulation in the lungs, new pneumonias may lead to inadequate oxygenation and change in CO2 may occur with worsening brain function (hepatic encephalopathy) or patient not able to breathe enough to eliminate CO2 adequately.
  • O2 Oxygen
  • CO2 Carbon dioxide
  • the method comprises measurement of blood gas analysis, including measurement of lactate. Therefore, blood gas analysis is an important component of monitoring patients while being treated by the method of the invention. It provides regular information about respiratory, circulatory, renal and homeostatic functions, each of which is important in defining the survival of a patient with ACLF.
  • the method comprises measurement of full blood count (FBC).
  • Full blood count (FBC) provides following important information: a. Haemoglobin (Hb) level - Regular Hb monitoring allows early detection of anaemia and need for blood transfusion - this is particularly relevant with extracorporeal therapy as dilutional anaemia can occur because of the priming of the filter. It is even more important with DIALIVE being a dual filter system and has a much higher priming volume because of two filters. To counteract this, the starting Hb level of at least 9g/dL (90g/L) is targeted.
  • Hb monitoring is also important for early identification of potential haemolysis, though uncommon, associated with extracorporeal therapy and, in unexplained anaemia require a full haemolysis screen (Hb, reticulocyte count, blood film analysis, lactic dehydrogenase (LDH), serum haptoglobin, split bilirubin; unconjugated and conjugated, urinary and effluent fluid free Hb)
  • Hb reticulocyte count, blood film analysis, lactic dehydrogenase (LDH), serum haptoglobin, split bilirubin; unconjugated and conjugated, urinary and effluent fluid free Hb
  • WCC White cell count
  • Platelet count - consumption of platelets is an important feature of extracorporeal intervention, can lead to severe reduction in platelet counts promoting bleeding complications. Monitoring platelet count closely and aiming for a platelet count of above 30,000/mm3 with platelet transfusion where required, especially in patients with high bleeding risk mitigates this risk.
  • the method comprises measurement of FBC including Haemoglobin (Hb) level, White cell count (WCC) and Platelet count.
  • Hb Haemoglobin
  • WCC White cell count
  • U/E urea and electrolytes
  • the method comprises monitoring of U/E to continuously assess acute kidney injury.
  • the method comprises conducting a Liver function test (LFT).
  • LFTs act to assess the trajectory of liver function during treatment. Examples of LFTs include measurement of total serum bilirubin.
  • the method comprises measurement of total serum bilirubin. Total serum bilirubin is most important LFT in defining liver-specific organ failure and its impact on the ACLF grade and severity. A measure of >12mg/dL total serum bilirubin constitutes liver organ failure.
  • Coagulation profile includes the following: a. Prothrombin time (PT) or International Normalised Ratio (INR) which are a direct function of the clotting factors produced by the liver and is usually deranged, in varying degree, in ACLF, an INR above 2.5 constitutes coagulation organ failure. b. Activated Partial Thromboplastin Time (APTT) which is a function of endothelial activation (for example following an infection) or heparin therapy, an anticoagulant agent used for most patients to prevent filter thrombosis/clotting, and APTT therefore is an important monitoring tool to assess optimal anti coagulation of the system and APTT ratio maintained at 1.5-2. c.
  • PT Prothrombin time
  • INR International Normalised Ratio
  • APTT Activated Partial Thromboplastin Time
  • Fibrinogen a coagulation factor synthesized by the liver may be low in liver failure to start with. Further reduction in levels can occur from potential consumption by extracorporeal treatment, or more commonly by severe infection, precipitating consumptive coagulopathy DIC (Disseminated Intravascular Coagulation) with exaggerated risk of both bleeding as well as thrombosis. Where DIC is suspected a full DIC screen must be sought which includes blood film analysis, platelet count, fibrinogen levels, D-dimer or fibrin degradation products (FDP).
  • DIC Dispertive coagulopathy
  • fibrinogen levels are detected in a blood sample taken from the patient, and a fibrinogen level of >1.0 g/L is to be considered before commencement of treatment.
  • fibrinogen levels are detected in a blood sample taken from the patient, and a fibrinogen level of >1.0 g/L is to be considered as best practice before commencement of treatment.
  • fibrinogen levels are detected in a blood sample taken from the patient with active search and treatment of any untreated or partially treated infection commenced.
  • a platelet count is carried out on a blood sample taken from the patient, and a platelet count of > 30,000 platelets/mm 3 is considered as best practice before commencement of treatment.
  • a platelet count > 30,000 platelets/mm 3
  • a fibrinogen level >1 g/L are standard pre-requisite for safely inserting a dialysis catheter required for DIALIVE and achieved by transfusion of platelets and cryoprecipitate respectively.
  • the method comprises measurement of blood gas analysis, including measurement of lactate, measurement of full blood count (FBC), measurement of, urea and electrolytes (U/E), conducting a Liver function test (LFT), and measurement of coagulation levels.
  • the method comprises 2-hourly arterial blood gas analysis (ABG including lactate) and 4 hourly bloods (FBC, U/E, LFT, coagulation) at 0, 4 and 8-12 hours (end of treatment). Any unexpected change to be investigated and treated accordingly. Any evidence of consumptive coagulopathy (platelets and fibrinogen falling significantly during treatment) should be investigated fully with DIC (Disseminated Intravascular Coagulation) screening.
  • the method comprises monitoring for the presence of anaemia. It is beneficial that unexplained anaemia during treatment is investigated for haemolysis.
  • the step of removing albumin from the blood of the individual comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and an initial blood flow rate through the means of approximately 30 - 60 ml/min, wherein the flow rate is increased during dialysis to no more than approximately 200 - 250 ml/min.
  • the initial flow rate through the means is approximately 30 ml/min, approximately 35 ml/min, approximately 40 ml/min, approximately 45 ml/min, approximately 50 ml/min, approximately 55 ml/min, or approximately 60 ml/min. In an especially preferred embodiment, an initial blood flow rate through the means is approximately 50 ml/min.
  • the flow rate is increased during dialysis to no more than approximately 200 ml/min, no more than approximately 210 ml/min, no more than approximately 220 ml/min, no more than approximately 220 ml/min., no more than approximately 230 ml/min, no more than approximately 240 ml/min or no more than approximately 250 ml/min.
  • the flow rate is increased during dialysis to no more than approximately 250 ml/min.
  • the initial blood flow rate through the means of approximately 50 ml/min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml/min.
  • blood flow rate through the system to be increased gradually from 50ml/min to 250ml/min and convective clearance rate (effluent production) increased slowly from IL/hour to pre-defined target of 50ml/kg/hr (approximately 3.5L/hr for a 75kg person), haemodynamic stability permitting.
  • the step of removing albumin from the blood of the individual comprises use of means for dialysis of albumin, said means comprising a high cut-off membrane in the first filter, e.g. Septex, having a pore size of greater than 45 kDa and less than 100 kDa, and an initial blood flow rate through the means to start gently at 50ml/min and increasing gradually to 250ml/min, provided the patient tolerates high blood flow rates in terms of haemodynamic stability.
  • a high cut-off membrane in the first filter e.g. Septex
  • an endotoxin binding filter can last for 48 hours without much reduction in its adsorptive capacity.
  • the method of treatment also comprises anti coagulation whilst the individual’s blood is treated.
  • the method of treatment also comprises anti coagulation of the means of dialysis whilst the individual’s blood is treated.
  • Anti coagulation of the means of dialysis whilst the individual’s blood is treated to ensure filter patency thus avoiding the need to change filters because of thrombosis and unnecessary interruption in treatment.
  • the anti coagulation is with unfractionated heparin.
  • the anti coagulation is achieved with unfractionated heparin.
  • the anti coagulation is achieved with infused unfractionated heparin.
  • the anti coagulation is achieved with infused unfractionated heparin (for example 500-1000 units/hour targeting an APTT of 1.5-2).
  • regional anti coagulation rather than systemic administration of heparin is provided to avoid unnecessarily increased bleeding risk associated with the latter.
  • unfractionated heparin is either completely avoided or the dose reduced and anti coagulation supplemented with alternatives such as the commonly used prostacycline analogue.
  • the anti coagulation is achieved with prostacycline analogues.
  • the anti coagulation is achieved with unfractionated heparin and/or prostacycline analogues.
  • prostacycline analogues include Treprostinil, Iloprost, Epoprostenol and Beraprost. Suitable doses for said treatment are known in the art. These preserve platelet function compared with heparin.
  • the method of treatment also comprises continuous measurement of mean arterial pressure (MAP) whilst the individual’s blood is treated.
  • MAP mean arterial pressure
  • Continuous measurement is defined herein as continuous invasive blood pressure monitoring, via for example, an arterial line.
  • Continuous measurement as described herein may be defined as, for example measurement of MAP for 10 seconds every 10 minutes.
  • MAP should be maintained at 90% or higher of pre-treatment MAP or above 65 mmHg, whichever is higher.
  • blood pressure monitoring is in place during treatment and rates adjusted to ensure a MAP of 65mmHg and above.
  • this should be invasive blood pressure monitoring. In the event of hypotension these rates should be reduced to prevent a reduction in blood pressure.
  • Other causes of hypotension should be searched for; for example, dehydration, septic shock etc. and treated accordingly.
  • vasopressors such as low-dose norepinephrine (0.1-0.2microgram/kg/min) should be considered early.
  • the method of treatment also comprises the use of replacement fluid (pre-dilution solution) started at a rate of 1000 ml/hr and increased gradually to up to 3500 ml/hr (50mls/kg/hr for a 75 kg person) subject to hemodynamic stability.
  • the concomitant dialysis component should run at 1500 ml/hr (25 ml/kg/hr for a 75 kg person).
  • the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin).
  • the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin) when blood passes through the means for removing albumin.
  • the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin) when blood passes through the means for removing albumin, such as the first filter e.g. a Septex filter. Rate of effluent production determines how much of these solutes are removed.
  • rate of removal has been increased from 35ml/kg/hr (approximately 2.5 L/hr for a 75 kg person) to 50ml/kg/hr (3.5 L/hr) for more effective convective clearance.
  • rate of removal has been increased from 35ml/kg/hr (approximately 2.5 L/hr for a 75 kg person) to 50ml/kg/hr (3.5 L/hr) for more effective convective clearance starting slow and at low volume of IL/hr and increasing slowly to a pre-defined target of 50ml/kg/hr, haemodynamic stability permitting.
  • the waste volume can be then replaced in similar quantities as a continuous infusion by standard replacement fluid where blood enters the Septex filter (called pre-dilution replacement).
  • an additional counter-current dialysis component is also incorporated running through the Septex filter to improve clearance of very small molecules and for better acid base homeostasis.
  • the rate for this was increased from IL/hr in the previous iteration to 1.5L/hr ((25 ml/kg/hr for a 75 kg person).
  • the method of treatment also comprises the simultaneous exchange of albumin. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 3-10g/hr. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 5g/hr.
  • the method of treatment also comprises the simultaneous replacement of removed albumin with exogenous bottled 20% Human albumin solution exchange of albumin at a rate of approximately 5g/hr before the purified blood had been returned back to the patient.
  • the amount of albumin lost during DIALIVE treatment was assessed from animal studies, further in-vitro studies and from data collected from the first few treated patients in the trial.
  • the invention also relates to method of treating blood extracorporeally by removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease.
  • Said method may be an in vitro method.
  • This method may be achieved by any suitable means as described herein and comprises the additional step of adding to the blood albumin that does not derive from the individual.
  • Blood which has been treated in this way may be returned to the individual for therapeutic purposes, or may be used for another purpose. For example, blood may be treated in this way prior to transfusion into a different individual.
  • the method of treating blood extracorporeally by selectively removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease as described herein comprises further steps.
  • the method comprising treating said individual’s blood may also comprise measurement of levels of various chemicals and/or biomarkers in the blood.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets/ mm 3 .
  • the platelet count is more than about 30,000 platelets/ mm 3 .
  • the method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g/L.
  • the fibrinogen level more than about 1.0 g/L.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L maximises the safety of the method and reduces the risk of hypotension.
  • platelet count and fibrinogen levels are monitored during the method.
  • the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets/ mm 3 or lower and the fibrinogen level is l.Og/L or lower.
  • the method comprises measurement of blood gas analysis as defined herein.
  • the method comprises measurement of blood gas analysis, including measurement of lactate.
  • the method comprises measurement of full blood count (FBC).
  • FBC full blood count
  • the method comprises measurement of FBC including Haemoglobin (Hb) level, White cell count (WCC) and Platelet count.
  • the method comprises measurement of urea and electrolytes (U/E).
  • the method comprises monitoring of U/E to continuously assess acute kidney injury.
  • the method comprises conducting a Liver function test (LFT). Examples of LFTs include measurement of total serum bilirubin.
  • the method comprises measurement of total serum bilirubin.
  • Total serum bilirubin is most important LFT in defining liver-specific organ failure and its impact on the ACLF grade and severity. A measure of >12mg/dL total serum bilirubin constitutes liver organ failure.
  • the method comprises measurement of blood gas analysis, including measurement of lactate, measurement of full blood count (FBC), measurement of, urea and electrolytes (U/E), conducting a Liver function test (LFT), and measurement of coagulation levels.
  • the method comprises 2-hourly arterial blood gas analysis (ABG including lactate) and 4 hourly bloods (FBC, UZE, LFT, coagulation) at 0, 4 and 8-12 hours (end of the method). Any evidence of consumptive coagulopathy (platelets and fibrinogen falling significantly during the method) should be investigated fully with DIC (Disseminated Intravascular Coagulation) screening.
  • the method comprises monitoring the blood for the presence of anaemia. It is beneficial that unexplained anaemia during the method is investigated for haemolysis.
  • the step of selectively removing albumin from the blood of the individual comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and an initial blood flow rate through the means of approximately 30 - 60 ml/min, wherein the flow rate is increased during dialysis to no more than approximately 200 - 250 ml/min.
  • the initial flow rate through the means is approximately 30 ml/min, approximately 35 ml/min, approximately 40 ml/min, approximately 45 ml/min, approximately 50 ml/min, approximately 55 ml/min, or approximately 60 ml/min.
  • the initial blood flow rate through the means is approximately 50 ml/min.
  • the flow rate is increased during dialysis to no more than approximately 200 ml/min, no more than approximately 210 ml/min, no more than approximately 220 ml/min, no more than approximately 220 ml/min, no more than approximately 230 ml/min, no more than approximately 240 ml/min or no more than approximately 250 ml/min.
  • the flow rate is increased during dialysis to no more than approximately 250 ml/min.
  • the initial blood flow rate through the means of approximately 50 ml/min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml/min.
  • the method also comprises the use of replacement fluid (pre-dilution solution) started at a rate of 1000 ml/hr and increased gradually to up to 3500 ml/hr (50mls/kg/hr for a 75 kg person) subject to hemodynamic stability.
  • the concomitant dialysis component should run at 1500 ml/hr (25 ml/kg/hr for a 75 kg person).
  • the method also comprises the simultaneous exchange of albumin should at a rate of approximately 3-10g/hr. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 5g/hr.
  • the invention also relates to albumin that does not derive from the blood of an individual to be treated for use in a method of liver disease, said method comprising the steps of:
  • step (c) introducing said albumin that does not derive from the individual to be treated into the blood of the individual; wherein step (a) is carried out by dialysis using means comprising a membrane having a pore size of greater than 45kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets/mm 3 and the fibrinogen level is >1.0 g/L.
  • This method may be achieved by any suitable means as described herein.
  • the method comprising treating said individual may also comprise measurement of levels of various chemicals and/or biomarkers in the blood of said individual as described herein.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets/ mm 3 .
  • the platelet count is more than about 30,000 platelets/ mm 3 .
  • the method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g/L.
  • the fibrinogen level more than about 1.0 g/L.
  • the platelet count and fibrinogen level in the blood of the individual to be treated is determined.
  • the method is carried out on individuals who have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets/ mm 3 and a fibrinogen level of about >1.0 g/L maximises the safety of the method and reduces the risk of hypotension.
  • platelet count and fibrinogen levels are monitored during the method.
  • the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets/ mm 3 or lower and the fibrinogen level is l.Og/L or lower.
  • monitoring of the patient is conducted before the method of the invention is conducted.
  • the risk of blood pressure drop during treatment is mitigated through pre-treatment with fluids before starting treatment.
  • the need for pre-treatment and volume of fluid required to achieve this will vary from patient to patient and is to be assessed by a clinician.
  • an algorithm is used to guide the clinician on the need and criteria for the pre-treatment.
  • Patients with liver failure are often dehydrated from reduced oral intake and renal and bowel losses from diuretic and laxative use which are common treatments for decompensated chronic liver disease.
  • a method of treating an individual with liver disease comprising infusing the individual’s blood with 5% Human Albumin Solution (HAS); and then subsequently treating said individual’s blood by:
  • HAS Human Albumin Solution
  • step (h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:
  • the fluid for pre-treatment is 5% Human Albumin Solution (HAS), infused as boluses of 250 ml, to a maximum of IL.
  • HAS Human Albumin Solution
  • the individual to be treated according to the invention is an individual having liver disease.
  • Liver failure is the final stage of liver disease. Liver failure is divided into types depending on the rapidity of onset. Acute liver failure develops rapidly, but chronic liver failure may take months or years to develop. By definition, liver failure occurs when the liver is so diseased, and functioning so poorly, that encephalopathy is evident. Any progressive liver disease can result in liver failure; examples include: acetaminotophen toxicity, cirrhosis, viral hepatitis, and metastatic cancer of the liver. Other signs of liver disease such as jaundice, ascites, fetor hepaticus, and failure of coagulation indicate that the liver is having trouble performing its normal physiological duties, but it is not termed liver failure until the mental status changes appear.
  • the individual to be treated may be an individual whose liver is decompensated or which shows hepatic encephalopathy.
  • the individual’s liver may be in the compensated state.
  • the individual may have chronic liver disease.
  • the individual may have liver cirrhosis, for example with or without alcoholic hepatitis.
  • the individual may have acute liver failure.
  • the individual may have hepatic encephalopathy.
  • the onset of both acute and chronic liver disease may be due to a xenobiotic cause.
  • the individual may have been exposed to a chemical, drug or some other agent which causes liver damage.
  • the individual may have a reaction to an over-the- counter, prescriptive or “recreational” drug which causes liver damage.
  • the individual may have been taking RezulinTM (troglitazone; Parke-Davis), SerzoneTM (nefazodone; Bristol-Myers Squibb) or other drugs thought to cause liver damage.
  • the individual may be one who has had an overdose of a particular drug or exceeded the recommended dosage of a drug capable of causing liver damage.
  • the individual may have taken an overdose of paracetamol.
  • the individual may have been exposed to chemicals which can cause liver damage such as, for example, at their place of work.
  • the individual may have been exposed to such chemicals in an industrial or agricultural context.
  • the individual may have consumed plants which contain compounds which can cause liver damage, in particular this may be the case where the individual is an animal, such as a herbivore.
  • the individual may have consumed a plant containing pyrrolizidine alkaloid such as ragwort.
  • the individual may have been exposed to environmental toxins thought to cause liver disease.
  • Drug-related liver toxicity comprises more than 50% of all cases with acute liver disease (acute liver failure).
  • Acetaminophen-(also known as paracetamol and N-acetyl-p- aminophenol) toxicity is the most common cause of acute liver failure in the United States and Great Britain.
  • Long-term moderate to heavy alcohol users who take acetaminophen in therapeutic or modestly excessive doses are at risk of severe hepatic injury and possibly acute liver failure. Alcohol use potentiates the toxic effects of acetaminophen.
  • Idiosyncratic drug toxicity also contributes to acute liver failure. Idiosyncratic drug toxicity is thought to be a hypersensitivity response wherein the individual responds to a drug in a pharmacologically abnormal way. This abnormal response can lead to acute liver failure.
  • the acute liver failure or chronic liver disease may be caused by infection with a pathogenic organism.
  • the liver disease may be due to viral infection.
  • the individual may be infected, or have been infected, with a virus which causes hepatitis.
  • the individual may have chronic viral hepatitis.
  • the virus may, for example, be hepatitis B, C or D virus.
  • the individual may also be infected with HIV-I or II.
  • the individual may have AIDS. It is possible that the individual may have been, or be, infected with other organisms which cause liver disease and in particular those which are present in the liver during some stage of their life cycle. For example, the individual may have, or have had, liver fluke.
  • the individual may have an inherited disease which causes, or increases the risk of, chronic liver disease.
  • the individual may have one or more of hepatic hemochromatosis, Wilson’s disease or a- 1 -antitrypsin deficiency.
  • the individual may have an inherited disorder which causes some kind of structural or functional abnormality in the liver which increases the likelihood of liver fibrosis.
  • the individual may be genetically predisposed to develop an autoimmune disorder which damages the liver and hence which can contribute to liver fibrosis.
  • the chronic liver disease may be alcohol-induced.
  • a man or woman to be treated may be, or have been, an alcoholic. He or she may be, or have been, consuming on average 50 or more units of alcohol per week, 60 or more units of alcohol per week, 75 or more units of alcohol per week and even 100 or more units of alcohol per week. The man or woman may be, or have been, consuming on average up to 100 units of alcohol per week, up to 150 units of alcohol per week and even up to 200 units of alcohol per week.
  • the measurement of one unit of alcohol differs from country to country. Here, one unit equals 8 grams of ethanol in accordance with the United Kingdom standard.
  • the man or woman may have been consuming such levels of alcohol for 5 or more years, 10 or more years, 15 or more years or 20 or more years.
  • the individual may have been consuming such levels of alcohol for up to 10 years, up to 20 years, up to 30 years and even up to 40 years.
  • the individual may be aged, for example, 25 years or over, 35 years or over, 45 years or over and even over 60 years.
  • the individual may be male or female. Women may be more susceptible to the adverse effects of alcohol than men. Women can develop alcoholic chronic liver disease in a shorter time frame and from smaller amounts of alcohol than men. There seems to be no single factor to account for increased susceptibility to alcoholic liver damage in females, but the effect of hormones on the metabolism of alcohol may play an important role.
  • Alcoholic hepatitis may range from a mild hepatitis, with abnormal laboratory tests being the only indication of disease, to severe liver dysfunction with complications such as jaundice (yellow skin caused by bilirubin retention), hepatic encephalopathy, ascites, bleeding esophageal varices, abnormal blood clotting and coma.
  • the individual may be suffering from acute-on-chronic liver failure (ACLF).
  • ACLF acute-on-chronic liver failure
  • the individual may have one or more of a number of other conditions known to result in liver damage such as, for example, primary biliary cirrhosis, autoimmune chronic active hepatitis, and/or schistosomiasis (parasitic infection).
  • the individual may have or have had a bile duct blockage.
  • the underlying cause of liver disease may not be known.
  • the individual may have been diagnosed as having cryptogenic cirrhosis. Accordingly, the individual may be suspected of having any of the conditions listed herein.
  • Methods for diagnosing liver disease such as acute liver failure and hepatic encephalopathy are well known in the art and in particular to clinicians and veterinarians in the field.
  • the individual will have been diagnosed as having a liver disease and hepatic encephalopathy, for example by a medical or veterinarian professional.
  • the individual may display one or more symptoms associated with liver disease such as one or more of jaundice, ascites, skin changes, fluid retention, nail changes, easy bruising, nose bleeds, oesophageal varices, and in male individuals may have enlargement of breasts.
  • the individual may display exhaustion, fatigue, loss of appetite, nausea, weakness and/or weight loss.
  • the individual may also display one or more symptoms associated with hepatic encephalopathy such as one or more of confusion, disorientation, dementia, stupor, coma, cerebral edema, multiorgan failure (respiratory failure, cardiovascular failure or kidney failure), muscle stiffness/rigidity, seizures or speech impairment.
  • the individual to be treated may or may not be taking other drugs to treat liver disease.
  • the individual to be treated may be at risk of developing hepatic encephalopathy.
  • liver disease may have been, or be, confirmed by physical examination including techniques such as ultrasound.
  • Liver biopsies may have been taken to look for build-up of fibrosis, necrotic cells, cellular degeneration and/or inflammation and other characteristic features of liver disease.
  • Liver function may have been assessed in the individual to determine whether this is compromised in the individual.
  • the nature and underlying cause of the liver disease may be characterized. Any history of exposure to causative agents of liver disease may be determined.
  • the individual to be treated may be at risk for hepatic encephalopathic episodes, for example patients who are awaiting liver transplants, surgical and/or portal hypertension patients.
  • a person at risk for hepatic encephalopathic episodes is a person who has not suffered any hepatic encephalopathic episodes or has not suffered any hepatic encephalopathic episode for an extended period of time (about 12 weeks or longer), but has a disorder or medical condition which creates a risk of hepatic encephalopathic episodes.
  • a hepatic encephalopathic episode is a clinical condition characterised by the presence of cerebral dysfunction in patients with liver disease or dysfunction.
  • the individual on which the method of the invention is practiced may be a liver transplant patient, an individual suffering from reperfusion injury, for example in a graft after liver transplantation or a patient at risk of developing or who has developed multiorgan failure.
  • an agent may be administered orally, for example as tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules.
  • the agent may also be administered parenterally, either subcutaneously, intravenously, intramuscularly, intranasally, intrasternally, transdermally or by infusion techniques.
  • the agent may also be administered in the form of a suppository. A physician will be able to determine the required route of administration for each particular patient.
  • an agent will depend upon factors such as the nature of the exact agent, whether a pharmaceutical or veterinary use is intended, etc.
  • An agent which is to be used to treat liver disease may be formulated for simultaneous, separate or sequential use.
  • An agent is typically formulated for administration in the present invention with a pharmaceutically acceptable carrier or diluent.
  • the pharmaceutical carrier or diluent may be, for example, an isotonic solution.
  • solid oral forms may contain, together with the active compound, diluents, e.g. lactose, dextrose, saccharose, cellulose, com starch or potato starch; lubricants, e.g. silica, talc, stearic acid, magnesium or calcium stearate, and/or polyethylene glycols; binding agents; e.g. starches, gum arabic, gelatin, methylcellulose, carboxymethylcellulose or polyvinyl pyrrolidone; disaggregating agents, e.g.
  • Such pharmaceutical preparations may be manufactured in known manner, for example, by means of mixing, granulating, tabletting, sugar-coating, or film-coating processes.
  • Liquid dispersions for oral administration may be syrups, emulsions or suspensions.
  • the syrups may contain as carriers, for example, saccharose or saccharose with glycerine and/or mannitol and/or sorbitol.
  • Suspensions and emulsions may contain as carrier, for example a natural gum, agar, sodium alginate, pectin, methylcellulose, carboxymethylcellulose, or polyvinyl alcohol.
  • the suspensions or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g. sterile water, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and if desired, a suitable amount of lidocaine hydrochloride.
  • Solutions for intravenous administration or infusion may contain as carrier, for example, sterile water or preferably they may be in the form of sterile, aqueous, isotonic saline solutions.
  • the dose of an agent may be determined according to various parameters, especially according to the substance used; the age, weight and condition of the patient to be treated; the route of administration; and the required regimen.
  • a typical daily dose is from about 0.1 to 50 mg per kg of body weight, according to the activity of the specific inhibitor, the age, weight and conditions of the individual to be treated, the type and severity of the degeneration and the frequency and route of administration.
  • daily dosage levels are from 5 mg to 2 g-
  • a method of treating an individual with liver disease comprising treating said individual’s blood by: (a) removing albumin from the blood of the individual;
  • step (h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:
  • a membrane having a pore size of greater than 45 kDa and less than 100 kDa (1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa
  • steps (a) and (b) comprise different means for removing albumin and reducing the level of endotoxin.
  • step (j) removing toxins bound to albumin from the blood of the individual. 5.
  • step (a) comprises the use of a solid support capable of selectively binding albumin.
  • step (b) comprises the use of a solid support capable of selectively binding endotoxin.
  • an ex vivo method of treating blood extracorporeally by removing albumin and endotoxin from the blood comprising:
  • step (h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:
  • a membrane having a pore size of greater than 45 kDa and less than 100 kDa (1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa
  • steps (i) steps (a) and (b) of the method comprise different means for removing albumin and removing endotoxin;
  • the solid support of (a) comprises an antibody that specifically binds albumin.
  • a method of treating an individual with liver disease comprising treating said individual’s blood by:
  • step (h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising: (i) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and
  • a method of treating an individual with liver disease comprising treating said individual’s blood by:
  • step (h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:
  • a membrane having a pore size of greater than 45 kDa and less than 100 kDa (1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa
  • MAP mean arterial blood pressure
  • Blood pressure monitoring can be performed using either as an invasive monitoring (preferred) using an arterial catheter inserted in a peripheral artery (radial or brachial artery) for beat-to-beat (pressure with every heartbeat) BP monitoring.
  • standard non-invasive BP monitoring can be considered.
  • the latter uses a standard BP cuff measuring BP every 10 minutes at a minimum or more frequently if clinical condition demands.
  • Invasive methods offer the additional advantage of obtaining frequent blood samples from the indwelling line without the need for multiple venepunctures. Mitigation of risk of blood pressure drop through pre-treatment with fluids before starting a session of DIALIVE treatment.
  • liver failure Patients with liver failure are often dehydrated from reduced oral intake and renal and bowel losses from diuretic and laxative use which are common treatments for decompensated chronic liver disease.
  • acute decompensation and ACLF because of intense systemic inflammation and endothelial dysfunction, causes capillary leak and increased capillary permeability with body fluids re-distributed away from the circulation to tissues, causing further depletion of the circulatory volume and making patients susceptible to haemodynamic instability during an extracorporeal intervention.
  • the preferred fluid for pre-treatment is 5% Human Albumin Solution (HAS), infused as boluses of 250 ml to a maximum of IL.
  • HAS Human Albumin Solution
  • Blood pressure monitoring should be in place during this and rates adjusted to ensure a MAP of 65mmHg and above. Preferably, this should be invasive blood pressure monitoring. In the event of hypotension these rates should be reduced to prevent a reduction in blood pressure. Other causes of hypotension should be searched for; example dehydration, septic shock etc. and treated accordingly. If required, vasopressors such as low-dose norepinephrine (0.1-0.2microgram/kg/min) should be considered early.
  • Treatment dose escalation to achieve both better convective and diffusive clearance former achieved by increasing effluent production rate from 17ml/kg/hr to up to lOOml/kg/hr (haemodynamic stability permitting) and the latter by increasing the dialysis component which runs countercurrent to the blood flow in Septex filter from 0.5L/hr to 3L/hr.
  • Anti coagulation should be performed to optimize circuit life with minimal interruptions to treatment without increasing any bleeding risk through the use of unfractionated heparin and/or epoprostenol, a prostacycline analogue throughout the treatment.
  • a multi-center, randomized clinical trial of DIALIVE versus standard of care (SOC) was designed to test its safety and verify the hypothesis that DIALIVE will significantly improve the prognostic scores of patients with alcoholic cirrhosis and ACLF by impacting on the pathophysiological mechanisms and resolving organ failure.
  • the study was approved by the relevant Institutional Review Boards of the participating sites and was conducted according to the protocol, the ISO 14155, the ethical principles originating from the Declaration of Helsinki, and consistent with ICH Guidelines. Patients were required to supply written informed consent prior to participating.
  • the study protocol(s) are presented as Appendix 1.
  • the first major amendment included incorporation of recommendations of the Data Safety Monitoring Board (DSMB) to make DIALIVE therapy safer with detailed treatments to be carried out within intensive care unit (ICU) environment with frequent monitoring, immediate recognition and treatment of hypotensive episodes, volume pre-loading in clinically hypovolemic patients and albumin replacement simultaneously to removal (Appendix 2).
  • DSMB Data Safety Monitoring Board
  • the participant (or their legal representative) was allowed to voluntarily withdraw from the study at any time for any reason.
  • the investigator also had the right to withdraw a patient at any time due to failure to follow clinical investigation plan, administrative, safety or other reason.
  • SAE serious adverse event
  • DIALIVE device To evaluate the performance of DIALIVE device as measured by change in plasma endotoxin level (endotoxin activity and concentration), albumin function, 28-day mortality; change in individual organ function, in CLIF-OFs, ACLF Grade and CLIF-C ACLF score; ICU and hospital stay.
  • ID IB APS independent group
  • EFCLIF Data Management Centre
  • PL independent group
  • JC independent statistician
  • the Safety population (Safety set) was defined as the subset of randomized patients who received at least one session of treatment (in the DIALIVE arm).
  • the Modified Safety population (Modified Safety set) only included the evaluable patients to estimate the efficacy endpoints including the biomarkers. Values are reported as using mean and standard deviation if the variable is quantitative and with frequencies and percentages otherwise.
  • MMRM Mixed Models for Repeated Measurements
  • Mean age 49 years and approximately 75% patients were male. All had clinical, radiological, or histological evidence of underlying alcoholic cirrhosis.
  • the precipitating event in all patients was alcoholic hepatitis (NIAAA criteria) with superimposed infection in 4 cases in each group.
  • DIALIVE therapy was administered for a median of 3-sessions (range 1-5), each session lasting 8-12 hours, in the first 3 -days (range 1-6). Two patients were treated for 1-day, 11 for 3-days, 1 for 4-days and 3 for 5-days. User errors occurred in 3- patients and filter clotting occurred in 5-patients. The latter resolved with filter replacement.
  • the main improvement to the DIALIVE process was the identification of specific risk factors in the patient population to be treated.
  • the inventors found that a platelet count of about > 30,000 platelets/mm 3 and a fibrinogen level of about >1.0 g/L in the blood of the patients were correlated with decreased safety risks and reduced risk of hypotension.
  • Blood flow rates on DIALIVE device should be started at 50 ml/min and increased gradually over 1-2 hours to up to a maximum of 250 ml/min.
  • Replacement fluid should be started at a rate of 1000 ml/hr and increased gradually to up to 3500 ml/hr (50mls/kg/hr for a 75 kg person), subject to hemodynamic stability.
  • Concomitant dialysis component should run at 1500 ml/hr (25 ml/kg/hr for a 75 kg person).
  • Albumin should be exchanged simultaneously with DIALIVE treatment. Infusion of bottled albumin (through the Hepalbin filter or without) at a rate of 5 g/hr (to replace albumin removed by the device). This equates to an infusion of 20% human albumin solution at a rate of 25ml/hr.
  • Mean arterial pressure (MAP) should be continuously monitored. MAP should be maintained at 90% or higher of pre-treatment MAP or above 65 mmHg, whichever is higher.
  • a senior staff member should closely supervise the dialysis procedure during the first few hours of treatment, with a clear internal escalation plan available, and discuss with study Chief Investigator where necessary.
  • DIC Disseminated Intravascular coagulation
  • HMA human mercaptalbumin
  • HNA-1 human non-mercapt albumin 1
  • HNA-2 HNA 2
  • EAA Endotoxin activity assay
  • DIALIVE in clinical practice for the first time depicts evidence of a learning curve as evidenced by two deaths in the early phase of the study. These deaths occurred in hemodynamically unstable patients. Following extensive review by the DSMB, important necessary changes were made to patient management including requirement for managing these patients in a high dependency area and albumin replacement to occur concomitant to treatment and not at the end of treatment session.
  • two other DIALIVE treated patients died; one of whom had a CLIF-C ACLF score of 66 which is now widely regarded as a sub-group associated with extremely high risk of death and potential futility of ongoing ICU care. Nevertheless, this patient tolerated the treatment well but died from sepsis due to a previously undiagnosed osteomyelitis. The second death was precipitated by an acute myocardial infarction well after the end of DIALIVE treatment and thought to be unrelated to DIALIVE treatment. All three deaths in the SOC group were thought to be liver related.
  • DIALIVE patients had greater incidence of thrombocytopenia, bleeding, and hypotension, which are not uncommon in critically ill patients receiving extracorporeal therapy. Following protocol modification after the inclusion of Cohort 2, the incidence of hypotension was almost fully addressed. A further two milder episodes were corrected with prompt recognition and appropriate action around the time of starting DIALIVE therapy.
  • the most frequent SAE in the SOC patients was infection, which is well-known to complicate the course of ACLF and is a major cause of death.
  • DIALIVE-treated patients had lower rates of new infections and this is likely secondary to attenuation/dampening of endotoxemia, which drives the risk of infection through its deleterious effects on neutrophil function. In pre-clinical studies, DIALIVE has also shown to restored neutrophil function.
  • Albumin is the most abundant plasma protein in humans and has many pleotropic effects. In ACLF, there is both a reduction in the quantity and function of the circulating albumin, which not only adversely impacts on its detoxification ability, but the oxidized forms act as pro-inflammatory species and contribute to systemic inflammation. DIALIVE by virtue of exchanging the dysfunctional albumin with bottled albumin showed significantly improved albumin function. This was despite there being no difference in the concentration of circulating albumin between the DIALIVE and the SOC groups. During the 8-hour period, about 40-50g of albumin was recovered from the effluent, which is roughly what was replaced.
  • DIALIVE treatment resulted in an improvement in the thiol function, reduction in the deleterious (HNA-1) and permanently damaged fraction of albumin (HNA-2), binding and detoxification function and metal binding ability. It is important to note that this improved functionality was apparent even at day- 10 which is well beyond the scheduled treatment limited to 5 days, indicating perhaps that the sustained improvement might be a reflection of the modification of pathogenic factors responsible for albumin dysfunction.
  • Bacterial translocation is a particular feature of cirrhosis and ACLF and, manifests as accumulation of PAMPs. As many of these substances are ligands for the tolllike receptor and inflammasome pathways, they can drive systemic inflammation. There is good evidence linking accumulation of lipopolysaccharides with systemic inflammation and risk of mortality in ACLF.
  • DIALIVE was therefore, specifically designed to remove endotoxin.
  • Data from this study demonstrated that significantly greater reduction in the severity of endotoxemia using the LAL assay was observed in the DIALIVE treated patients, which was also sustained at Day- 10. It is difficult to draw conclusions from the results of the EAA assay as the data was analyzed in only about two thirds of the patients in both groups due to the high coefficient of variation in the others. Nevertheless, DIALIVE treatment reached the pre-defined acceptable value for >20% reduction from baseline in 80% and 30% patients at 5-days and 10-days compared with 36% and 50% in the SOC group respectively, but this was not statistically significant.
  • DIALIVE does not allow identification of a particular pathway but confirms the importance of albumin dysfunction and, PAMPs and DAMPs in the pathogenesis of ACLF as these were the main variables directly targeted by DIALIVE.
  • DIALIVE is likely to be safe with careful patient management and monitoring of the hemodynamically unstable patient population to be treated.
  • DIALIVE achieves its aims of reducing endotoxin and improving albumin function, which impacts positively on organ function allowing a greater proportion of patients to resolve ACLF with greater rapidity.
  • Toll-like receptor 4 is a therapeutic target for prevention and treatment of liver failure. J Hepatol 2020;73: 102-112.
  • Extracorporeal cellular therapy in severe alcoholic hepatitis: A multinational, prospective, controlled, randomized trial. Liver Transpl 2018;24:380-393.
  • ELAD Extracorporeal cellular therapy
  • Sundaram V Jalan R, Wu T, Volk ML, Asrani SK, Klein AS, et al. Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation. Gastroenterology 2019;156: 1381-1391 el383.
  • liver endothelial cells correlates with poor hepatocyte regeneration in acute-on-chronic liver failure.

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Abstract

L'invention concerne le traitement d'un individu souffrant d'une maladie hépatique. L'invention concerne des méthodes pour le traitement d'un tel individu et des méthodes in vitro de nettoyage extracorporel du sang.
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EP0129786A2 (fr) 1983-06-24 1985-01-02 Toray Industries, Inc. Matière de détoxication d'endotoxines
US5476715A (en) 1989-10-03 1995-12-19 Fresenius Ag Particulate adsorbent for the removal of biomacromolecules such as LDL and endotoxins from whole blood in extracorporeal circuits
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