MARS dialysis in decompensated alcoholic liver disease: a single-center experience

Application of the Molecular Adsorbent Recirculating System in Type 1 Hepatorenal Syndrome in the Course of Alcohol-Related Acute on Chronic Liver Failure

BACKGROUND This study aimed to evaluate the Molecular Adsorbent Recirculating System (MARS) effectiveness in patients with alcohol-related acute-on-chronic liver failure (AoCLF) complicated with type 1 hepatorenal syndrome (HRS). So far, MARS efficacy and safety has been demonstrated in various acute liver failure scenarios. MATERIAL AND METHODS Data from 41 MARS procedures (10 patients with type 1 HRS, in the course of alcohol-related AoCLF were considered for this study. Biochemical tests of blood serum were performed before and after each procedure. The condition of patients was determined before and after the treatment with the use of the model for end-stage liver disease - sodium (MELD-Na) and the stage of encephalopathy severity based on the West Haven criteria. RESULTS During the observation period (20.5±13.9 days), 5 patients died, and the remaining 5 surviving patients were discharged from the hospital. In the group of 10, the 14-day survival, starting from the first MARS treatment, was 90%. The MARS procedure was associated with a 19% reduction in bilirubin (27.5±6.1 versus 22.3±4.0 mg/dL, P<0.001), 37% reduction in ammonia (44.1±22.5 versus 27.6±20.9 P<0.001), 27% reduction in creatinine (1.5±1.0 versus 1.1±0.6 mg/dL, P<0.001) and 14% reduction urea (83.8±36.1 versus 72.1±33.3, P<0.001) in blood serum samples, with stable hemodynamic parameters. In the group of patients discharged from the clinic (n=5), the MARS treatments resulted in an improvement in hepatic encephalopathy (West Haven; P=0.043), as well as a reduction in the MELD-Na score (P=0.015). CONCLUSIONS MARS is a hemodynamically safe method for supporting the function of the liver and the kidneys. Application of the MARS reduces the symptoms of encephalopathy in patients with alcohol-related type 1 HRS.

Therapeutic alternatives for the treatment of type 1 hepatorenal syndrome: A Delphi technique-based consensus

AIM

To propose several alternatives treatment of type 1 hepatorenal syndrome (HRS-1) what is the most severe expression of circulatory dysfunction on patients with portal hypertension.

METHODS

A group of eleven gastroenterologists and nephrologists performed a structured analysis of available literature. Each expert was designated to review and answer a question. They generated draft statements for evaluation by all the experts. Additional input was obtained from medical community. In order to reach consensus, a modified three-round Delphi technique method was used. According to United States Preventive Services Task Force criteria, the quality of the evidence and level of recommendation supporting each statement was graded.

RESULTS

Nine questions were formulated. The available evidence was evaluated considering its quality, number of patients included in the studies and the consistency of its results. The generated questions were answered by the expert panel with a high level of agreement. Thus, a therapeutic algorithm was generated. The role of terlipressin and norepinephrine was confirmed as the pharmacologic treatment of choice. On the other hand the use of the combination of octreotide, midodrine and albumin without vasoconstrictors was discouraged. The role of several other options was also evaluated and the available evidence was explored and discussed. Liver transplantation is considered the definitive treatment for HRS-1. The present consensus is an important effort that intends to organize the available strategies based on the available evidence in the literature, the quality of the evidence and the benefits, adverse effects and availability of the therapeutic tools described.

CONCLUSION

Based on the available evidence the expert panel was able to discriminate the most appropriate therapeutic alternatives for the treatment of HRS-1.

Cell and tissue engineering for liver disease

Despite the tremendous hurdles presented by the complexity of the liver's structure and function, advances in liver physiology, stem cell biology and reprogramming, and the engineering of tissues and devices are accelerating the development of cell-based therapies for treating liver disease and liver failure. This State of the Art Review discusses both the near- and long-term prospects for such cell-based therapies and the unique challenges for clinical translation.

Impact of molecular adsorbent recirculating system on renal recovery in type-1 hepatorenal syndrome patients with chronic liver failure

BACKGROUND AND AIM

Liver transplantation remains the best option for treating type-1 hepatorenal syndrome (HRS1). The aim of this retrospective study was to determine whether the molecular adsorbent recirculation system (MARS) can improve renal function in HRS1 patients.

METHODS

Thirty-two patients with chronic liver disease and HRS1 were treated by MARS sessions which were performed every other day. The endpoint was renal function improvement by 28 days after diagnosis of HRS1 that was defined as a serum-creatinine level of < 133 μmol/L. Partial renal recovery was defined as a 10% decrease in baseline serum-creatinine level.

RESULTS

The mean number of MARS sessions required by each patient was 3.5 ± 1.5. The median time between admission and the start of MARS therapy was 3 (0-15) days. Of the total patients, 13 (40%) had improved renal function. Among these, nine (28%) had complete renal recovery. Among the patients that survived, only 40% (6/15) had improved renal function, and among the patients that died within the first month after the initiation of MARS, seven patients had a renal response. The 28-day survival rate was 47%. Seven patients received a liver transplant after diagnosis of HRS. Of these, four had complete or partial recovery after transplantation (57%) versus 9 of the 25 patients who did not undergo liver transplantation (36%), P = not significant.

CONCLUSION

MARS therapy improved renal function in only very few patients with HRS1. Further controlled studies including large number of patients are required.

Alcoholic hepatitis: diagnosis and management in 2012

Alcoholic hepatitis is a severe form of alcohol-related liver injury and one of the most frequent liver presentations seen by acute medical services. The condition typically affects young and middle-aged adults who present with jaundice and coagulopathy. Many patients fulfil the criteria for acute-on-chronic liver failure, though often the diagnosis of cirrhosis is only made after hospitalization. Despite over four decades of study, controversy surrounds many aspects of diagnosis and management, and short-term mortality in severe disease remains high. This review summarizes recent and important literature of relevance to clinicians, including aids to diagnosis, clinical prognostic scores and evidence for current medical therapies. Contentious issues such as the need for liver biopsy in diagnosis and the role for liver transplantation in those who fail to respond to medical treatment are also discussed.

Diagnosis and management of alcoholic hepatitis

Alcoholic hepatitis is a form of severe, cholestatic liver disease that results from consumption of large amount of alcohol during a sustained period of time in a subset of alcoholics. Symptoms could be mild and nonspecific to more severe. The diagnosis of alcoholic hepatitis can be made with a thorough history, physical examination, and review of laboratory results. Liver biopsy is confirmatory but generally not indicated for the diagnosis. Abstinence is the key form of therapeutic intervention. Despite variable results in clinical trials, corticosteroids and pentoxifylline seem to provide moderate survival benefit. Liver transplantation in acute alcoholic hepatitis is contentious.

Cost-effectiveness of the artificial liver support system MARS in patients with acute-on-chronic liver failure

BACKGROUND

For patients with an acute exacerbation of chronic liver failure (ACLF), the molecular adsorbent recirculating system (MARS) can result in a prolongation of life, but data on costs and cost-effectiveness are lacking.

METHODS

A health economic evaluation of a prospective controlled cohort trial in patients with ACLF not eligible for liver transplantation with 3 years follow-up and consecutive modelling of long-term costs, outcomes and cost-effectiveness was conducted. Costs were calculated from the perspective of the German health-care system.

RESULTS

One hundred and forty-nine patients with ACLF were included of which 67 (44.9%) were treated with MARS and 82 (55.1%) assigned to the control group. Mean survival was 692 days in MARS-treated patients (33% survival after 3 years) and 453 days in control patients (15% after 3 years, logrank P = 0.022). MARS patients gained 0.66 [95% confidence interval (CI): -0.12 to 1.46] life years (LYs), determined by the bootstrap method. The mean cost difference was 19.835 euro (95% CI: 13.308-25.429) with 35639 euro for MARS-treated patients and 15804 euro for controls. Incremental costs per LY gained were 29.985 euro (95% CI: 9.441-321.761) and 43.040 euro (95% CI: 13.551-461.856) per quality-adjusted LY gained.

CONCLUSION

There is an acceptable cost-effectiveness of MARS, compared with other medical technologies presently reimbursed. Randomized controlled trials with sufficient sample size are necessary before a final recommendation for MARS can be given.

Alcoholic liver disease

These recommendations provide a data-supported approach. They are based on the following: (i) a formal review and analysis of the recently published world literature on the topic (Medline search); (ii) American College of Physicians Manual for Assessing Health Practices and Designing Practice Guidelines (1); (iii) guideline policies, including the American Association for the Study of Liver Diseases (AASLD) Policy on the development and use of practice guidelines and the AGA Policy Statement on Guidelines (2); and (iv) the experience of the authors in the specified topic. Intended for use by physicians, these recommendations suggest preferred approaches to the diagnostic, therapeutic, and preventive aspects of care. They are intended to be flexible, in contrast to the standards of care, which are inflexible policies to be followed in every case. Specific recommendations are based on relevant published information. To more fully characterize the quality of evidence supporting the recommendations, the Practice Guideline Committee of the AASLD requires a Class (reflecting the benefit vs. risk) and Level (assessing the strength or certainty) of Evidence to be assigned and reported with each recommendation (Table 1, adapted from the American College of Cardiology and the American Heart Association Practice Guidelines) (3,4).

Survival predictors in patients treated with a molecular adsorbent recirculating system

AIM: To identify prognostic factors for survival in patients with liver failure treated with a molecular adsorbent recirculating system (MARS).

METHODS: MARS is a liver-assisting device that has been used in the treatment of liver failure to enable native liver recovery, and as a bridge to liver transplantation (LTX). We analyzed the 1-year outcomes of 188 patients treated with MARS, from 2001 to 2007, in an intensive care unit specializing in liver disease. Demographic, clinical and laboratory parameters were recorded before and after each treatment. One-year survival and the number of LTXs were recorded. Logistic regression analysis was performed to determine factors predicting survival.

RESULTS: The study included 113 patients with acute liver failure (ALF), 62 with acute-on-chronic liver failure (AOCLF), 11 with graft failure (GF), and six with miscellaneous liver failure. LTX was performed for 29% of patients with ALF, 18% with AOCLF and 55% with GF. The overall 1-year survival rate was 74% for ALF, 27% for AOCLF, and 73% for GF. The poorest survival rate, 6%, was noted in non-transplanted patients with alcohol-related AOCLF and cirrhosis, whereas, patients with enlarged and steatotic liver had 55% survival. The etiology of liver failure was the most important predictor of survival (P < 0.0001). Other prognostic factors were encephalopathy (P = 0.001) in paracetamol-related ALF, coagulation factors (P = 0.049) and encephalopathy (P = 0.064) in non-paracetamol-related toxic ALF, and alanine aminotransferase (P = 0.013) and factor V levels (P = 0.022) in ALF of unknown etiology.

CONCLUSION: The etiology of liver disease was the most important prognostic factor. MARS treatment appears to be ineffective in AOCLF with end-stage cirrhosis without an LTX option.

Liver support devices

PURPOSE OF REVIEW

Liver support devices are used either as a bridge to liver transplantation or liver recovery in patients with acute or acute-on-chronic liver failure. The review analyzes the recent literature and asks if the current enthusiasm for these devices is justified.

RECENT FINDINGS

Many liver support devices exist and are discussed. Clinical data on artificial devices are rapidly emerging, especially on the molecular adsorbents recirculating system, and fractionated plasma separation and adsorption (Prometheus). While hepatic encephalopathy is improved by the molecular adsorbents recirculating system and probably Prometheus too, neither system has been shown to improve survival. Less clinical data exist for bioartificial support devices. These may use human hepatocytes, such as the extracorporeal liver assist device, although most devices use porcine hepatocytes, such as HepatAssist.

SUMMARY

Enthusiasm in liver support devices is justified as many nonrandomized studies have suggested some biochemical and clinical benefits. The results of several ongoing multicenter randomized controlled trials are anxiously awaited. Meanwhile, because mortality without liver transplantation remains high despite the use of liver support devices, these devices should only be used in the research setting or by experts proficient in their use and as a bridge to liver transplantation rather than liver recovery.