Molecular Adsorbent Recirculating System as a Diagnostic and Therapeutic Modality

Despite the many advancements in liver transplantation (LT), mortality in patients with hepatic failure remains high, and to date, many patients die while awaiting LT. The molecular adsorbent recirculating system (MARS^®) is an extracorporeal liver support system intended to provide short-term metabolic detoxification, often as a vital bridge to LT. We report the case of a 41-year-old non-Hispanic White male who developed worsening multi-factorial encephalopathy in the setting of decompensated alcoholic cirrhosis. He continued to deteriorate despite supportive medical therapy, and extensive investigation for alternative causes of encephalopathy aside from hepatic was unrevealing; as a result, there was concern that his encephalopathy was due to irreversible causes from which he may not recover appropriately following LT. We herein: i) describe the implementation of MARS as a diagnostic intervention for encephalopathy of uncertain etiology in a patient with end stage liver disease who, on the basis of prompt psychomotor improvement, underwent LT 19 days post-MARS implementation with an excellent clinical outcome and thus ii) propose the use of extracorporeal liver support not only as a short-term bridge but also as a diagnostic (and potentially therapeutic) measure in cases of cryptogenic encephalopathy, particularly in the setting of advanced liver disease.

Immune modulator therapy for microscopic colitis in a case series of 73 patients

BACKGROUND

Microscopic colitis (MC) is a common cause of chronic diarrhoea. Various treatment options have been described, but there are limited data describing outcomes of corticosteroid-sparing treatments.

AIM

To evaluate the outcomes of patients with active MC treated with immune modulators.

METHODS

All patients seen at Mayo Clinic, Rochester between January 1, 1997 and November 30, 2016 with a histological diagnosis of MC were identified. Patients treated with an immune modulator of interest were selected and clinical outcomes recorded.

RESULTS

Seventy-three MC patients (50 collagenous colitis and 23 lymphocytic colitis) with a median disease duration of 24 months (range, 7-60) were included. The indications for treatment were budesonide-refractoriness in 66%, budesonide dependence in 29%, and budesonide intolerance in 5%. Median age was 51.8 years (range, 43.4-63.1) and 61 (84%) were female. Thiopurines were used in 49 patients (67%) for a median of 4 months (range, 1.5-15). Complete and partial response occurred in 43% and 22% respectively. Adverse effects resulting in therapy cessation occurred in 17 patients (35%). Twelve patients (16%) were treated with methotrexate for a median of 14 months (3-18.8). Complete and partial response occurred in 58% and 17%, respectively. Anti-TNF therapy was used in 10 patients (14%) for a median of 4 months (range, 2.3-5.5). Complete response occurred in four patients and partial response in four patients.

CONCLUSIONS

The majority of patients with active MC responded to thiopurines, methotrexate, or anti-TNF therapy. Larger controlled studies are required to confirm the efficacy and safety of these medications in MC.