The molecular adsorbent recirculating system in posthepatectomy liver failure: Results from a prospective phase I study

Abstract

Posthepatectomy liver failure (PHLF) represents the single most important cause of postoperative mortality after major liver resection, yet no effective treatment option is available. Extracorporeal liver support devices might be helpful, but systematic studies are lacking. Accordingly, we aimed to assess the safety and feasibility of the Molecular Adsorbent Recirculating System (MARS) in patients with PHLF. Between December 2012 and May 2015, a total of 206 patients underwent major or extended hepatectomy, and 10 consecutive patients with PHLF (according to the Balzan 50:50 criteria) were enrolled into the study. MARS treatment was initiated on postoperative day 5‐7, and five to seven consecutive treatment sessions were completed for each patient. In total, 59 MARS cycles were implemented, and MARS was initiated and completed without major complications in any patient. However, 1 patient developed an immense asymptomatic hyperbilirubinemia (without encephalopathy), 1 had repeated clotting problems in the MARS filter, and 2 patients experienced access problems with the central venous line. Otherwise, no adverse events were observed. In 9 patients, the bilirubin level and international normalized ratio decreased significantly (P < 0.05) during MARS treatment. The 60‐ and 90‐day mortality was 0% and 10%, respectively. Among the 9 survivors, 4 still had liver dysfunction at 90 days postoperatively. Five patients were alive 1 year postoperatively without any signs of liver dysfunction or disease recurrence. Conclusion: The use of MARS in PHLF is feasible and safe and improves liver function in patients with PHLF. In the present study, 60‐ and 90‐day mortality rates were unexpectedly low compared to a historical control group. The impact of MARS treatment on mortality in PHLF should be further evaluated in a randomized controlled clinical trial. (Hepatology Communications 2018;2:445‐454)

The impact of post-hepatectomy liver failure on mortality: a population-based study

“…Recent reports focused on validating especially the ISGLS criteria [9,19] but on the other hand, even the '50:50' criteria as well as the Mullen criteria are still used in current publications [20,21]. In a recently published Swedish single-center study on extracorporeal liver support in patients with PHLF, the 50:50 criteria were found to serve as valid inclusion criteria [22]. Therefore, the 50:50 criteria have been used to define PHLF in the current study, too.…”

Cyclin-dependent kinase inhibitors p21 and p27 function as critical regulators of liver regeneration following 90% hepatectomy in the rat

“…To compensate for the loss of liver function, extracorporeal hepatic support devices have been evaluated in patients presenting with acute post-operative liver failure. These devices, such as MARS®, Prometheus®, and SPAD, are albumin-linked hemodialysis systems that improve the biochemical parameters of patients but fail to improve survival rates[ 33 ]. A study combining the use of both liver support and portal ring devices needs to be envisaged in the future so as to determine the effects on perioperative outcomes and long-term survival.…”

The 3-60 criteria challenge established predictors of postoperative mortality and enable timely therapeutic intervention after liver resection

“…In addition, therapy with the molecular adsorbent recirculating system was shown to attenuate hyperbilirubinemia and hepatic encephalopathy in patients with postoperative LD, even though its impact on survival was limited in more recent analyses (19,20). However, growing evidence suggests that liver support devices are primarily effective, if they are introduced early, which further underlines the importance of a tool for early risk assessment, such as the 3-60 criteria (21,22). Here, the 3-60 criteria might lead to augmented results, as early introduction of the molecular absorbent and recirculation system might be used as a bridging therapy for patients classified as high risk no later than POD1, which in turns could lead to further improvement of patients' outcome.…”