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MARS: THE NEW FRONTIER IN TREATMENT OF LIVER FAILURE? INITIAL CANADIAN EXPERIENCE IN MOLECULAR ADSORBENT RECIRCULATING SYSTEM
K Tsoi, R McCready, M Levstik
Multiorgan Transplant Program, London Health Science Centre, London Ontario
BACKGROUND: Liver failure represents a common final pathway for acute and chronic liver disease, with neurological compromise being a frequent complication. Standard medical therapy with lactulose and antibiotics have limited success in treatment of advanced hepatic encephalopathy (HE). Molecular Adsorbent Recirculating System (MARS) is a novel technique in which protein-bound neuroactive molecules are removed via an albumin dialysis circuit. Despite its reported use in Europe, Asia and United States, data from Canadian centres are lacking. In this study we report the first case series of patients undergoing MARS treatment in Canada.
METHODS: All patients who underwent MARS therapy at London Health Science Centre were included in this retrospective review. Biochemical, hematological and coagulation parameters were measured pre- and post- treatment. Hemodynamic data and changes in neurological status were recorded. Adverse outcomes during the procedure or after treatment as a direct result of the therapy were also noted.
RESULTS: Four patients received a total of five cycles of MARS therapy. Diagnosis includes fulminant liver failure (acetaminophen overdose) and acute-on-chronic liver failure (alcohol, HCV and PBC). At the time of therapy, patients have an average Childs-Pugh Score of 12 and a MELD score of 23. Duration of treatment varies between 6 and 20 hours per cycle. No significant electrolyte alterations or hemodynamic instability occurred during MARS therapy. Bilirubin and creatinine levels decreased on average 22% and 29% respectively. Prolonged PTT was observed without clinically overt bleeding. No significant neurological recovery as per Westhaven Criteria was observed.
CONCLUSION: We report the first Canadian experience with MARS treatment for advanced liver failure. MARS treatment was well tolerated in our cohort and demonstrated biochemical improvement. The lack of survival benefit in this series is likely due to irreversible advanced liver failure. Ongoing studies aim to target patient population who may benefit from MARS. Concomitant MARS therapy for patients with poor predicted prognosis, rather than its use as a salvage therapy, may improve overall survival of this cohort.