Abstract
IntroductionLiver failure is associated with reduced synthesis of clotting factors, consumptive coagulopathy, and platelet dysfunction. The aim of the study was to evaluate the effects of liver support using a molecular adsorbent recirculating system (MARS) on the coagulation system in patients at high risk of bleeding.MethodsWe studied 61 MARS treatments in 33 patients with acute liver failure (n = 15), acute-on-chronic liver failure (n = 8), sepsis (n = 5), liver graft dysfunction (n = 3), and cholestasis (n = 2). Standard coagulation tests, standard thromboelastography (TEG), and heparinase-modified and abciximab-fab-modified TEG were performed immediately before and 30 minutes after commencement of MARS, and after the end of MARS treatment. Prostaglandin I2 was administered extracorporeally to all patients; 17 patients additionally received unfractioned heparin.ResultsThree moderate bleeding complications in three patients, requiring three to four units of packed red blood cells, were observed. All were sufficiently managed without interrupting MARS treatment. Although there was a significant decrease in platelet counts (median, 9 G/l; range, -40 to 145 G/l) and fibrinogen concentration (median, 15 mg/dl; range, -119 to 185 mg/dl) with a consecutive increase in thrombin time, the platelet function, as assessed by abciximab-fab-modified TEG, remained stable. MARS did not enhance fibrinolysis.ConclusionMARS treatment appears to be well tolerated during marked coagulopathy due to liver failure. Although MARS leads to a further decrease in platelet count and fibrinogen concentration, platelet function, measured as the contribution of the platelets to the clot firmness in TEG, remains stable. According to TEG-based results, MARS does not enhance fibrinolysis.
Highlights
Liver failure is associated with reduced synthesis of clotting factors, consumptive coagulopathy, and platelet dysfunction
All were sufficiently managed without interrupting molecular adsorbent recirculating system (MARS) treatment
MARS leads to a further decrease in platelet count and fibrinogen concentration, platelet function, measured as the contribution of the platelets to the clot firmness in TEG, remains stable
Summary
Liver failure is associated with reduced synthesis of clotting factors, consumptive coagulopathy, and platelet dysfunction. The aim of the study was to evaluate the effects of liver support using a molecular adsorbent recirculating system (MARS) on the coagulation system in patients at high risk of bleeding. Extracorporeal detoxification circuits, such as MARS, must be highly biocompatible and anticoagulatory measures α = angle alpha; aPTT = activated partial thromboplastin time; AT = antithrombin; CI = coagulation index; CL30 = clot lysis after 30 minutes; FFP = fresh frozen plasma; K = clot formation time; MA = maximum amplitude; MARS = molecular adsorbent recirculating system; MELD = model of endstage liver disease; PT = prothrombin time; R = reaction time; SOFA = sepsis related organ failure assessment; TEG = thromboelastography; TP = time point; TT = thrombin time
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