Molecular Adsorbent Recirculating System Dialysis Research Articles

Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series.

ENWEndNote BIBJabRef, Mendeley RISPapers, Reference Manager, RefWorks, Zotero AMA Antoszewska M, Spychalski P, Elisabeth Villadsen G, Kristian Muff Aagaard N. Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series. Gastroenterology Review/Przegląd Gastroenterologiczny. 2021;16(3):254-256. doi:10.5114/pg.2021.108992. APA Antoszewska, M., Spychalski, P., Elisabeth Villadsen, G., & Kristian Muff Aagaard, N. (2021). Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series. Gastroenterology Review/Przegląd Gastroenterologiczny, 16(3), 254-256. https://doi.org/10.5114/pg.2021.108992 Chicago Antoszewska, Magdalena, Piotr Spychalski, Gerda Elisabeth Villadsen, and Niels Kristian Muff Aagaard. 2021. "Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series". Gastroenterology Review/Przegląd Gastroenterologiczny 16 (3): 254-256. doi:10.5114/pg.2021.108992. Harvard Antoszewska, M., Spychalski, P., Elisabeth Villadsen, G., and Kristian Muff Aagaard, N. (2021). Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series. Gastroenterology Review/Przegląd Gastroenterologiczny, 16(3), pp.254-256. https://doi.org/10.5114/pg.2021.108992 MLA Antoszewska, Magdalena et al. "Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series." Gastroenterology Review/Przegląd Gastroenterologiczny, vol. 16, no. 3, 2021, pp. 254-256. doi:10.5114/pg.2021.108992. Vancouver Antoszewska M, Spychalski P, Elisabeth Villadsen G, Kristian Muff Aagaard N. Treatment of intractable pruritus in patients with cholestasis with molecular adsorbents recirculating system dialysis: a case series. Gastroenterology Review/Przegląd Gastroenterologiczny. 2021;16(3):254-256. doi:10.5114/pg.2021.108992.

Experience with molecular adsorbent recirculating system treatment in 20 children listed for high-urgency liver transplantation.

For more than 10 years, children at our national center for pediatric liver transplantation (LT) have been treated with Molecular Adsorbent Recirculating System (MARS) liver dialysis as a bridging therapy to high-urgency LT. Treatment was reserved for 20 patients with the highest degrees of hepatic encephalopathy (HE; median grade = 3.5). Death from neurological sequelae was considered imminent for these patients, and this was further reflected in significantly higher international normalized ratios and ammonia levels and worse prognostic liver indices (Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores and liver injury units) in comparison with 32 wait-listed patients who did not receive MARS dialysis. MARS therapy was generally well tolerated, with a reduction in thrombocytes and hemorrhaging as the most common side effects. HE improvement was documented in 30% of the treated patients, but progression to grade IV encephalopathy occurred in 45% of the patients despite the treatment. Serum ammonia, bilirubin, bile acid, and creatinine levels significantly decreased during treatment. Eighty percent of MARS-treated patients survived to undergo LT, and their survival was equivalent to that of non-MARS-treated patients with severe liver failure (69%, P = 0.52). The heterogeneity between MARS-treated patients and non-MARS-treated patients in our cohort precluded a statistical evaluation of a benefit from MARS for patient survival. Our data demonstrate the safety of MARS even in the most severely ill patients awaiting LT, but strategies that promote the more rapid and widespread availability of high-quality donor organs remain of critical importance for improving patient survival in cases of severe acute liver failure.

Quest for Life on MARS

Quest for Life on MARS

The role of molecular adsorbent recirculating system dialysis for extracorporeal liver support in children

The majority of children with acute, acute-on-chronic, and progressive chronic liver failure require liver transplantation. Since organ availability is limited, extracorporeal liver support systems are increasingly applied to bridge the time until transplantation. At present, four different devices are available: the molecular adsorbent recirculating system (MARS), Prometheus dialysis, plasma exchange combined with hemodialysis (PE/HD), and single-pass albumin dialysis (SPAD). Randomized trials in adults have demonstrated efficient toxin removal, improved portal hypertension, hemodynamic stability, and improved hepatic encephalopathy compared with standard medical therapy. None of the liver support systems has yet been evaluated systematically in children. Knowledge of the specific indications and technical features of the different devices is essential if applied in children. MARS combines albumin dialysis with conventional hemodialysis and allows for efficient removal of water and protein-bound toxins without exogenous protein delivery and the associated infectious and allergic risks. It has successfully been applied in children with otherwise intractable cholestatic pruritus and with liver failure. The benefits, however, need to be balanced against the costs and the risk of volume and nitrogen overload if repeated plasma infusion is required. In cases of active bleeding, plasma exchange in combination with hemodialysis should be preferred.

Molecular Adsorbents Recirculating System dialysis in children with cholestatic pruritus

Cholestatic pruritus may severely compromise quality of life. The Molecular Adsorbents Recirculating System (MARS) allows removal of pruritogenic substances without exposure to foreign proteins. Pediatric data, however, are scant. We retrospectively analyzed the efficacy of MARS in three boys with severe cholestatic pruritus. They received a total of 135 MARS sessions during 8, 4, and 13 months prior to liver transplantation. Total serum bilirubin and bile acids were monitored, and pruritus was assessed by a numerical rating scale (NRS 0 = no pruritus, 10 = maximal pruritus). MARS sessions were initially performed three times weekly at a mean duration of 6.3 ± 1.4 h. Sessions could be reduced to once weekly and once every other week in two patients. Pre-MARS plasma bile acid concentrations averaged 207 ± 67 μmol/l. They declined to 67 ± 9%, 48 ± 3%, 38 ± 14%, and 37 ± 5% of baseline within 2, 4, 6 and 8 h of therapy, respectively (all p < 0.05). The average interdialytic increase of plasma bile acids was 34 ± 33 μmol/l per day. Mean NRS score decreased from 6.5 ± 2.3 to 3.3 ± 2.9 (p < 0.01). Skin lesions from itching disappeared. All MARS treatments were well tolerated. MARS dialysis substantially reduces cholestatic pruritus in children refractory to pharmacological treatment.

Molecular adsorbent recirculating system is ineffective in the management of type 1 hepatorenal syndrome in patients with cirrhosis with ascites who have failed vasoconstrictor treatment

BackgroundThe pathogenetic mechanism of hepatorenal syndrome (HRS) is paradoxical renal vasoconstriction consequent upon systemic and splanchnic arterial vasodilatation. Molecular adsorbent recirculating system (MARS) is a specialised form of dialysis that...

Aromatic Amino Acid Metabolism during Liver Failure

Liver failure is associated with hepatic encephalopathy (HE). An imbalance in plasma levels of aromatic amino acids (AAA) phenylalanine, tyrosine, and tryptophan and branched chain amino acids (BCAA) and their BCAA/AAA ratio has been suggested to play a causal role in HE by enhanced brain AAA uptake and subsequently disturbed neurotransmission. Until recently, data on this subject and the role of the liver and splanchnic bed were scarce, particularly in humans, due to inaccessibility of portal and hepatic veins. Here, we discuss, against a background of relevant literature, data obtained in patients undergoing liver resection or with a transjugular intrahepatic portasystemic stent shunt (TIPSS), where these veins are accessible. The BCAA/AAA ratio remained unchanged after major liver resection, but plasma AAA levels were inversely correlated (P < 0.001) with residual liver volume, in keeping with the observed hepatic AAA uptake. In patients with stable cirrhosis and a TIPSS, the plasma BCAA/AAA ratio was lower than in controls (1.19 ± 0.09 vs. controls: 3.63 ± 0.34). Gastrointestinal bleeding in cirrhotics with a TIPSS induced disturbances in BCAA levels and the BCAA/AAA ratio and induced catabolism, which could partly be corrected by isoleucine administration. AAA may be important in the pathogenesis of HE, but it is unlikely that they are the sole factors. HE most likely is a syndrome with multifactorial pathogenesis, where hyperammonemia, AAA/BCAA imbalances, inflammation, brain edema, and neurotransmitter changes interact. Novel therapies to normalize AAA levels in patients with liver failure (such as the molecular adsorbent recirculating system dialysis device) should probably be combined with supplementation of e.g. isoleucine and enhancing ammonia excretion by the kidneys.

Comment on Camus et al.: “Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation”

Comment on Camus et al.: “Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation”

Reply to Karvellas et al. regarding “Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation”

Reply to Karvellas et al. regarding “Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation”

Acute liver failure due to leptospirosis successfully treated with MARS (molecular adsorbent recirculating system) dialysis

Leptospirosis is a re-emerging infectious disease, which may lead to multiple organ failure (MOF)and death. We report the first case of severe leptospirosis complicated with acute renal and liver failure, successfully treated with albumin dialysis--molecular adsorbent recirculating system (MARS). Despite antibiotic therapy, optimum medical supportive treatment and timely initiated haemodialysis, the outcome was complicated by severe liver failure: hepatic encephalopathy grade III, hypoglycemia, prominent hyperbilirubinemia (TBIL 31.3 mg/dl, DBIL 28.6 mg/dl)and hepatic cytolysis (ALT 535 IU/l, AST 179 IU/l) and prolongation of the prothrombine time (68.4 sec). The patient underwent two sesions of albumin dialysis with the MARS procedure with complete recovery of hepatic and renal function. Albumin dialysis may confer a significant survival benefit on patients with leptospirosis-induced acute liver failure (ALF).

Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation

To assess the usefulness of dialysis with the molecular adsorbent recirculating system (MARS) in patients with acute liver failure who fulfil criteria for liver transplantation. Observational cohort study. ICU at a liver transplantation centre. Twenty-two patients (23 episodes) received MARS dialysis. They were either listed for LT (n=14), delayed (n=1), or not listed (contra-indication, n=7). A total of 56 MARS treatments (median per patient 2; mean duration 7.6+/-2.6h) were performed on haemodialysis. Clinical and biological variables were assessed before and 24[Symbol: see text]h after MARS therapy. The rate of recovery of liver function without transplantation was compared with an expected rate and survival was analysed. Following MARS dialysis, we observed an improvement in the grade of hepatic encephalopathy (P=0.02) and the Glasgow coma score (P=0.02), a decrease in conjugated bilirubin (P=0.05) and INR (P=0.006), and an increase in prothrombin index (P=0.005). Overall, liver function improved in seven patients (32%): four listed patients in whom transplantation could be avoided and three patients among those not listed due to contra-indications. The transplant-free recovery rate in listed patients was 29% (vs. expected 9%, P=0.036). Listed patients (n=14) had a higher 30-day survival rate [86% (12/14) vs 38% (3/8), P=0.05] and a higher long-term survival rate (P=0.02). A statistically significant improvement of liver function was observed after MARS therapy. Transplant-free recovery was more frequent than expected. The apparent benefit of MARS dialysis to treat acute liver failure needs to be confirmed by a controlled study.

Phenytoin intoxication in critically ill patients

Phenytoin intoxication can result in major and possibly life-threatening disorders. Furthermore, the hepatic clearance can become saturated, thus, shifting the elimination from first- to zero-order kinetics. This results in a slow elimination of the compound in case of intoxication. The treatment modalities for phenytoin overdose are limited. Taking into account the high level of protein binding, the molecule is not easily eliminated from the body by means of extracorporal epuration. Although reports exist on the use of MARS (molecular adsorbents recirculating system) dialysis, peritoneal dialysis, and standard dialysis for the elimination, in practice, hemoperfusion, is the most often applied technique. The authors report the case of a hypoalbuminemic patient with severe neurologic signs of phenytoin intoxication (total concentration moderately elevated, free fraction high). A combination of high-flux dialysis and hemoperfusion resulted in a considerable extraction of the drug, accelerating the natural clearance from the body and ameliorating clinical signs of intoxication. In selected patients (with a high free fraction of phenytoin), high-flux dialysis may be a valuable alternative or adjuvant to hemoperfusion.