Elsevier

Transplantation Proceedings

Volume 41, Issue 1, January–February 2009, Pages 253-258
Transplantation Proceedings

Liver transplantation
Complication: Technical
Molecular Adsorbent Recirculating System (MARS) in Patients with Primary Nonfunction and Other Causes of Graft Dysfunction After Liver Transplantation in the Era of Extended Criteria Donor Organs

https://doi.org/10.1016/j.transproceed.2008.10.066Get rights and content

Abstract

Liver dysfunction is an important cause of morbidity and mortality after orthotopic liver transplantation (OLT). The Molecular Adsorbent Recirculating System (MARS) is an albumin-based dialysis system designed to enhance the excretory function of a failing liver. MARS has been successfully used in patients affected by advanced liver disease and presenting with severe cholestasis. The aim of this study was to evaluate the safety and clinical efficacy of MARS in patients with liver dysfunction after OLT. Seven patients (primary nonfunction, 2 patients; graft dysfunction, 5 patients) fulfilled the inclusion criteria of serum bilirubin level >15 mg/dL and least 1 of the following clinical signs: hepatic encephalopathy (HE) ≥grade II, hepatorenal syndrome (HRS), and intractable pruritus. Graft and patient survival rates at 6 months were 42.8% and 57.1%, respectively. All patients tolerated MARS treatment, with no adverse event. In all patients, a decrease in serum bilirubin (P < .05), bile acids (P < .05), serum creatinine, and ammonia levels was observed after treatment with MARS. A considerable improvement of HE, as well as renal and synthetic liver functions, was observed in 4 of 5 patients with graft dysfunction, but not among those with primary nonfunction. The patients with intractable pruritus showed significant improvement of this symptom after MARS therapy. Thus, MARS is a safe, therapeutic option for the treatment of liver dysfunction after OLT. Further studies are necessary to confirm whether this treatment is able to improve both graft and patient survival.

Section snippets

Patients and Methods

From July 2001 to December 2007, 34 adult patients in the ICU affected by liver failure were treated with MARS (125 sessions). During this period, the 7 patients who presented with PNF or GD after their first OLT were enrolled into the study. The diagnosis of PNF was made on the basis of progressive HE, severe coagulopathy, transaminases >3000 mU/L, bilirubin levels >10 mg/mL, absence of bile production, and occurrence of renal, cardiovascular, and respiratory failure within the first 24–48

Results

Twenty-eight MARS sessions were performed in 7 patients (5 males and 2 females) of median age 52 years (range, 28–59). Each patient underwent 1 to 7 MARS sessions, lasting 5 ± 1 hours. Demographic data, primary liver disease, causes of liver dysfunction after OLT, donor quality (standard graft vs ECD graft), clinical score, and number of MARS sessions are reported in Table 1.

Discussion

PNF was a critical complication in the early experience of liver transplantation, accounting for a high morbidity of the graft and a high mortality of the patient. This condition, when not treated by prompt re-OLT, led to death within a few days.1 Several risk factors have been identified as predictors of PNF, such as inadequate ICU donor management, primordial perfusion solutions, and long cold ischemia times. In the late 1980s, the introduction of the University of Wisconsin solution reduced

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