A liver support system or diachysis is a type of therapeutic device to assist in performing the functions of the liver. Such systems focus either on removing the accumulating toxins (liver dialysis), or providing additional replacement of the metabolic functions of the liver through the inclusion of hepatocytes to the device (bioartificial liver device). This system is in trial to help people with acute liver failure (ALF) or acute-on-chronic liver failure.[1]
The primary functions of the liver include removing toxic substances from the blood, manufacturing blood proteins, storing energy in the form of glycogen, and secreting bile. The hepatocytes that perform these tasks can be killed or impaired by disease, resulting in acute liver failure (ALF) which can be seen in person with previously diseased liver or a healthy one.
Etymology
The word diachysis derives from the Greek word, διάχυσησ, which means "Diffusion"
The word dialysis derives from the Greek word, διάλυσις, which means "Dissolution"
Liver failure
Classification for hepatic insufficiency
In hyperacute and acute liver failure, the clinical picture develops rapidly with progressive encephalopathy and multiorgan dysfunction such as hyperdynamic circulation, coagulopathy, acute kidney injury and respiratory insufficiency, severe metabolic alterations, and cerebral edema that can lead to brain death.[2][3] In these cases the mortality without liver transplantation (LTx) ranges between 40-80%.[4][5] LTx is the only effective treatment for these patients although it requires a precise indication and timing to achieve good results. Nevertheless, due to the scarcity of organs to carry out liver transplantations, it is estimated that one third of patients with ALF die while waiting to be transplanted.[6]
On the other hand, a patient with a chronic hepatic disease can suffer acute decompensation of liver function following a precipitating event such as variceal bleeding, sepsis and excessive alcohol intake among others that can lead to a condition referred to as acute-on-chronic liver failure (ACLF).
Both types of hepatic insufficiency, ALF and ACLF, can potentially be reversible and liver functionality can return to a level similar to that prior to the insult or precipitating event.
LTx has shown an improvement in the prognosis and survival with severe cases of ALF. Nevertheless, cost and donor scarcity have prompted researchers to look for new supportive treatments that can act as “bridge” to the transplant procedure. By stabilizing the patient's clinical state, or by creating the right conditions that could allow the recovery of native liver functions, both detoxification and synthesis can improve, after an episode of ALF or ACLF.[7]
Three different types of supportive therapies have been developed: bio-artificial, artificial and hybrid liver support systems (Table 2).
Bioartificial liver devices are experimental extracorporeal devices that use living cell lines to provide detoxification and synthesis support to the failing liver. Bio-artificial liver (BAL) Hepatassist 2000 uses porcine hepatocytes whereas ELAD system employs hepatocytes derived from human hepatoblastoma C3A cell lines.[19][20] Both techniques can produce, in fulminant hepatic failure (FHF), an improvement of hepatic encephalopathy grade and biochemical parameters. Potential side effects that have been documented include immunological issues (porcine endogenous retrovirus transmission), infectious complications, and tumor transmigration.
Other biological hepatic systems are Bioartificial Liver Support (BLSS) and Radial Flow Bioreactor (RFB). Detoxification capacity of these systems is poor and therefore they must be used combined with other systems to mitigate this deficiency. Today, its use is limited to centers with high experience in their application.[21]
A bioartificial liver device (BAL) is an artificial extracorporeal liver support (ELS) system for an individual who is suffering from acute liver failure (ALF) or acute-on-chronic liver failure (ACLF). The fundamental difference between artificial and BAL systems lies in the inclusion of hepatocytes into the reactor, often operating alongside the purification circuits used in artificial ELS systems. The overall design varies between different BAL systems, but they largely follow the same basic structure, with patient blood or plasma flow through an artificial matrix housing hepatocytes. Plasma is often separated from the patient’s blood to improve efficiency of the system, and the device can be connected to artificial liver dialysis devices in order to further increase the effectiveness of the device in filtration of toxins. The inclusion of functioning hepatocytes in the reactor allows the restoration of some of the synthetic functions that the patient’s liver is lacking.[22]
History
Early history
The first bioartificial liver device was developed in 1993 by Dr. Achilles A. Demetriou at Cedars-Sinai Medical Center. The bioartificial liver helped an 18-year-old southern California woman survive without her own liver for 14 hours until she received a human liver using a 20-inch-long, 4-inch-wide plastic cylinder filled with cellulose fibers and pig liver cells. Blood was routed outside the patient's body and through the artificial liver before being returned to the body.[23][24]
Dr. Kenneth Matsumara's work on the BAL led it to be named an invention of the year by Time magazine in 2001.[25] Liver cells obtained from an animal were used instead of developing a piece of equipment for each function of the liver. The structure and function of the first device also resembles that of today's BALs. Animal liver cells are suspended in a solution and a patient's blood is processed by a semipermeable membrane that allow toxins and blood proteins to pass but restricts an immunological response.[25]
Development
Advancements in bioengineering techniques in the decade after Matsumara's work have led to improved membranes and hepatocyte attachment systems.[26] Cell sources now include primary porcine hepatocytes, primary human hepatocytes, human hepatoblastoma (C3A), immortalized human cell lines and stem cells.[26]
Use
The purpose of BAL-type devices is not to permanently replace liver functions, but to serve as a supportive device,[27] either allowing the liver to regenerate properly upon acute liver failure, or to bridge the individual's liver functions until a transplant is possible.
Function
BALs are essentially bioreactors, with embedded hepatocytes (liver cells) that perform the functions of a normal liver. They process oxygenated blood plasma, which is separated from the other blood constituents.[28] Several types of BALs are being developed, including hollow fiber systems and flat membrane sheet systems.[29]
Various types of hepatocytes are used in these devices. Porcine hepatocytes are often used due to ease of acquisition and cost; however, they are relatively unstable and carry the risk of cross-species disease transmission.[30] Primary human hepatocytes sourced from donor organs present several problems in their cost and difficulty to obtain, especially with the current lack in transplantable tissue.[30] In addition, questions have been raised about tissue collected from patients transmitting malignancy or infection via the BAL device. Several lines of human hepatocytes are also used in BAL devices, including C3A and HepG2 tumour cell lines, but due to their origin from hepatomas, they possess the potential to pass on malignancy to the patient.[31] There is ongoing research into the cultivation of new types of human hepatocytes capable of improved longevity and efficacy in a bioreactor over currently used cell types, that do not pose the risk of transfer of malignancy or infection, such as the HepZ cell line created by Werner et al..[32]
Hollow fibre systems
Similar to kidney dialysis, hollow fiber systems employ a hollow fiber cartridge. Hepatocytes are suspended in a gel solution such as collagen, which is injected into a series of hollow fibers. In the case of collagen, the suspension is then gelled within the fibers, usually by a temperature change. The hepatocytes then contract the gel by their attachment to the collagen matrix, reducing the volume of the suspension and creating a flow space within the fibers. Nutrient media is circulated through the fibers to sustain the cells. During use, plasma is removed from the patients blood. The patient's plasma is fed into the space surrounding the fibers. The fibers, which are composed of a semi-permeable membrane, facilitate transfer of toxins, nutrients and other chemicals between the blood and the suspended cells. The membrane also keeps immune bodies, such as immunoglobulins, from passing to the cells to prevent an immune system rejection.[33]
Cryogel-Based Systems
Currently, hollow-fibre bioreactors are the most commonly accepted design for clinical use due to their capillary-network allowing for easy perfusion of plasma across cell populations.[34] However, these structures have their limitations, with convectional transport issues, nutritional gradients, non-uniform seeding, inefficient immobilisation of cells, and reduced hepatocyte growth restricting their effectiveness in BAL designs.[35] Researchers are now investigating the use of cryogels to replace hollow-fibres as the cell carrier components in BAL systems.
Cryogels are super-macroporous three-dimensional polymers prepared at sub-zero temperatures, by the freezing of a solution of cryogel precursors and solvent. The pores develop during this freezing process – as the cryogel solution cools, the solvent begins to form crystals. This causes the concentration of the cryogel precursors in the solution to increase, initiating the cryogelation process and forming the polymer walls. As the cryogel warms, the solvent crystals thaw, leaving cavities that form the pores.[36] Cryogel pores range in size from 10-100μm in size, forming an interconnected network that mimics a capillary system with a very large surface area to volume ratio, supporting large numbers of immobilised cells. Convection mediated transport is also supported by cryogels, enabling even distribution of nutrients and metabolite elimination, overcoming some of the shortcomings of hollow-fibre systems.[35] Cryogel scaffolds demonstrate good mechanical strength and biocompatibility without triggering an immune response, improving their potential for long-term inclusion in BAL devices or in-vitro use.[37] Another advantage of cryogels is their flexibility for use in a variety of tasks, including separation and purification of substances, along with acting as extracellular matrix for cell growth and proliferation. Immobilisation of specific ligands onto cryogels enables adsorption of specific substances, supporting their use as treatment options for toxins,[38] for separation of haemoglobin from blood,[39] and as a localised and sustained method for drug delivery.[40]
Developing an effective bioartificial liver (BAL) remains a formidable challenge, as it necessitates the intricate optimization of cell colonization, biomaterial scaffold design, and BAL fluid dynamics. Expanding upon prior research indicating its potential as a blood perfusion device for detoxification, some studies have explored the application of Arg-Gly-Asp (RGD)-containingPoly(2-hydroxyethyl methacrylate) (pHEMA)-alginate cryogels as scaffolds for BAL. These cryogels, incorporating alginate to mitigate protein fouling and functionalized with an RGD-containing peptide to enhance hepatocyte adhesion, represent a promising avenue for BAL scaffold development. Methods for characterizing internal flow within the porous cryogel matrix such as Particle Image Velocimetry (PIV), enables visualization of flow dynamics. PIV analysis revealed the laminar flow characteristics within cryogel pores, prompting the design of a multi-layered bioreactor consisting of spaced cryogel discs to optimize blood/hepatocyte mass exchange. Compared to the column configuration, the stacked bioreactor demonstrated significantly elevated production of albumin and urea, alongside enhanced cell colonization and proliferation over time.[35]
Recent developments in bioartificial liver (BAL) using living liver cells have shown promising advancements in the field of liver support and regeneration. These developments focus on utilizing various cell sources, scaffold materials, and bioreactor designs to enhance the functionality and viability of BAL systems. Key advancements include:
Cell Sources: Researchers have explored different cell sources for BAL, including primary hepatocytes, stem cell-derived hepatocyte-like cells, and immortalized liver cell lines. Efforts have been made to optimize cell culture conditions to maintain cell viability and functionality within BAL systems.
Scaffold Materials: Biomaterial scaffolds play a critical role in providing structural support and facilitating cell attachment and proliferation in BAL systems. Recent studies have investigated the use of natural and synthetic materials, such as hydrogels, alginate, and decellularized liver scaffolds, to create biomimetic environments conducive to liver cell growth and function.
Bioreactor Designs: Innovative bioreactor designs have been developed to enhance the performance of BAL systems by optimizing mass transfer, fluid dynamics, and cell-matrix interactions. These designs include perfusion-based bioreactors, microfluidic devices, and three-dimensional (3D) bioprinted constructs, which aim to mimic the physiological microenvironment of the liver and promote liver cell function and survival.
Functional Assessment: Advances in bioanalytical techniques have enabled researchers to assess the functionality of liver cells within BAL systems more accurately. These techniques include measuring the secretion of liver-specific biomarkers, such as albumin, urea, and bile acids, as well as evaluating metabolic activity, drug metabolism, and detoxification capacity.
Clinical Studies
There have been numerous clinical studies involving hollow-fibre bioreactors. Overall, they show promise but do not provide statistically significant evidence supporting their effectiveness. This is generally due to inherent design limitations, causing convectional transport issues, nutritional gradients, non-uniform seeding, inefficient immobilisation of cells, and reduced hepatocyte growth.[35] As of writing, no cryogel-based devices have entered clinical trials. However, laboratory results have been promising,[35][41] and hopefully trials will begin soon.
HepatAssist
The HepatAssist, developed at the Cedars-Sinai Medical Center, is a BAL device containing porcine hepatocytes within a hollow-fibre bioreactor. These semi-permeable fibres act as capillaries, allowing the perfusion of plasma through the device, and across the hepatocytes surrounding the fibres. The system incorporates a charcoal column to act as a filter, removing additional toxins from the plasma.[42]
Demetriou et al.[42] carried out a large, randomised, multicentre, controlled trial on the safety and efficacy of the HepatAssist device. 171 patients with ALF stemming from viral hepatitis, paracetamol overdose or other drug complications, primary non-function (PNF), or of indeterminate aetiology, were involved in the study and were randomly assigned to either the experimental or control groups. The study found that at the primary end-point 30-day post admission mark, there was an increased survival rate in BAL patients over control patients (71% vs 62%), but the difference was not significant. However, when patients with PNF are excluded from the results there is a 44% reduction in mortality for BAL treated patients, a statistically significant advantage. The investigators noted that exclusion of PNF patients is justifiable due to early retransplantation and lack of intercranial hypertension, so HepatAssist would give little benefit to this group. For the secondary end-point of time-to-death, in patients with ALF of known aetiology there was a significant difference between BAL and control groups, with BAL patients surviving for longer. There was no significant difference for patients of unknown aetiology, however.
The conclusions of the study suggest that such a device has potentially significant importance when used as a treatment measure. While the overall findings were not statistically significant, when the aetiology of the patients was taken into account the BAL group gained a statistically significant reduction in mortality over the control group. This suggests that while the device may not be applicable to patients as an overall treatment for liver dysfunction, it can provide an advantage when the heterogeneity of patients is considered and is used with patients of specific aetiology.
Extracorporeal Liver Assist Device
The Extracorporeal Liver Assist Device (ELAD) is a human-cell based treatment system. A catheter removes blood from the patient, and an ultrafiltrate generator separates the plasma from the rest of the blood. This plasma is then run through a separate circuit containing cartridges filled with C3A cells, before being returned to the main circuit and re-entering the patient.[43]
Thompson et al.[43] performed a large open-label trial, measuring the effectiveness of ELAD on patients with severe alcoholic hepatitis resulting in ACLF. Their study involved patients screened at 40 sites across the US, UK, and Australia, and enrolled a total of 203 patients. Patients were then randomised into either ELAD (n=96) or standard medical care (n=107) groups, with even distribution for patients in terms of sex, MELD score, and bilirubin levels. Of the 96 patients in the ELAD group, 45 completed the full 120 hours of treatment – the rest were unable to complete the full regimen due to a variety of reasons, including withdrawal of consent or severe adverse events, though 37 completed >72 hours of treatment, with results showing minimal difference in mortality between those receiving either >72 hours or the full 120 hours of treatment. The study was unable to complete its goal, finding no statistically significant improvement in mortality rates for patients that received ELAD treatment over those receiving standard care at 28 and 91 days (76.0% versus 80.4% and 59.4% versus 61.7%, respectively). Biomarker measurements showed a significantly reduced level of bilirubin and alkaline phosphatase in ELAD patients, though neither improvement translated into increased survivability rates. Outcomes for patients with MELD score <28 showed trends towards improved survival on ELAD, whereas those with MELD >28 had decreased survivability on ELAD. These patients presented with raised creatinine from kidney failure, suggesting a reason why ELAD decreased survival chance over standard care. Unlike artificial ELS devices and HepatAssist, ELAD does not incorporate any filtration devices, such as charcoal columns and exchange resins. Therefore, it cannot replace the filtration capability of the kidneys and cannot compensate for multi-organ failure from more severe presentations of ACLF, resulting in increased mortality rates.
While the results of the study cannot provide conclusive evidence to suggest that a BAL device like ELAD improves the outcome of severe ACLF, it does suggest that it can aid the survival of patients with a less severe form of the disease. In those patients with a MELD <28, beneficial effects were seen 2–3 weeks post treatment, suggesting that while C3A incorporating BAL devices are unable to provide short-term aid like artificial albumin filtration devices, they instead provide more long-term aid in recovery of the patient’s liver.[43]
A randomized, phase 3 trial of the ELAD device in patients with severe alcoholic hepatitis failed to show benefit on overall survival and development was discontinued.[44]
Liver dialysis
Artificial liver support systems are aimed to temporarily replace native liver detoxification functions and they use albumin as scavenger molecule to clear the toxins involved in the physiopathology of the failing liver. Most of the toxins that accumulate in the plasma of patients with liver insufficiency are protein bound, and therefore conventional renal dialysis techniques, such as hemofiltration, hemodialysis or hemodiafiltration are not able to adequately eliminate them.
Liver dialysis has shown promise for patients with hepatorenal syndrome. It is similar to hemodialysis and based on the same principles, but hemodialysis does not remove toxins bound to albumin that accumulate in liver failure. Like a bioartificial liver device, it is a form of artificial extracorporeal liver support.[45][46]
A critical issue of the clinical syndrome in liver failure is the accumulation of toxins not cleared by the failing liver. Based on this hypothesis, the removal of lipophilic, albumin-bound substances such as bilirubin, bile acids, metabolites of aromatic amino acids, medium-chain fatty acids and cytokines should be beneficial to the clinical course of a patient in liver failure. This led to the development of artificial filtration and absorption devices.
Liver dialysis is performed by physicians and surgeons and specialized nurses with training in gastroenterological medicine and surgery, namely, in hepatology, alongside their colleagues in the intensive or critical care unit and the transplantation department, which is responsible for procuring and implanting a new liver, or a part (lobe) of one, if and when it becomes available in time and the patient is eligible. Because of the need for these experts, as well as the relative newness of the procedure in certain areas, it is usually available only in larger hospitals, such as level I trauma center teaching hospitals connected with medical schools.
Between the different albumin dialysis modalities, single pass albumin dialysis (SPAD) has shown some positive results at a very high cost;[47] it has been proposed that lowering the concentration of albumin in the dialysate does not seem to affect the detoxification capability of the procedure.[48] Nevertheless, the most widely used systems today are based on hemodialysis and adsorption. These systems use conventional dialysis methods with an albumin containing dialysate that is later regenerated by means of adsorption columns, filled with activated charcoal and ion exchange resins. At present, there are two artificial extracorporeal liver support systems: the Molecular Adsorbents Recirculating System (MARS) from Gambro and Fractionated Plasma Separation and Adsorption (FPSA), commercialised as Prometheus (PROM) from Fresenius Medical Care. Of the two therapies, MARS is the most frequently studied, and clinically used system to date.
Prognosis/survival
While the technique is in its infancy, the prognosis of patients with liver failure remains guarded. Liver dialysis is currently only considered to be a bridge to transplantation or liver regeneration (in the case of acute liver failure)[49][50][51] and, unlike kidney dialysis (for kidney failure), cannot support a patient for an extended period of time (months to years).
Devices
Artificial detoxification devices currently under clinical evaluation include the Single Pass Albumin Dialysis (SPAD), Molecular Adsorbent Recirculating System (MARS), Prometheus system, and Dialive.
Single Pass Albumin Dialysis (SPAD)
Single pass albumin dialysis (SPAD) is a simple method of albumin dialysis using standard renal replacement therapy machines without an additional perfusion pump system: The patient's blood flows through a circuit with a high-flux hollow fiber hemodiafilter, identical to that used in the MARS system. The other side of this membrane is cleansed with an albumin solution in counter-directional flow, which is discarded after passing the filter. Hemodialysis can be performed in the first circuit via the same high-flux hollow fibers.
Molecular adsorbents recirculation system
The Molecular Adsorbents Recirculation System (MARS) is the best known extracorporal liver dialysis system. It consists of two separate dialysis circuits. The first circuit consists of human serum albumin, is in contact with the patient's blood through a semipermeable membrane and has two filters to clean the albumin after it has absorbed toxins from the patient's blood. The second circuit consists of a hemodialysis machine and is used to clean the albumin in the first circuit, before it is recirculated to the semipermeable membrane in contact with the patient's blood.
Comparing SPAD, MARS and CVVHDF
SPAD, MARS and continuous veno-venous haemodiafiltration (CVVHDF) were compared in vitro with regard to detoxification capacity.[52] SPAD and CVVHDF showed a significantly greater reduction of ammonia compared with MARS. No significant differences could be observed between SPAD, MARS and CVVHDF concerning other water-soluble substances. However, SPAD enabled a significantly greater bilirubin reduction than MARS. Bilirubin serves as an important marker substance for albumin-bound (non-water-soluble) substances. Concerning the reduction of bile acids no significant differences between SPAD and MARS were seen. It was concluded that the detoxification capacity of SPAD is similar or even higher when compared with the more sophisticated, more complex and hence more expensive MARS.
Albumin dialysis is a costly procedure: for a seven-hour treatment with MARS, approximately €300 for 600 mL human serum albumin solution (20%), €1740 for a MARS treatment kit, and €125 for disposables used by the dialysis machine have to be spent. The cost of this therapy adds up to approximately €2165. Performing SPAD according to the protocol by Sauer et al., however, requires 1000 mL of human albumin solution (20%) at a cost of €500. A high-flux dialyzer costing approximately €40 and the tubings (€125) must also be purchased. The overall costs of a SPAD treatment is approximately €656—30% of the costs of an equally efficient MARS therapy session. The expenditure for the MARS monitor necessary to operate the MARS disposables is not included in this calculation.
Prometheus
The Prometheus system (Fresenius Medical Care, Bad Homburg, Germany) is a device based on the combination of albuminadsorption with high-flux hemodialysis after selective filtration of the albumin fraction through a specific polysulfon filter (AlbuFlow). It has been studied[53] in a group of eleven patients with hepatorenal syndrome (acute-on-chronic liver failure and accompanying kidney failure). The treatment for two consecutive days for more than four hours significantly improved serum levels of conjugated bilirubin, bile acids, ammonia, cholinesterase, creatinine, urea and blood pH. Prometheus was proven to be a safe supportive therapy for patients with liver failure.
Dialive
Dialive (Yaqrit Limited, London, UK) incorporates albumin removal and replacement and, endotoxin removal. It is at "Technology readiness level" (TRL) 5, which means it is validated in the disease environment.[54][55]
The MARS System
MARS was developed by a group of researchers at the University of Rostock (Germany), in 1993 and later commercialized for its clinical use in 1999.[56] The system is able to replace the detoxification function of the liver while minimizing the inconvenience and drawbacks of previously used devices.[57][58][59]
In vivo preliminary investigations indicated the ability of the system to effectively remove bilirubin, biliary salts, free fatty acids and tryptophan while important physiological proteins such as albumin, alpha-1-glicoproteine, alpha 1 antitrypsin, alpha-2-macroglobulin, transferrin, globulin tyrosine, and hormonal systems are unaffected.[60] Also, MARS therapy in conjunction with CRRT/HDF can help clear cytokines acting as inflammatory and immunological mediators in hepatocellular damage, and therefore can create the right environment to favour hepatocellular regeneration and recovery of native liver function.
MARS System Components
Combined MARS and PrismaFlex monitors
MARS is an extracorporeal hemodialysis system composed of three different circuits: blood, albumin and low-flux dialysis. The blood circuit uses a double lumen catheter and a conventional hemodialysis device to pump the patient's blood into the MARS FLUX, a biocompatible polysulfone high-flux dialyser. With a membrane surface area of 2.1 m2, 100nm of thickness and a cut-off of 50 KDa, the MARSFLUX is essential to retaining the albumin in the dialysate. Blood is dialysed against a human serum albumin (HSA) dialysate solution that allows blood detoxification of both water-soluble and protein-bound toxins, by means of the presence of albumin in the dialysate (albumin dialysis). The albumin dialysate is then regenerated in a close loop in the MARS circuit by passing through the fibres of the low-flux diaFLUX filter, to clear water-soluble toxins and provide electrolyte/acid-base balance, by a standard dialysis fluid. Next, the albumin dialysate passes through two different adsorption columns; protein-bound substances are removed by the diaMARS AC250, containing activated charcoal and anionic substances are removed by the diaMARS IE250, filled with cholestyramine, an anion-exchange resin. The albumin solution is then ready to initiate another detoxifying cycle of the patient's blood that can be sustained until both adsorption columns are saturated, eliminating the need to continuously infuse albumin into the system during treatment (Fig. 1).
Albumin dialysis circuit
Figure 1: The MARS system
Results published in the literature with the MARS system
A systematic review of the literature from 1999 to June 2011 was performed in the following databases:
Specialized in systematic reviews: Cochrane Library Plus and NHS Centre database for Reviews and Dissemination (HTA, DARE and NHSEED).
General databases: Medline, Pubmed and Embase.
On-going clinical trials and research project databases: Clinical Trials Registry (National Institutes of Health, EE.UU.) and Health Services Research Projects in Progress.
General web searching engines: Scholar Google.
Effects of MARS treatment on Hepatic Encephalopathy (HE)
Hepatic encephalopathy (HE) represents one of the more serious extrahepatic complications associated with liver dysfunction.[61][62] Neuro-psychiatric manifestations of HE affect consciousness and behaviour.
Evidence suggests that HE develops as some neurotoxins and neuro active substances, produced after hepatocellular breakdown, accumulates in the brain as a consequence of a portosystemic shunt and the limited detoxification capability of the liver. Substances involved are ammonia, manganese, aromatic aminoacids, mercaptans, phenols, medium chain fatty acids, bilirubin, endogenous benzodiazepines, etc. The relationship between ammonia neurotoxicity and HE was first described in animal studies by Pavlov et al.[63] Subsequently, several studies in either animals or humans have confirmed that, a ratio in ammonia concentration higher than 2 mM between the brain and blood stream, causes HE, and even a comatose state when the value is greater than 5 mM. Some investigators have also reported a decrease in serum ammonia following a MARS treatment (Table 3).
Table 3. Clinical studies showing some improvement in the treatment of HE following a MARS treatment
Manganese and copper serum levels are increased in patients with either acute or acute on chronic liver failure. Nevertheless, only in those patients with chronic hepatic dysfunction, a bilateral magnetic resonance alteration on Globos Pallidus is observed,[68] probably because this type of patients selectively shows higher cerebral membrane permeability. Imbalance between aromatic and branched chain aminoacids (Fischer index), traditionally involved in HE genesis,[69][70][71] can be normalized following a MARS treatment. The effects are noticeable even after 3 hours of treatment and this reduction in the Fisher index is accompanied with an improvement in the HE.[72]
Novelli G et al.[73] published their three years experience on MARS analyzing the impact of the treatment in the cerebral level for 63 patients reporting an improvement in Glasgow Coma Score (GCS) for all observed in all patients. In the last 22 patients, cerebral perfusion pressure was monitored by Doppler (mean flow velocity in middle cerebral artery), establishing a clear relationship between a clinical improvement (especially neurological) and an improvement in arterial cerebral perfusion. This study confirms other results showing similar increments in cerebral perfusion in patients treated with MARS.[66]
More recently, several studies have shown a significant improvement of HE in patients treated with MARS. In the studies by Heemann et al.[74] and Sen et al.[75] an improvement in HE was considered when encephalopathy grade was reduced by one or more grades vs. basal values; for Hassenein et al., in their randomized controlled trial, improvement was considered when a decrease of two grades was observed.[76] In the latter, 70 patients with acute on chronic liver failure and encephalopathy grade III and IV were included. Likewise, Kramer et al.[77] estimated an HE improvement when an improvement in peak N70 latency in electroencephalograms was observed. Sen et al.44 observed a significant reduction in Child-Pugh Score (p<0,01) at 7 days following a MARS treatment, without any significant change in the controls. Nevertheless, when they looked at the Model for End-Stage Liver Disease Score (MELD), a significant reduction in both groups, MARS and controls, was recorded (p<0,01 y p<0,05, respectively). Likewise, in several case series, an improvement in HE grade with MARS therapy is also reported.[78][79][80][81][82][83][84][85][86]
Effects of MARS Treatment on Unstable Hemodynamics
Hemodynamic instability is often associated with acute liver insufficiency, as a consequence of endogenous accumulation of vasoactive agents in the blood. This is characterized by a systemic vasodilatation, a decrease of systemic vascular resistance, arterial hypotension, and an increase of cardiac output that gives rise to a hyperdynamic circulation. During MARS therapy, systemic vascular resistance index and mean arterial pressure have been shown to increase and show improvement.[78][80][82][87][88] Schmidt et al.[89] reported the treatment of 8 patients, diagnosed with acute hepatic failure, that were treated with MARS for 6 hours, and were compared with a control group of 5 patients to whom ice pads were applied to match the heat loss produced in the treatment group during the extracorporeal therapy. They analyzed hemodynamic parameters in both groups hourly. In the MARS group, a statistically significant increase of 46% on systemic vascular resistance was observed (1215 ± 437 to 1778 ± 710 dinas x s x cm−5 x m−2) compared with a 6% increase in the controls. Mean arterial pressure also increased (69 ± 5 to 83 ± 11 mmHg, p< 0.0001) in the MARS group, whereas no difference was observed in the controls. Cardiac output and heart rate also decreased in the MARS group as a consequence of an improvement in the hyperdynamic circulation. Therefore, it was shown that a statistically significant improvement was obtained with MARS when compared with the SMT.
Catalina et al.[90] have also evaluated systemic and hepatic hemodynamic changes produced by MARS therapy. In 4 patients with acute decompensation of chronic liver disease, they observed after MARS therapy, an attenuation of hyperdynamic circulation and a reduction in the portal pressure gradient was measured. Results are summarized in table 4.
Table 4: Hemodinamic parameters during MARS treatment
There are other studies also worth mentioning with similar results: Heemann et al.[74] and Parés et al.[91] among others. Dethloff T et al.[92] concluded that there is a statistically significant improvement favourable to MARS in comparison with Prometheus system (Table 5).
Table 5. Changes in hemodynamic parameters with MARS therapy
Hepatorenal syndrome is one of the more serious complications in patients with acute decompensation of cirrhosis and increased portal hypertension. It is characterized by hemodynamic changes in splanchnic, systemic and renal circulation. Splanchnic vasodilatation triggers the production of endogenous vasoactive substances that produce renal vasoconstriction and low glomerular filtration rate, leading to oliguria with a concomitant reduction in creatinine clearance. Renal insufficiency is always progressive with an inferior prognosis,[93][94] with survival at 1 and 2 months of 20 and 10% respectively.
Pierre Versin[95] is one of the pioneers in the study of hepatorenal syndrome in patients with liver impairment. Great efforts have been made trying to improve the prognosis of this type of patient; however, few have solved the problem. Orthotopic liver transplantation is the only treatment that has shown to improve acute and chronic complications derived from severe liver insufficiency. Today it is possible to combine albumin dialysis with continuous veno-venous hemodialfiltration, which provides a greater expectation for these patients[96] by optimization of their clinical status.
MARS treatment lowers serum urea and creatinine levels improving their clearance,[88][89][90][92] and even favors resolution of hepatorenal syndrome.[74][81][82][87][97] Results are confirmed in a randomized controlled trial published by Mitzner et al..[93] in which 13 patients diagnosed with hepatorenal syndrome type I was treated with MARS therapy. Mean survival was 25,2±34,6 days in the MARS group compared to 4,6±1,8 days observed in the controls in whom hemodiafiltration and standard care (SMT) was applied. This resulted in a statistically significance difference in survival at 7 and 30 days (p<0.05). Authors concluded that MARS therapy, applied to liver failure patients (Child-Pugh C and UNOS 2A scores) who develop hepatorenal syndrome type I, prolonged survival compared to patients treated with SMT.
Although mechanisms explaining previous findings are not yet fully understood, it has been reported that there was a decrease in plasma renin concentrations in patients diagnosed with acute on chronic liver failure with renal impairment that were treated with MARS. Likewise, other studies have suggested some efficacy for MARS in the treatment of hepatorenal syndrome.[98][99][100] However, other references have been published that do not show efficacy in the treatment of these types of patients with MARS therapy. Khuroo et al..[101] published a meta-analysis based on 4 small RCT's and 2 non RCT's in patients diagnosed with ACLF, concluding that MARS therapy would not bring any significant increment in survival compared with SMT. Another observational study in 6 patients with cirrhosis, refractory ascites and hepatorenal syndrome type I, not responding to vasoconstrictor therapy, showed no impact on hemodynamics following MARS therapy; however authors concluded that MARS therapy could effectively serve as bridge to liver transplantation.[83][102]
Effects of MARS Treatment on Biochemical Parameters
Total bilirubin was the only parameter analyzed in all trials that was always reduced in the groups of patients treated with MARS; Banayosy et al..[103] measured bilirubin levels 14 days after since MARS therapy was terminated and observed a consistent, significant decrease not only for bilirubin but also for creatinine and urea (Table 6).
Table 6: Biochemical parameters analysis with MARS therapy
Primary goal in the Heemann trial was to achieve a bilirubin level beloiw 15mg/dL during three consecutive days, which was observed in 42% of the patients treated with MARS® compared to 17% in the control group.
Impact of MARS therapy on plasma biliary acids levels was evaluated in 3 studies. In the study from Stadbauer et al..,[105] that was specifically addressing the topic, it is reported that MARS and Prometheus systems lower to the same extent biliary acids plasma concentration. Heemann et al..[74] and Laleman et al..[88] have also published a significant improvement for these organic ions.
Effects of MARS Treatment on Pruritus
Pruritus is one of the most common clinical manifestations in cholestasis liver diseases and one of the most distressing symptoms in patients with chronic liver disease caused by viral hepatitis C. Many hypotheses have been formulated to explain physio pathogenesis of such manifestation, including incremental plasma concentration of biliary acids, abnormalities in the bile ducts,[106] increased central neurotransmitters coupling opioid receptors,[107][108] etc. Despite the number of historical drugs used, individually or combined (exchange resins, hydrophilic biliary acids, antihistamines, antibiotics, anticonvulsants, opioid antagonists), there are reported cases of intractable or refractory pruritus with a dramatic reduction in patients’ quality of life (i.e. sleep disorders, depression, suicide attempts...).[109][110] Intractable pruritus can be an indication for liver transplantation.
The MARS indication for intractable pruritus is therapeutically an option that has shown to be beneficial for patients in desperate cases, although at high cost.[111][112][113][114] In several studies, it was confirmed that after MARS treatments, patients remain free from pruritus for a period of time ranging from 6 to 9 months.[114] Nevertheless, some authors have concluded that besides the good results found in the literature, application of MARS therapy in refractory pruritus requires larger evidence.[112]
Effects of MARS Treatment on Drugs and Poisons clearance
Pharmacokinetics and pharmacodynamics for a majority of drugs can be significantly be modified with liver failure, affecting the therapeutic approach and potential toxicity of the drugs. In these type of patients, Child-Pugh score represents a poor prognostic factor to assess the metabolic capacity of the failing liver.
Metabolic performance of the liver depends on several factors:
In patients with hepatic failure, drugs that are only metabolized in the liver, accumulate in the plasma right after they are administered, and therefore it is needed to modify drug dosing in both, concentration and time intervals, to lower the risk of toxicity. It is also necessary to adjust the dosing for those drugs that are exclusively metabolized by the liver, and have low affinity for prioteins and high distribution volume, such as fluoroquinolones (Levofloxacin and Ciprofloxacin).[115][116][117][118]
Extracorporeal detoxification with albumin dialysis increases the clearance of drugs that are bound to plasmatic proteins (Table 7).
Table 7: Drugs Highly Bound to Proteins
NSAIDs
Antibiotics
Anti-H2
Statins
Antipsychotics
Diclofenac
Cephazoline
Omeprazole
Clofibrate
Chlorpromazine
Ibuprofen
Cefoperazone
Antifungals
Lovastatin
Haloperidol
Indomethacin
Ceftriaxone
Amphotericine B
Simvastatine
Chemotherapy Drugs
Ketoprofen
Cloxacilin
Itraconazole
Fluvastatine
Chlorambucil
Naproxen
Oxacilin
Ketoconazole
Hypotensors
Etoposide
Phenylbutazone
Clindamycin
Barbiturates
Hydralacine
Melphalan
Piroxicam
Erythromycin
Thiopental
Irbesartan
D-penicillamine
Anaesthetics
Teicoplanin
Benzodiazepines
Losartan
Tamoxifen
Bupivacaine
Rifampicin
Clonazepam
Misoprostol
Opioids
Calcium Anthagonists
Rifabutin
Diazepam
Prazosin
Fentanyl
Nimodipine
Antidepresants
Flunitrazepam
Valsartan
Methadone
Nifedipine
Amitriptyline
Flurazepam
ACE's
Antipsychotics
Nitrendipine
Desipramine
Lorazepam
Fosinopropil
Clozapine
Antiarrhythmics
Imipramine
Midazolam
Quinapril
Fluoxetine
Amiodarone
Nortriptyline
Nitrazepam
Immunosuppressors
Risperidone
Quinidine
Anticoagulants
Oxacepam
Ciclosporin
Sertraline
Propafenone
Warfarin
Temazepam
Tacrolimus
Zolpidem
Lidocaine
Antiemetics
Beta Blockers
Methylprednisolone
Others
Digoxin
Ondansetron
Carvedilol
Prednisone
Celecoxib
Verapamil
Antiepilectics
Propanolol
Budesonide
Diphenhydramine
Oral Antidiabetics
Carbamazepine
Diuretics
-
Ethinylestradiol
Glibenclamide
Valproic acid
Furosemide
-
Mefloquine
-
-
Spironolactone
-
Paclitaxel
-
-
Torsemide
-
-
Effects of MARS on Survival
In the meta-analysis published by Khuroo et al..[101] which included 4 randomized trials[74][89][93][103] an improvement in survival for the patients with liver failure treated with MARS, compared with SMT, was not observed.
However, neither in the extracorporeal liver support systems review by the Cochrane[119] (published in 2004), nor the meta-analysis by Kjaergard et al..[120] was a significance difference in survival found for patients diagnosed with ALF treated with extracorporeal liver support systems. Nevertheless, these reviews included all kind of liver support systems and used a heterogeneous type of publication (abstracts, clinical trials, cohort, etc.).
There is literature showing favorable results in survival for patients diagnosed with ALF, and treated with MARS., In a randomized controlled trial, Salibà et al..[121] studied the impact on survival of MARS therapy for patients with ALF, waiting on the liver transplant list. Forty-nine patients received SMT and 53 were treated with MARS. They observed that patients that received 3 or more MARS sessions showed a statistically significance increase in transplant-free survival compared with the others patients of the study. Notably, 75% of the patients underwent liver transplantation in the first 24 hours after inclusion in the waiting list, and besides the short exposure to MARS therapy, some patients showed a better survival trend compared to controls, when they were treated with MARS prior to the transplant.
In a case-controlled study by Montejo et al..[104] it was reported that MARS treatment do not decrease mortality directly; however, the treatment contributed to significantly improve survival in patients that were transplanted. In studies by Mitzner et al..[93] and Heemann et al..[74] they were able to show a significance statistical difference in 30-day survival for patients in the MARS group. However, El Banayosy et al..[103] and Hassanein et al..[76] noticed a non significant improvement in survival, probably because of the short number of patients included in the trials. In the majority of available MARS studies published with patients diagnosed with ALF, either transplanted or not, survival was greater in the MARS group with some variations according to the type of trial, ranging from 20-30%,[122][123] and 60-80%.[83][124][125][126] Data is summarized in Tables 8, 9 and 10.
For patients diagnosed with acute on chronic liver failure and treated with MARS therapy, clinical trial results showed a not statistically significant reduction in mortality (odds ratio [OR] =0,78; confident interval [CI] =95%: 0,58 – 1,03; p= 0,1059, Figure 3)
border="0"
Figure 3: Meta-analysis showing the effect on survival of patients with ACLF treated with MARS therapy
A non-statistically significant reduction of mortality was shown in patients with ALF treated with MARS (OR = 0,75 [CI= 95%, 0,42 – 1,35]; p= 0,3427). (Figure 4)
border="0"
Figure 4. Meta-analysis showing the effect on survival of patients with ALF treated with MARS therapy.
Combined results yielded a non-significant reduction on mortality in patients treated with MARS therapy. However, the low number of patients included in each of the studies may be responsible for not being able to achieve enough statistical power to show differences between both treatment groups. Moreover, heterogeneity for the number of MARS sessions and severity of liver disease of the patients included, make it very difficult for the evaluation of MARS impact on survival.
Recently, a meta-analysis on survival in patients treated with an extra-hepatic therapy has been published.[131] Searching strategies yielded 74 clinical trials: 17 randomized controlled trials, 5 case control and 52 cohort studies. Eight studies were included in the meta-analysis: three addressing acute liver failure, one with MARS therapy[103] and five addressing acute on chronic, being four MARS related.[74][75][76][93] Authors concluded that extra-hepatic detoxifying systems improve survival for acute liver insufficiency, whereas results for acute decompensation of chronic liver diseases suggested a non significant survival benefit. Also, due to an increased demand for liver transplantation together with an augmented risk of liver failure following large resections, development of detoxifying extrahepatic systems are necessary.
Safety Aspects
Safety, defined as presence of adverse events, is evaluated in few trials. Adverse events in patients receiving MARS therapy are similar to those in the controls with the exception of thrombocytopenia and hemorrhage that seems to occur more frequently with the MARS system.[132]
Heemann et al.[74] reported two adverse events most probably MARS related: fever and sepsis, presumably originated at the catheter.
In the study by Hassanein et al.,[76] two patients in the MARS group abandoned the study owing tohemodynamic instability, three patients required larger than average platelets transfusion and three more patients presented gastrointestinal bleeding.
Laleman et al..[88] detected one patient with thrombocytopenia in both the MARS and Prometheus treatment groups, and an additional patient with clotting of the dialysis circuit and hypotension, only in the Prometheus group.
Kramer et al.. (Biologic-DT)[77] wrote about 3 cases with disseminated intravascular coagulation in the interventional group, two of them with fatal outcomes.
Mitzner et al..[93] described, among patients treated with MARS, a thrombocytopenia case and a second patient with chronic hepatitis B, who underwent TIPS placement on day 44 after randomization and died on day 105 of multiorgan failure, as a consequence of complications related to the TIPS procedure.
Montejo et al..[104] showed that MARS is an easy technique, without serious adverse events related to the procedure, and also easy to implement in ICU settings that are used to renal extracorporeal therapies.
The MARS International Registry, with data from more than 500 patients (although sponsored by the manufacturer), shows that the adverse effects observed are similar to the control group. However, in these severely ill patients it is difficult to distinguish between complications of the disease itself and side effects attributable to the technique.
Health Economics
Only three Studies addressing cost-effectivenenss of MARS therapy have been found. Hassanein et al.[133] analysed costs of randomized patients with ACLF receiving MARS therapy or standard medical care. They used the study published in 2001 by Kim et al.[134] describing the impact of complications in hospitalization costs in patients diagnosed with alcoholic liver failure. Cost of 11 patients treated with standard medical care (SMT) were compared to those that received MARS, in addition to SMT (12 patients). In the MARS group, there was less in-hospital mortality and complications related to the disease, with a remarkable reduction in cost which compensated the MARS related expenditure (Table 11).
Table 11. Analysis of Complications According to the Modality of treatment.
MARS GROUP
n=12
CONTROL GROUP
n=11
In-hospital mortality
1/12
6/11
Worsening of hepatic encephalopathy (grade 4)
0/12
3/11
Worsening of renal function (Hepatorenal Syndrome)
1/12
7/11
Ascites
0/12
1/11
Variceal bleeding
0/12
1/11
Severe hypotension
2/12
3/11
Electrolyte disorders
4/12
10/11
Coagulopathy
4/12
3/11
There were 5 survivors in the control group, with a cost per patient of $35.904, whereas in the MARS group, 11 patients out of 12 survived with a cost per patient of $32.036 which represents a $4000 savings per patient in favors of the MARS group. Hessel et al.[135] published a 3-year follow-up of a cohort of 79 patients with ACLF, of whom 33 received MARS treatments and 46 received SMT. Survival was 67% for the MARS group and 63% for the controls, that was reduced to 58 and 35% respectively at one year follow-up, and then 52 and 17% at three years.
Hospitalization costs for the MARS treated group were greater than that for the controls (€31,539 vs. €7,543) and similarly direct cost at 3-year follow-up (€8,493 vs. €5,194). Nevertheless, after adjusting mortality rate, the annual cost per patient was €12,092 for controls and €5,827 for MARS group; also in the latter, they found an incremental cost-effectiveness ratio of 31.448 € per life-year gained (LYG) and an incremental costs per QALY gained of 47171 €.
Two years later, same authors published the results of 149 patients diagnosed with ACLF.[136] There were 67 patients (44,9%) treated with MARS and 82 patients (55,1%) were allocated to receive SMT. Mean survival time was 692 days in the MARS group (33% at 3 years) and 453 days in the controls (15% at 3 years); the results were significant (p=0,022). Differences in average cost was €19,853 (95% IC: 13.308-25.429): 35.639 € for MARS patients and 15.804 € for the control group. Incremental cost per LYG was 29.985 € (95% IC: 9.441-321.761) and €43,040 (95% IC: 13.551-461.856) per quality-adjusted life years (QALY).
Liver support systems, such as MARS, are very important to stabilize patients with acute or acute on chronic liver failure and avoid organ dysfunction, as well as a bridge-to-transplant. Although initial in-hospital costs are high, they are worth for the favorable outcome.
Attenuate pruritus symptoms and improve patients’ quality of life
MARS Therapy Indication
Pruritus not responding to SMT
Treatment Schedule:
3 to 5 eight-hour treatment sessions in consecutives days
Repeat treatment when symptoms reoccur
MARS Therapy Contraindications
Same contraindications as with any other extracorporeal treatment may be applied to MARS therapy.
Unstable hemodynamics with mean arterial pressure (MAP)< 55 mmHg despite vasoconstrictors administration
Uncontrolled hemorrhage
Severe coagulopathy
Severe thrombocytopenia
Treatment Parameters
Blood Flow
The trend is to use high flow rates, although it is determined by the technical specifications of the combined machine and catheters’ size
Intermittent treatments:
Without renal dysfunction, it is recommended a blood and albumin flow rates ranging from 150 to 250 mL/min
Continuous treatments:
With or without renal impairment it is recommended to use flow rates from 100 to 150 mL/min.
Dyalisate Flow Rate
Intermittent treatments:
Without renal impairment: 1800 a 3000 mL/hour
With renal impairment: 3000 a 6000 mL/hour
Continuous treatments:
Recommended flow rate: 1000 to 2000 mL/hour.
Replacement Flow Rate
According to medical criteria and same as in CVVHD
Heparin Anticoagulation
Similarly to CVVHD, it depends on previous patient's coagulation status. In many cases it will not be needed, unless the patient presents a PTT inferior to 160 seconds. In patients with normal values, a bolus of 5000 to 10000 IU of heparin could be administered at the commencement of the treatment, followed by a continuous perfusion, to keep PTT in ratios from 1,5 to 2,5 or 160 to 180 seconds.
Monitoring
A biochemical analysis is recommended (liver and kidney profile, ionic, glucose) together with a hemogram at the end of first session and before starting the following one.
Coagulation analysis must be also performed before starting the session to adjusting heparin dose.
In case that medication susceptible to be eliminated by MARS is being administered, it is also recommended to monitor their levels in blood
End of the Session
Once the treatment is finalized, blood should be returned following the unit procedure,
and both catheter's lumens heparinized
For the next session a new kit must be used
For continuous treatments, kit must be changed by a new one every 24 hours
Treatment must be stopped before schedule owing to the particular circumstances listed below:
MAP inferior to 40 mmHg at least for 10 minutes
Air embolism of the extracorporeal circuit
Transmembrane pressure (TMP) greater than 600 mmHg.
Blood leak detection in the albumin circuit
Disseminated intravascular coagulation (DIC)
Severe active hemorrhage
FDA Clearance (US only)
Federal Drug Administration (FDA) cleared, in a document dated on May 27, 2005, MARS therapy for the treatment of drug overdose and poisoning. The only requirement is that the drug or poison must be susceptible to be dialysed and removed by activated charcoal or anionic exchange resins.
More recently, on December 17, 2012, MARS therapy has been cleared by the FDA for the treatment of hepatic encephalopathy due to a decompensation of a chronic liver disease. Clinical trials conducted with MARS treatment in HE patients having a decompensation of chronic liver disease demonstrated a transient effect from MARS treatments to significantly decrease their hepatic encephalopathy scores by at least 2 grades compared to standard medical therapy (SMT).
The MARS is not indicated as a bridge to liver transplant. Safety and efficacy has not been demonstrated in controlled, randomized clinical trials.
The effectiveness of the MARS device in patients that are sedated could not be established in clinical studies and therefore cannot be predicted in sedated patients
LiverNet
The LiverNet is a database dedicated to the liver diseases treated with the support of extracorporeal therapies. To date, the most currently used system is the Molecular Adsorbent Recirculating System (MARS), which is based on the selective removal of albumin bound molecules and toxins from the blood in patients with acute and acute-on-chronic liver failure. The purpose is to register prospectively all patients treated worldwide with the MARS system in order to:
Improve our understanding of the clinical course, pathophysiology and treatment of these diseases
Evaluate the clinical impact of MARS therapy on the course of the disease in different specific indication
Increase the knowledge in this extremely innovative area, a basis for an improvement of liver support devices and the treatment of these patients in the next future
The liverNet is an eCRF database (www.livernet.net) using a SAS platform that allows major advantages for the centres including the automatic calculations of most liver rand ICU scoring systems, instant queries online, instant export of all patients included in the database of each centre to an Excel file for direct statistical analysis and finally instant online statistical analysis of selective data decided by the scientific committee. Therefore, the LiverNet is an important tool to progress in the knowledge of liver support therapies.
Ascites is the abnormal build-up of fluid in the abdomen. Technically, it is more than 25 ml of fluid in the peritoneal cavity, although volumes greater than one liter may occur. Symptoms may include increased abdominal size, increased weight, abdominal discomfort, and shortness of breath. Complications can include spontaneous bacterial peritonitis.
Alcoholic liver disease (ALD), also called alcohol-related liver disease (ARLD), is a term that encompasses the liver manifestations of alcohol overconsumption, including fatty liver, alcoholic hepatitis, and chronic hepatitis with liver fibrosis or cirrhosis.
Erythropoietic protoporphyria is a form of porphyria, which varies in severity and can be very painful. It arises from a deficiency in the enzyme ferrochelatase, leading to abnormally high levels of protoporphyrin in the red blood cells (erythrocytes), plasma, skin, and liver. The severity varies significantly from individual to individual.
Transplant rejection occurs when transplanted tissue is rejected by the recipient's immune system, which destroys the transplanted tissue. Transplant rejection can be lessened by determining the molecular similitude between donor and recipient and by use of immunosuppressant drugs after transplant.
Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of filtering the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of kidney failure. Hemodialysis is one of three renal replacement therapies. An alternative method for extracorporeal separation of blood components such as plasma or cells is apheresis.
Alcoholic hepatitis is hepatitis due to excessive intake of alcohol. Patients typically have a history of at least 10 years of heavy alcohol intake, typically 8–10 drinks per day. It is usually found in association with fatty liver, an early stage of alcoholic liver disease, and may contribute to the progression of fibrosis, leading to cirrhosis. Symptoms may present acutely after a large amount of alcoholic intake in a short time period, or after years of excess alcohol intake. Signs and symptoms of alcoholic hepatitis include jaundice, ascites, fatigue and hepatic encephalopathy. Mild cases are self-limiting, but severe cases have a high risk of death. Severity in alcoholic hepatitis is determined several clinical prediction models such as the Maddrey's Discriminant Function and the MELD score.
Autoimmune hepatitis, formerly known as lupoid hepatitis, plasma cell hepatitis, or autoimmune chronic active hepatitis, is a chronic, autoimmune disease of the liver that occurs when the body's immune system attacks liver cells, causing the liver to be inflamed. Common initial symptoms may include fatigue, nausea, muscle aches, or weight loss or signs of acute liver inflammation including fever, jaundice, and right upper quadrant abdominal pain. Individuals with autoimmune hepatitis often have no initial symptoms and the disease may be detected by abnormal liver function tests and increased protein levels during routine bloodwork or the observation of an abnormal-looking liver during abdominal surgery.
Hepatic encephalopathy (HE) is an altered level of consciousness as a result of liver failure. Its onset may be gradual or sudden. Other symptoms may include movement problems, changes in mood, or changes in personality. In the advanced stages it can result in a coma.
Acute liver failure is the appearance of severe complications rapidly after the first signs of liver disease, and indicates that the liver has sustained severe damage. The complications are hepatic encephalopathy and impaired protein synthesis. The 1993 classification defines hyperacute as within 1 week, acute as 8–28 days, and subacute as 4–12 weeks; both the speed with which the disease develops and the underlying cause strongly affect outcomes.
Hepatorenal syndrome is a life-threatening medical condition that consists of rapid deterioration in kidney function in individuals with cirrhosis or fulminant liver failure. HRS is usually fatal unless a liver transplant is performed, although various treatments, such as dialysis, can prevent advancement of the condition.
Hemofiltration, also haemofiltration, is a renal replacement therapy which is used in the intensive care setting. It is usually used to treat acute kidney injury (AKI), but may be of benefit in multiple organ dysfunction syndrome or sepsis. During hemofiltration, a patient's blood is passed through a set of tubing via a machine to a semipermeable membrane where waste products and water are removed by convection. Replacement fluid is added and the blood is returned to the patient.
Renal replacement therapy (RRT) is therapy that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well, which is called kidney failure and includes acute kidney injury and chronic kidney disease. Renal replacement therapy includes dialysis, hemofiltration, and hemodiafiltration, which are various ways of filtration of blood with or without machines. Renal replacement therapy also includes kidney transplantation, which is the ultimate form of replacement in that the old kidney is replaced by a donor kidney.
Hypoalbuminemia is a medical sign in which the level of albumin in the blood is low. This can be due to decreased production in the liver, increased loss in the gastrointestinal tract or kidneys, increased use in the body, or abnormal distribution between body compartments. Patients often present with hypoalbuminemia as a result of another disease process such as malnutrition as a result of severe anorexia nervosa, sepsis, cirrhosis in the liver, nephrotic syndrome in the kidneys, or protein-losing enteropathy in the gastrointestinal tract. One of the roles of albumin is being the major driver of oncotic pressure in the bloodstream and the body. Thus, hypoalbuminemia leads to abnormal distributions of fluids within the body and its compartments. As a result, associated symptoms include edema in the lower legs, ascites in the abdomen, and effusions around internal organs. Laboratory tests aimed at assessing liver function diagnose hypoalbuminemia. Once identified, it is a poor prognostic indicator for patients with a variety of different diseases. Yet, it is only treated in very specific indications in patients with cirrhosis and nephrotic syndrome. Treatment instead focuses on the underlying cause of the hypoalbuminemia. Albumin is an acute negative phase respondent and not a reliable indicator of nutrition status.
Congestive hepatopathy, is liver dysfunction due to venous congestion, usually due to congestive heart failure. The gross pathological appearance of a liver affected by chronic passive congestion is "speckled" like a grated nutmeg kernel; the dark spots represent the dilated and congested hepatic venules and small hepatic veins. The paler areas are unaffected surrounding liver tissue. When severe and longstanding, hepatic congestion can lead to fibrosis; if congestion is due to right heart failure, it is called cardiac cirrhosis.
The King's College Criteria or the King's College Hospital criteria were devised in 1989 to determine if there were any early indices of poor prognosis in patients with acute liver failure. Acute liver failure is defined as the onset of encephalopathy or coagulopathy within 26 weeks of a patient diagnosed with liver disease. Patients with hepatitis B acquired at birth, Wilson's disease and autoimmune hepatitis are included if their disease was identified within the past 26 weeks. These patients are very ill, and have a very high risk of dying of their illness without adequate treatment which may include liver transplantation. It is important that physicians find ways of identifying patients with acute liver failure early in their course who will do poorly, and may require liver transplantation. The King's College Criteria have consistently shown excellent operating characteristics for determining prognosis in these patients. As liver transplantation becomes a more accessible option for patients with acute liver failure, the King's College Criteria serve a role in determining which patients may require transplantation.
Liver failure is the inability of the liver to perform its normal synthetic and metabolic functions as part of normal physiology. Two forms are recognised, acute and chronic (cirrhosis). Recently, a third form of liver failure known as acute-on-chronic liver failure (ACLF) is increasingly being recognized.
Hemoperfusion or hæmoperfusion is a method of filtering the blood extracorporeally to remove a toxin. As with other extracorporeal methods, such as hemodialysis (HD), hemofiltration (HF), and hemodiafiltration (HDF), the blood travels from the patient into a machine, gets filtered, and then travels back into the patient, typically by venovenous access.
Paracetamol poisoning, also known as acetaminophen poisoning, is caused by excessive use of the medication paracetamol (acetaminophen). Most people have few or non-specific symptoms in the first 24 hours following overdose. These symptoms include feeling tired, abdominal pain, or nausea. This is typically followed by absence of symptoms for a couple of days, after which yellowish skin, blood clotting problems, and confusion occurs as a result of liver failure. Additional complications may include kidney failure, pancreatitis, low blood sugar, and lactic acidosis. If death does not occur, people tend to recover fully over a couple of weeks. Without treatment, death from toxicity occurs 4 to 18 days later.
Hepatic artery thrombosis occurs when a blood clot forms in the artery that provides blood flow to the liver. Hepatic artery thrombosis may occur as a complication after liver transplantation, and represents the most common complication of liver transplantation. Smoking tobacco increases the risk of hepatic artery thrombosis in people who have undergone liver transplantation.
Hyperbilirubinemia is a clinical condition describing an elevation of blood bilirubin level due to the inability to properly metabolise or excrete bilirubin, a product of erythrocytes breakdown. In severe cases, it is manifested as jaundice, the yellowing of tissues like skin and the sclera when excess bilirubin deposits in them. The US records 52,500 jaundice patients annually. By definition, bilirubin concentration of greater than 3 mg/ml is considered hyperbilirubinemia, following which jaundice progressively develops and becomes apparent when plasma levels reach 20 mg/ml. Rather than a disease itself, hyperbilirubinemia is indicative of multifactorial underlying disorders that trace back to deviations from regular bilirubin metabolism. Diagnosis of hyperbilirubinemia depends on physical examination, urinalysis, serum tests, medical history and imaging to identify the cause. Genetic diseases, alcohol, pregnancy and hepatitis viruses affect the likelihood of hyperbilirubinemia. Causes of hyperbilirubinemia mainly arise from the liver. These include haemolytic anaemias, enzymatic disorders, liver damage and gallstones. Hyperbilirubinemia itself is often benign. Only in extreme cases does kernicterus, a type of brain injury, occur. Therapy for adult hyperbilirubinemia targets the underlying diseases but patients with jaundice often have poor outcomes.
↑ Morsiani E, Pazzi P, Puviani AC, Brogli M, Valieri L, Gorini P, Scoletta P, Marangoni E, Ragazzi R, Azzena G, Frazzoli E, Di Luca D, Cassai E, Lombardi G, Cavallari A, Faenza S, Pasetto A, Girardis M, Jovine E, Pinna AD (March 2002). "Early experiences with a porcine hepatocyte-based bioartificial liver in acute hepatic failure patients". The International Journal of Artificial Organs. 25 (3): 192–202. doi:10.1177/039139880202500305. PMID11999191. S2CID196422022.
↑ Mundt, A; Puhl, G; Müller, A; Sauer, I; Müller, C; Richard, R; Fotopoulou, C; Doll, R; Gäbelein, G; Höhn, W; Hofbauer, R; Neuhaus, P; Gerlach, J (June 2002). "A method to assess biochemical activity of liver cells during clinical application of extracorporeal hybrid liver support". The International Journal of Artificial Organs. 25 (6): 542–8. doi:10.1177/039139880202500609. PMID12117294. S2CID38686470.
↑ van de Kerkhove MP, Di Florio E, Scuderi V, Mancini A, Belli A, Bracco A, Dauri M, Tisone G, Di Nicuolo G, Amoroso P, Spadari A, Lombardi G, Hoekstra R, Calise F, Chamuleau RA (October 2002). "Phase I clinical trial with the AMC-bioartificial liver". The International Journal of Artificial Organs. 25 (10): 950–9. doi:10.1177/039139880202501009. PMID12456036. S2CID196427668.
↑ Rifai K, Ernst T, Kretschmer U, etal. (December 2003). "Prometheus—a new extracorporeal system for the treatment of liver failure". J. Hepatol. 39 (6): 984–90. doi:10.1016/S0168-8278(03)00468-9. PMID14642616.
↑ Mitzner, S; Loock, J; Peszynski, P; Klammt, S; Majcher-Peszynska, J; Gramowski, A; Stange, J; Schmidt, R (December 2002). "Improvement in central nervous system functions during treatment of liver failure with albumin dialysis MARS--a review of clinical, biochemical, and electrophysiological data". Metabolic Brain Disease. 17 (4): 463–75. doi:10.1023/A:1021986624600. PMID12602522. S2CID19491464.
↑ Sorkine P, Ben Abraham R, Szold O, Biderman P, Kidron A, Merchav H, Brill S, Oren R (July 2001). "Role of the molecular adsorbent recycling system (MARS) in the treatment of patients with acute exacerbation of chronic liver failure". Critical Care Medicine. 29 (7): 1332–6. doi:10.1097/00003246-200107000-00006. PMID11445681. S2CID42225349.
↑ Bergeron, M; Layrargues, GP; Butterworth, RF (September 1989). "Aromatic and branched-chain amino acids in autopsied brain tissue from cirrhotic patients with hepatic encephalopathy". Metabolic Brain Disease. 4 (3): 169–76. doi:10.1007/bf01000293. PMID2796871. S2CID24524207.
↑ Bergeron, M; Swain, MS; Reader, TA; Grondin, L; Butterworth, RF (July 1990). "Effect of ammonia on brain serotonin metabolism in relation to function in the portacaval shunted rat". Journal of Neurochemistry. 55 (1): 222–9. doi:10.1111/j.1471-4159.1990.tb08842.x. PMID1693945. S2CID2219787.
↑ Fischer, JE; Funovics, JM; Aguirre, A; James, JH; Keane, JM; Wesdorp, RI; Yoshimura, N; Westman, T (September 1975). "The role of plasma amino acids in hepatic encephalopathy". Surgery. 78 (3): 276–90. PMID807982.
↑ Loock, J; Stange, J; Mitzner, S; Schmidt, R; Gramowski, A; Schiffmann, D; Weiss, D; Keefer, EW; Gross, GW (June 2001). "Influence of albumin dialysis (MARS) on neuronal network activity in vitro--early results". Zeitschrift für Gastroenterologie. 39 (Suppl 2): 28–32. doi:10.1055/s-2001-919055. PMID16215892. S2CID260344744.
↑ Novelli, G; Rossi, M; Pretagostini, R; Novelli, L; Poli, L; Ferretti, G; Iappelli, M; Berloco, P; Cortesini, R (2003). "A 3-year experience with Molecular Adsorbent Recirculating System (MARS): our results on 63 patients with hepatic failure and color Doppler US evaluation of cerebral perfusion". Liver International. 23 (Suppl 3): 10–5. doi:10.1034/j.1478-3231.23.s.3.4.x. PMID12950955. S2CID25173997.
↑ Gaspari, R; Cavaliere, F; Sollazzi, L; Perilli, V; Melchionda, I; Agnes, S; Gasbarrini, A; Avolio, AW (Jan–Feb 2009). "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". Transplantation Proceedings. 41 (1): 253–8. doi:10.1016/j.transproceed.2008.10.066. hdl:10807/141915. PMID19249528.
1 2 Stefoni S, Colì L, Bolondi L, Donati G, Ruggeri G, Feliciangeli G, Piscaglia F, Silvagni E, Sirri M, Donati G, Baraldi O, Soverini ML, Cianciolo G, Boni P, Patrono D, Ramazzotti E, Motta R, Roda A, Simoni P, Magliulo M, Borgnino LC, Ricci D, Mezzopane D, Cappuccilli ML (February 2006). "Molecular adsorbent recirculating system (MARS) application in liver failure: clinical and hemodepurative results in 22 patients". The International Journal of Artificial Organs. 29 (2): 207–18. doi:10.1177/039139880602900207. hdl:11585/24619. PMID16552668. S2CID22591855.
1 2 Di Campli C, Santoro MC, Gaspari R, Merra G, Zileri Dal Verme L, Zocco MA, Piscaglia AC, Di Gioacchino G, Novi M, Santoliquido A, Flore R, Tondi P, Proietti R, Gasbarrini G, Pola P, Gasbarrini A (Jul–Aug 2005). "Catholic university experience with molecular adsorbent recycling system in patients with severe liver failure". Transplantation Proceedings. 37 (6): 2547–50. doi:10.1016/j.transproceed.2005.06.048. PMID16182739.
1 2 3 Camus, C; Lavoué, S; Gacouin, A; Compagnon, P; Boudjéma, K; Jacquelinet, C; Thomas, R; Le Tulzo, Y (December 2009). "Liver transplantation avoided in patients with fulminant hepatic failure who received albumin dialysis with the molecular adsorbent recirculating system while on the waiting list: impact of the duration of therapy". Therapeutic Apheresis and Dialysis. 13 (6): 549–55. doi:10.1111/j.1744-9987.2009.00708.x. PMID19954480. S2CID24898728.
↑ Steiner, C; Mitzner, S (2002). "Experiences with MARS liver support therapy in liver failure: analysis of 176 patients of the International MARS Registry". Liver. 22 (Suppl 2): 20–5. doi:10.1034/j.1600-0676.2002.00003.x. PMID12220298.
↑ Camus C, Lavoué S, Gacouin A, Le Tulzo Y, Lorho R, Boudjéma K, Jacquelinet C, Thomas R (November 2006). "Molecular adsorbent recirculating system dialysis in patients with acute liver failure who are assessed for liver transplantation". Intensive Care Medicine. 32 (11): 1817–25. doi:10.1007/s00134-006-0340-1. PMID16941171. S2CID8003937.
1 2 Catalina, MV; Barrio, J; Anaya, F; Salcedo, M; Rincón, D; Clemente, G; Bañares, R (2003). "Hepatic and systemic haemodynamic changes after MARS in patients with acute on chronic liver failure". Liver International. 23 (Suppl 3): 39–43. doi:10.1034/j.1478-3231.23.s.3.10.x. PMID12950960. S2CID2200601.
↑ Parés, A; Escorsell, A; Cisneros, L (2002). "Effects of the molecular adsorbent recirculating system (MARS) on vasoactive agents and systemic hemodynamics in patients with severe alcoholic hepatitis". 4th ISAD 2002 Abstrac.
↑ Versin P, Hirsch-Marie H, Catan R (1962). "Línsufissance rénale circulatoire spntané du cirrhotique. Son évolution". Sem Hôp Paris. 38: 3598–3602.
↑ McIntyre, CW; Fluck, RJ; Freeman, JG; Lambie, SH (November 2002). "Characterization of treatment dose delivered by albumin dialysis in the treatment of acute renal failure associated with severe hepatic dysfunction". Clinical Nephrology. 58 (5): 376–83. doi:10.5414/CNP58376. PMID12425489.
1 2 Saich, R; Collins, P; Ala, A; Standish, R; Hodgson, H (May 2005). "Benign recurrent intrahepatic cholestasis with secondary renal impairment treated with extracorporeal albumin dialysis". European Journal of Gastroenterology & Hepatology. 17 (5): 585–8. doi:10.1097/00042737-200505000-00018. PMID15827452. S2CID23033545.
↑ Cárdenas, A; Ginès, P (June 2006). "Therapy insight: Management of hepatorenal syndrome". Nature Clinical Practice Gastroenterology & Hepatology. 3 (6): 338–48. doi:10.1038/ncpgasthep0517. PMID16741553. S2CID12302583.
↑ Moreau, R; Lebrec, D (2007). "Diagnosis and treatment of acute renal failure in patients with cirrhosis". Best Practice & Research. Clinical Gastroenterology. 21 (1): 111–23. doi:10.1016/j.bpg.2006.10.004. PMID17223500.
↑ Wong, F (January 2007). "Drug insight: the role of albumin in the management of chronic liver disease". Nature Clinical Practice Gastroenterology & Hepatology. 4 (1): 43–51. doi:10.1038/ncpgasthep0680. PMID17203088. S2CID23729017.
↑ Wong, F; Raina, N; Richardson, R (March 2010). "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". Gut. 59 (3): 381–6. doi:10.1136/gut.2008.174615. PMID19710033. S2CID13455917.
1 2 3 4 Montejo González JC, Catalán González M, Meneu Díaz JC, Moreno Elola-Olaso A, De la Cruz J, Moreno González E (Mar–Apr 2009). "Artificial liver support system in acute liver failure patients waiting liver transplantation". Hepato-gastroenterology. 56 (90): 456–61. PMID19579620.
↑ Bergasa, NV; Thomas, DA; Vergalla, J; Turner, ML; Jones, EA (1993). "Plasma from patients with the pruritus of cholestasis induces opioid receptor-mediated scratching in monkeys". Life Sciences. 53 (16): 1253–7. doi:10.1016/0024-3205(93)90569-o. PMID8412484.
↑ Marchesini G, Bianchi G, Amodio P, Salerno F, Merli M, Panella C, Loguercio C, Apolone G, Niero M, Abbiati R, Italian Study Group for quality of life in cirrhosis (January 2001). "Factors associated with poor health-related quality of life of patients with cirrhosis". Gastroenterology. 120 (1): 170–8. doi:10.1053/gast.2001.21193. PMID11208726.
↑ Younossi, ZM; Kiwi, ML; Boparai, N; Price, LL; Guyatt, G (February 2000). "Cholestatic liver diseases and health-related quality of life". The American Journal of Gastroenterology. 95 (2): 497–502. doi:10.1111/j.1572-0241.2000.01774.x. PMID10685757. S2CID1584814.
↑ Huster, D; Schubert, C; Achenbach, H; Caca, K; Mössner, J; Berr, F (June 2001). "Successful clinical application of extracorporal albumin dialysis in a patient with benign recurrent intrahepatic cholestasis (BRIC)". Zeitschrift für Gastroenterologie. 39 (Suppl 2): 13–4. doi:10.1055/s-2001-919024. PMID16215886. S2CID260344650.
↑ Mullhaupt, B; Kullak-Ublick, GA; Ambühl, PM; Stocker, R; Renner, EL (April 2003). "Successful use of the Molecular Adsorbent Recirculating System (MARS) in a patient with primary biliary cirrhosis (PBC) and treatment refractory pruritus". Hepatology Research. 25 (4): 442–446. doi:10.1016/s1386-6346(02)00310-8. PMID12699855.
1 2 Macia, M; Avilés, J; Navarro, J; Morales, S; García, J (January 2003). "Efficacy of molecular adsorbent recirculating system for the treatment of intractable pruritus in cholestasis". The American Journal of Medicine. 114 (1): 62–4. doi:10.1016/s0002-9343(02)01354-2. PMID12543292.
↑ Majcher-Peszynska, J; T. Schneider; S. Müller; P. Peszynski; R. Mundowski; A. Berg; S. Klammt; B. Drewelow (2002). "Elimination of Fluoroquinolones during Extracorporeal Albumin Dialysis (MARS)". 4th ISAD (Abstracts).
↑ Majcher-Peszynska, J; S. Klammt; EM. Hehk (2000). "Removal of Albumin Bound Drugs in Albumin Dialysis (MARS)- A New Liver Support System". J. Hepatol. Suppl. 2. 32: 60. doi:10.1016/s0168-8278(00)80562-0.
↑ Kjaergard, LL; Liu, J; Als-Nielsen, B; Gluud, C (2003). "Artificial and bioartificial support systems for acute and acute-on-chronic liver failure: a systematic review". JAMA. 289 (2): 217–222. doi:10.1001/jama.289.2.217. PMID12517233.
↑ Lai, WK; Haydon, G; Mutimer, D; etal. (2005). "The effect of molecular adsorbent recirculating system on pathophysiological parameters in patients with acute liver failure". Intensive Care Med. 31 (11): 1544–1549. doi:10.1007/s00134-005-2786-y. PMID16155752. S2CID6642381.
↑ Lee, KH; Lee, MK; Sutedja, DS; etal. (2005). "Outcome from molecular adsorbent recycling system (MARS) liver dialysis following drug-induced liver failure". Liver Int. 25 (5): 973–977. doi:10.1111/j.1478-3231.2005.01091.x. PMID16162155. S2CID44868151.
1 2 Zhou, XM; Miao, JY; Yang, Y; etal. (2004). "Clinical experience with molecular adsorbent recirculating system (MARS) in patients with drug-induced liver failure". Artificial Organs. 28 (5): 483–486. doi:10.1046/j.1525-1594.2003.00953.x-i1. PMID15113343.
↑ Camus, C; Lavoue, S; Gacouin, A; etal. (2009). "Liver transplantation avoided in patients with fulminant hepatic failure who received albumin dialysis with the molecular adsorbent recirculating system while on the waiting list: impact of the duration of therapy". Ther Apher Dial. 13 (6): 549–555. doi:10.1111/j.1744-9987.2009.00708.x. PMID19954480. S2CID24898728.
↑ Evenepoel, P; Laleman, W; Wilmer, A; Claes, K; Kuypers, D; Bammens, B; Nevens, F; Vanrenterghem, Y (Apr 2006). "Prometheus versus molecular adsorbents recirculating system: comparison of efficiency in two different liver detoxification devices". Artificial Organs. 30 (4): 276–84. doi:10.1111/j.1525-1594.2006.00215.x. PMID16643386.
1 2 Faenza S, Baraldi O, Bernardi M, Bolondi L, Coli L, Cucchetti A, Donati G, Gozzetti F, Lauro A, Mancini E, Pinna AD, Piscaglia F, Rasciti L, Ravaioli M, Ruggeri G, Santoro A, Stefoni S (May 2008). "Mars and Prometheus: our clinical experience in acute chronic liver failure". Transplantation Proceedings. 40 (4): 1169–71. doi:10.1016/j.transproceed.2008.03.069. PMID18555140.
1 2 Krisper, P; Haditsch, B; Stauber, R; Jung, A; Stadlbauer, V; Trauner, M; Holzer, H; Schneditz, D (Sep 2005). "In vivo quantification of liver dialysis: comparison of albumin dialysis and fractionated plasma separation". Journal of Hepatology. 43 (3): 451–7. doi:10.1016/j.jhep.2005.02.038. PMID16023249.
↑ Kim WR, Gross JB Jr, Poterucha JJ, Locke GR 3rd, Dickson ER (Jan 2001). "Outcome of hospital care of liver disease associated with hepatitis C in the United States". Hepatology. 33 (1): 201–6. doi:10.1053/jhep.2001.20798. PMID11124837. S2CID21550617.
↑ Hessel, FP; Bramlage, P; Wasem, J; Mitzner, SR (Feb 2010). "Cost-effectiveness of the artificial liver support system MARS in patients with acute-on-chronic liver failure". European Journal of Gastroenterology & Hepatology. 22 (2): 213–20. doi:10.1097/meg.0b013e3283314e48. PMID19773666. S2CID21972813.
↑ Sen, S; Mookerjee, RP; Cheshire, LM; Davies, NA; Williams, R; Jalan, R (Jul 2005). "Albumin dialysis reduces portal pressure acutely in patients with severe alcoholic hepatitis". Journal of Hepatology. 43 (1): 142–8. doi:10.1016/j.jhep.2005.01.032. PMID15878216.
↑ Jalan, R; Sen, S; Steiner, C; Kapoor, D; Alisa, A; Williams, R (Jan 2003). "Extracorporeal liver support with molecular adsorbents recirculating system in patients with severe acute alcoholic hepatitis". Journal of Hepatology. 38 (1): 24–31. doi:10.1016/s0168-8278(02)00334-3. PMID12480556.
1 2 Manz, T; Ochs, A; Bisse, E; Strey, C; Grotz, W (2003). "Liver support--a task for nephrologists? Extracorporeal treatment of a patient with fulminant Wilson crisis". Blood Purification. 21 (3): 232–6. doi:10.1159/000070695. PMID12784049. S2CID45543585.
↑ Chen, S; Zhang, L; Shi, Y; Yang, X; Wang, M (2002). "Molecular Adsorbent Recirculating System: clinical experience in patients with liver failure based on hepatitis B in China". Liver. 22 (Suppl 2): 48–51. doi:10.1034/j.1600-0676.2002.00009.x. PMID12220304.
↑ Sen, S; Ytrebø, LM; Rose, C; Fuskevaag, OM; Davies, NA; Nedredal, GI; Williams, R; Revhaug, A; Jalan, R (Mar 2004). "Albumin dialysis: a new therapeutic strategy for intoxication from protein-bound drugs". Intensive Care Medicine. 30 (3): 496–501. doi:10.1007/s00134-003-2141-0. hdl:1866/24039. PMID14735236. S2CID30840312.
↑ Koivusalo, AM; Yildirim, Y; Vakkuri, A; Lindgren, L; Höckerstedt, K; Isoniemi, H (Oct 2003). "Experience with albumin dialysis in five patients with severe overdoses of paracetamol". Acta Anaesthesiologica Scandinavica. 47 (9): 1145–50. doi:10.1034/j.1399-6576.2003.00190.x. PMID12969110. S2CID12576160.
↑ Rubik, J; Pietraszek-Jezierska, E; Kamiński, A; Skarzynska, A; Jóźwiak, S; Pawłowska, J; Drewniak, T; Prokurat, S; Grenda, R; Kaliciński, P (Jun 2004). "Successful treatment of a child with fulminant liver failure and coma caused by Amanita phalloides intoxication with albumin dialysis without liver transplantation". Pediatric Transplantation. 8 (3): 295–300. doi:10.1111/j.1399-3046.2004.00170.x. PMID15176968. S2CID38538438.
↑ Covic, A; Goldsmith, DJ; Gusbeth-Tatomir, P; Volovat, C; Dimitriu, AG; Cristogel, F; Bizo, A (2003). "Successful use of Molecular Absorbent Regenerating System (MARS) dialysis for the treatment of fulminant hepatic failure in children accidentally poisoned by toxic mushroom ingestion". Liver International. 23 (Suppl 3): 21–7. doi:10.1034/j.1478-3231.23.s.3.9.x. PMID12950957. S2CID39904706.
↑ Parés, A; Cisneros, L; Salmerón, JM; Caballería, L; Mas, A; Torras, A; Rodés, J (Jun 2004). "Extracorporeal albumin dialysis: a procedure for prolonged relief of intractable pruritus in patients with primary biliary cirrhosis". The American Journal of Gastroenterology. 99 (6): 1105–10. doi:10.1111/j.1572-0241.2004.30204.x. PMID15180733. S2CID22709637.
Evenepoel P, Maes B, Wilmer A, etal. (2003). "Detoxifying capacity and kinetics of the molecular adsorbent recycling system. Contribution of the different inbuilt filters". Blood Purif. 21 (3): 244–52. doi:10.1159/000070697. PMID12784051. S2CID12355239.
Mitzner S, Klammt S, Stange J, Nöldge-Schomburg GF, Schmidt R (April 2005). "[Extracorporeal blood purification in severe liver failure with the albumin dialysis MARS – impact on relevant intensive care parameters]". Anasthesiol Intensivmed Notfallmed Schmerzther (in German). 40 (4): 199–206. doi:10.1055/s-2004-826116. PMID15832238. S2CID259980836.
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