Molecular Adsorbent Recirculating System for Acute Liver Failure in a New Pediatric-Based Extracorporeal Liver Support Program

David R. Baker, MD; Helen Mac, MD; Benjamin Steinman, MD; Sara H. Soshnick, DO, MS; Shalom Z. Frager, MD; Beatrice Goilav, MD; Debora Kogan-Liberman, MD; Nadia Ovchinsky, MD, MBA; Mark Shlomovich, MD

doi:10.1097/CCE.0000000000001002

Critical Care Explorations (Nov 2023)

Molecular Adsorbent Recirculating System for Acute Liver Failure in a New Pediatric-Based Extracorporeal Liver Support Program

David R. Baker, MD,
Helen Mac, MD,
Benjamin Steinman, MD,
Sara H. Soshnick, DO, MS,
Shalom Z. Frager, MD,
Beatrice Goilav, MD,
Debora Kogan-Liberman, MD,
Nadia Ovchinsky, MD, MBA,
Mark Shlomovich, MD

Affiliations

David R. Baker, MD: 1 Division of Pediatric Critical Care, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Helen Mac, MD: 2 Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Benjamin Steinman, MD: 3 Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Sara H. Soshnick, DO, MS: 1 Division of Pediatric Critical Care, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Shalom Z. Frager, MD: 4 Division of Hepatology, Department of Medicine, Montefiore Medical Center, Bronx, NY.
Beatrice Goilav, MD: 3 Division of Pediatric Nephrology, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.
Debora Kogan-Liberman, MD: 5 Division of Pediatric Gastroenterology and Hepatology, Hassenfeld Children’s Hospital, NYU Grossman School of Medicine, New York, NY.
Nadia Ovchinsky, MD, MBA: 5 Division of Pediatric Gastroenterology and Hepatology, Hassenfeld Children’s Hospital, NYU Grossman School of Medicine, New York, NY.
Mark Shlomovich, MD: 1 Division of Pediatric Critical Care, The Children’s Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY.

DOI: https://doi.org/10.1097/CCE.0000000000001002
Journal volume & issue: Vol. 5, no. 11
p. e1002

Abstract

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IMPORTANCE:. Acute liver failure (ALF) carries significant morbidity and mortality, for both pediatric and adult patients. Albumin dialysis via the molecular adsorbent recirculating system (MARS) is a form of extracorporeal liver support (ELS) that can reduce hepatic encephalopathy (HE), a main driver of mortality in ALF. However, data on MARS and its benefit on mortality have been inconsistent. OBJECTIVES:. We sought to report our experiences and patient outcomes from the first 2 years of operation of a new ELS program, within an established pediatric liver transplantation center. DESIGN, SETTING, AND PARTICIPANTS:. Retrospective review of outcomes in pediatric and adult patients treated with MARS therapy for ALF, from 2021 to 2022. MAIN OUTCOMES AND MEASURES:. Outcomes included reduction in HE and biochemical markers of ALF after MARS therapy, survival, and transplant-free survival. Comparisons were made via Wilcoxon signed-rank test. RESULTS:. Five pediatric and two adult patients underwent MARS for ALF. Ages ranged from 2 to 29 years. Overall, 21 MARS runs were performed (median 3 runs per patient, 12.4 hr per run [interquartile range, IQR 10.1–17]). Overall survival was 85.7%, and transplant-free survival was 71.4%. There was a statistically significant reduction in HE score with MARS therapy (median 3 [IQR 3–4] to 1 [IQR 0–1], p = 0.03), and in ALF biomarkers including ammonia (256 µL/dL [195–265] to 75 µL/dL [58–101], p = 0.02), aspartate aminotransferase (6,362 U/L [920–8,305] to 212 U/L [72–431], p = 0.02), alanine aminotransferase (8,362 U/L [3,866–9,189] to 953 U/L [437–1,351], p = 0.02), and international normalized ratio (4.5 [3.3–6.7] to 1.3 [1.2–1.4], p = 0.02). CONCLUSIONS AND RELEVANCE:. MARS therapy for ALF was well tolerated by both pediatric and adult patients, and resulted in significant improvement in clinical and biochemical parameters. We demonstrated encouraging overall and transplant-free survival, suggesting that early initiation of MARS with relatively long and frequent cycle times may be of significant benefit to ALF patients, and is worthy of additional study in larger cohorts.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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