Preconditioning by Extracorporeal Liver Support
Purpose: The aim of this prospective study was to evaluate the effectiveness of preconditioning molecular adsorbent recirculating system (MARS) treatment on patients with acute-on-chronic liver failure (AoCLF), who were awaiting living donor liver transplantation (LDLT).
Patients and Methods: Between January and December 2001, 10 consecutive AoCLF patients (with progressive hyperbilirubinemia (>20 mg/dl) and hepatic encephalopathy grade ≥ 2) were studied. MARS was used in eight of these patients who were evaluated for LDLT during 2001. Three AoCLF patients who received LDLT before clinical use of MARS were used as historical controls.
Results: Because of a shortage of donors, only five out of 10 patients considered for LDLT could receive transplants. Three patients were treated with MARS for 8 h the day before receiving LDLT, and all three survived. The remaining two patients who received transplants, and who were not pretreated with MARS, died from sepsis and multi-organ failure within 2 weeks. Four of the patients who did not receive transplants because of donor shortage died despite 1 or 3 MARS treatments, however bilirubin levels and grade of encephalopathy were significantly reduced in these patients.
Conclusions: Results of this small pilot study suggest that MARS, by reducing the severity of jaundice and encephalopathy, might be effective as a bridging option in AoCLF patients awaiting LDLT.
There is a high incidence of chronic liver failure (LF) in Korea, caused by hepatitis B-associated liver diseases. Since most patients with acute-on-chronic liver failure (AoCLF) cannot receive high urgency liver transplantation (LTx) because of the shortage of cadaveric donors, living donor liver transplantation (LDLT) is increasingly used. In Korea, 1174 LDLTs have been performed (up to May 2003), and in 2002, 92% of all LTxs were LDLTs. Patients undergoing LTx for acute LF have a worse prognosis than patients with chronic LF. Recently, the MARS (Teraklin AG, Rostock, Germany) has become available for decreasing albumin-bound toxin levels, thus improving renal and cerebral dysfunction in patients with acute LF. Given these features, MARS has been proposed as a bridging option, if LTx is not possible. Furthermore, in patients suffering from cirrhosis with severe LF, progressive jaundice, and encephalopathy, the prognosis of LDLT is considerably influenced by the recipient's perioperative condition. Considering the emotional and ethical issues associated with LDLT, every additional option to improve the prognosis of LDLT should be thoroughly evaluated. Employing MARS as a preconditioning therapy might be effective in this situation, however, there is a scarcity of data describing the effectiveness of a preconditioning MARS therapy for LDLT in end-stage liver cirrhosis patients.
During this observational study we investigated whether MARS therapy could improve preoperative conditions in patients with end-stage liver cirrhosis and severe LF evaluated for LDLT.
Purpose: The aim of this prospective study was to evaluate the effectiveness of preconditioning molecular adsorbent recirculating system (MARS) treatment on patients with acute-on-chronic liver failure (AoCLF), who were awaiting living donor liver transplantation (LDLT).
Patients and Methods: Between January and December 2001, 10 consecutive AoCLF patients (with progressive hyperbilirubinemia (>20 mg/dl) and hepatic encephalopathy grade ≥ 2) were studied. MARS was used in eight of these patients who were evaluated for LDLT during 2001. Three AoCLF patients who received LDLT before clinical use of MARS were used as historical controls.
Results: Because of a shortage of donors, only five out of 10 patients considered for LDLT could receive transplants. Three patients were treated with MARS for 8 h the day before receiving LDLT, and all three survived. The remaining two patients who received transplants, and who were not pretreated with MARS, died from sepsis and multi-organ failure within 2 weeks. Four of the patients who did not receive transplants because of donor shortage died despite 1 or 3 MARS treatments, however bilirubin levels and grade of encephalopathy were significantly reduced in these patients.
Conclusions: Results of this small pilot study suggest that MARS, by reducing the severity of jaundice and encephalopathy, might be effective as a bridging option in AoCLF patients awaiting LDLT.
There is a high incidence of chronic liver failure (LF) in Korea, caused by hepatitis B-associated liver diseases. Since most patients with acute-on-chronic liver failure (AoCLF) cannot receive high urgency liver transplantation (LTx) because of the shortage of cadaveric donors, living donor liver transplantation (LDLT) is increasingly used. In Korea, 1174 LDLTs have been performed (up to May 2003), and in 2002, 92% of all LTxs were LDLTs. Patients undergoing LTx for acute LF have a worse prognosis than patients with chronic LF. Recently, the MARS (Teraklin AG, Rostock, Germany) has become available for decreasing albumin-bound toxin levels, thus improving renal and cerebral dysfunction in patients with acute LF. Given these features, MARS has been proposed as a bridging option, if LTx is not possible. Furthermore, in patients suffering from cirrhosis with severe LF, progressive jaundice, and encephalopathy, the prognosis of LDLT is considerably influenced by the recipient's perioperative condition. Considering the emotional and ethical issues associated with LDLT, every additional option to improve the prognosis of LDLT should be thoroughly evaluated. Employing MARS as a preconditioning therapy might be effective in this situation, however, there is a scarcity of data describing the effectiveness of a preconditioning MARS therapy for LDLT in end-stage liver cirrhosis patients.
During this observational study we investigated whether MARS therapy could improve preoperative conditions in patients with end-stage liver cirrhosis and severe LF evaluated for LDLT.
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