Liver support systems

The MARS System

MARS was developed by a group of researchers at the University of Rostock (Germany), in 1993¹⁰ and later commercialized for its clinical use in 1999. The system is able to replace the detoxification function of the liver while minimizing the inconvenience and drawbacks of previously used devices.

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. 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

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, 100 nm 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).

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:

1. Specialized in systematic reviews: Cochrane Library Plus and NHS Centre database for Reviews and Dissemination (HTA, DARE and NHSEED).
2. General databases: Medline, Pubmed and Embase.
3. On-going clinical trials and research project databases: Clinical Trials Registry (National Institutes of Health, EE.UU.) and Health Services Research Projects in Progress.
4. General web searching engines: Scholar Google.

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:

1. Improve our understanding of the clinical course, pathopysiology and treatment of these diseases
2. Evaluate the clinical impact of MARS therapy on the course of the disease in different specific indication
3. 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.

Effects of MARS treatment on Hepatic Encephalopathy (HE)

Hepatic encephalopathy (HE) represents one of the more serious extrahepatic complications associated with liver dysfunction. 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.
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).

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, 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, 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.

Novelli G et al. 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.

More recently, several studies have shown a significant improvement of HE in patients treated with MARS. In the studies by Heemann et al. and Sen et al. 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. In the latter, 70 patients with acute on chronic liver failure and encephalopathy grade III and IV were included. Likewise, Kramer et al. 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.

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.
Schmidt et al. 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. 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.

There are other studies also worth mentioning with similar results: Heemann et al. and Parés et al. among others. Dethloff T et al. concluded that there is a statistically significant improvement favourable to MARS in comparison with Prometheus system (Table 5).

Effects of MARS Treatment on Renal Function

Hepatorenal syndrome is one of the more serious complications in patients with an 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 a very poor prognosis, with survival at 1 and 2 months of 20 and 10% respectively.

Pierre Versin 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 by optimization of their clinical status.

MARS treatment lowers serum urea and creatinine levels improving their clearance, and even favors resolution of hepatorenal syndrome. Results are confirmed in a randomized controlled trial published by Mitzner et al. in which 13 patients diagnosed with hepatorenal syndrome type I were 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 rennin 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.
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. published a metaanalysis based in 4 small RCT’s and 2 non RCT’s in patients diagnosed with ACLF, concluding that MARS therapy would not bring any significant increment on survival compared with SMT. Another observational study in 6 patients with cirrhosis, refractory ascitis 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.

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. 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).

Impact of MARS therapy on plasma biliary acids levels was evaluated in 3 studies. In the study from Stadbauer et al., 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. and Laleman et al. 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 hypothesis have been formulated to explain physio pathogenesis of such manifestation, including incremental plasma concentration of biliary acids, abnormalities in the bile ducts, increased central neurotransmitters coupling opioid receptors, etc.…. Despite the number of historical drugs used, individually or combined (exchange resins, hidrophilic 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…). 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. 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. Nevertheless, some authors have concluded that besides the good results found in the literature, application of MARS therapy in refractory pruritus requires larger evidence.

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:

Hepatic flow rate

Cytochrome P-450 enzimatic activity

Albumin affinity for the drug

Extrahepatic clearance for the drug

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 proteins and high distribution volume, such as fluoroquinolones (Levofloxacin and Ciprofloxacin).

Extracorporeal detoxification with albumin dialysis increases the clearance of drugs that are bound to plasmatic proteins (Table 7).

Effects of MARS on Survival

In the meta-analysis published by Khuroo et al. which included 4 randomized trials 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 (published in 2004), nor the meta-analysis by Kjaergard et al. 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. 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. 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. and Heemann et al. they were able to show a significance statistical difference in 30-day survival for patients in the MARS group. However, El Banayosy et al. and Hassanein et al. 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%, and 60-80%. 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)

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)

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. 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 and five addressing acute on chronic, being four MARS related. 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.

Heemann et al. reported two adverse events most probably MARS related: fever and sepsis, presumably originated at the catheter.

In the study by Hassanein et al., two patients in the MARS group abandoned the study owing to hemodynamic instability, three patients required larger than average platelets transfusion and three more patients presented gastrointestinal bleeding.

Laleman et al. 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) wrote about 3 cases with disseminated intravascular coagulation in the interventional group, two of them with fatal outcomes.

Mitzner et al. 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. 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. 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. 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).

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. 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. 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.

Acute on Chronic Liver Failure

Etiology:

Chronic viral hepatitis

Alcoholic liver disease

Autoimmune disease

Metabolic disease such as hemochromatosis

Idiopathic Cirrhosis

Goals of MARS Therapy

Re-compensation of previous chronic state.

Prolong survival time and bridge to urgent or elective transplant

Pre-transplant optimization of the patient

MARS Therapy Indication

Bilirubin > 15 mg/dl (255 μmol/l), not responding to standard medical care alter 3 days

Renal dysfunction or hepatorenal syndrome.

Hepatic encephalopathy ≥ II

Treatment Schedule:

3 to 5 eight-hour treatment sessions in consecutives days

Continuous treatment with hemodynamic inestability (in any case, treatment kit must be replaced every 24 hours)

Acute Liver failure

Etiology:

Viral infection

Poisoning (paracetamol overdose, mushrooms)

Multiorgan dysfunction (severe sepsis)

Vascular diseases (Budd Chiari syndrome)

Hypoxic hepatitis

Liver failure during pregnancy or Reye syndrome

Unknown etiology

Goals of MARS Therapy

Native liver recovery.

Bridging to liver transplant

Pre-transplant optimization of the patient.

MARS Therapy Indication

King’s College or Clichy criteria for liver transplantation

Hepatic encephalopathy ≥ II

Increased intracraneal pressure

Acute hypoxic hepatitis with bilirubin > 8 mg/dl (100 μmol/l)

Renal dysfunction or hepatorenal syndrome

Progressive intrahepatic cholestasis

Fulminant Wilson disease

Acute liver dysfunction following paracetamol overdose

Treatment Schedule:

3 to 5 eight-hour treatment sessions in consecutives days

Hypoxic hepatitis. 3 eight-hour treatment sessions in consecutives days

Paracetamol overdose: 3 to 5 twenty four-hour treatment sessions

Mushroom poisoning: 3 to 5 twenty four-hour treatment sessions

Fulminant Wilson: minimum 5 twenty four-hour treatment sessions owing to copper saturation of the treatment kit

Drug overdose: 3 to 5 eight-hour treatment sessions in consecutives days

MARS in Graft Dysfucntion After Liver Transplant

Etiology:

Graft damage during preparation and transportation

Infection

Hepatotoxic drugs

Graft rejection

Technical complications (vascular, biliary)

Recurrence of primary disease

Goals of MARS Therapy

Recovery and prevention of re-transplantation

• Prolong survival time and stabilize the patient to receive a re-transplant if the above goal is not achieved

MARS Therapy Indication

Primary graft dysfunction

Hepatic encephalopathy ≥ II

Increased intracranial pressure

Renal dysfunction or hepatorenal syndrome.

Progressive intrahepatic cholestasis

Treatment Schedule:

3 to 5 eight-hour treatment sessions in consecutives days

Continuous treatment with hemodynamic inestability (in any case, treatment kit must be replaced every 24 hours)

Etiology:

Liver Resection in hepatocellular carcinoma

Transarterial Chemoembolization (TACE)

Partial resection in living donor transplantation

Other surgical intervenctions

Goals of MARS Therapy

Recovery until hepatic regeneration

MARS Therapy Indication

Hepatic encephalopathy ≥ II

Renal dysfunction or hepatorenal syndrome.

Progressive intrahepatic cholestasis

Treatment Schedule:

3 to 5 eight-hour treatment sessions in consecutives days

Continuous treatment with hemodynamic inestability (in any case, treatment kit must be replaced every 24 hours)

MARS for intractable pruritus in Cholestasis

Etiology:

Primary biliary cirrhosis (PBC), primary sclerosing cholangitis (PSC)

Benign intrahepatic cholestasis (BIC)

Biliary Atresia

Goals of MARS Therapy

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 of 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:

1. MAP inferior to 40 mmHg at least for 10 minutes
2. Air embolism of the extracorporeal circuit
3. Transmembrane pressure (TMP) greater than 600 mmHg.
4. Blood leak detection in the albumin circuit
5. Disseminated intravascular coagulation (DIC)
6. 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