UMEM Educational Pearls

Category: Critical Care

Title: Liver Dialysis on MARS (Molecular Adsorbent Recirculating System)

Keywords: liver failure, dialysis, MARS, Molecular Adsorbent Recirculating System (PubMed Search)

Posted: 10/10/2017 by Kami Hu, MD
Click here to contact Kami Hu, MD

Takeaways

Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."  

  • Limited data, small studies
  • Consistently shown to improve hemodynamics, toxin clearance, and hepatic homeostasis
  • No consistent proven mortality benefit
  • Only performed by limited number of US hospitals (including the University of Maryland)
  • May depend on the acute liver failure subpopulation, but best use currently seems to be for severe acute liver failure due to a potentially reversible/recoverable cause (toxin ingestion, trauma, acute alcoholic hepatitis, etc) or as a bridge to transplant

Take-Home:

1. Consider MARS in your patient with severe acute liver failure due to potentially reversible/recoverable etiology

2. Know if and where MARS is offered near you

 

(http://findbesttreatment.com/images/healthnet_dialyse_schema.gif)

In-Depth

Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."   

Its use demonstrates apparent effective replacement of liver function, with consistently-proven improvements in hemodynamics, hepatic encephalopathy, hepatorenal syndrome, drug clearance, hyperbilirubinemia, and other markers of hepatic homeostasis.

It has been repeatedly demonstrated to work well as a short-term bridge to liver recovery or liver transplant in severe ALF of various causes, especially those that are generally reversible with support and time severe trauma, toxic ingestions, and acute alcoholic hepatitis.

Mortality benefit remains unclear and may be dependent on the subtype of acute liver failure. Most of the current literature is made up of case reports, or case studies with small study populations. In acute on chronic liver failure, the 23-patient randomized, controlled RELIEF trial failed to show survival advantage at 28 days.  Gerth et al, however, found a 14-day mortality benefit in ACF patients by retrospective analysis, which may indicate that MARS use as a bridge to transplant is the most appropriate utilization in this patient population.

References

  • Bañares R, Nevens F, Larsen FS, et al. Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology. 2013;57(3): 1153-62.
  • Gerth HU, Pohlen M, Thölking G, et al. Molecular adsorbent recirculating system (MARS) in acute liver injury and graft dysfunction: Results from a case-control study.  PLoS One. 2017;12(4):e0175529.
  • Gerth HU, Pohlen M, Thölking G, et al. Molecular adsorbent recirculating system can reduce short-term mortality among patients with acute-on-chronic liver failure—a retrospective analysis. Crit Care Med. 2017;45(10): 1616-1624.
  • Hanish SI, Stein DM, Scalea JR, et al. Molecular adsorbent recirculating system effectively replaces hepatic function in severe acute liver failure. Ann Surg. 2017;266(4):677-684.