Continuous molecular adsorbent recirculating system treatment in 69 patients listed for liver transplantation

Figures & data

Figure 1. All patients treated with the Molecular Adsorbent Recirculating System at Oslo University Hospital, Rikshospitalet between March 2005 and January 2014.

Table I. Indications for molecular adsorbent recirculating system (MARS) treatment in 69 patients listed for liver transplantation in Norway since 2005.

	Number
Acute liver failure	39
Intoxication	19
Paracetamol	14
Unknown	9
Other	11
Acute on chronic liver failure	16
Hepatitis B	3
Hepatitis C	4
Alcoholic cirrhosis	3
Primary biliary atresia	2
Primary sclerosing cholangitis	2
Biliary atresia	1
Chronic graft dysfunction	1
Primary non-function of liver transplant	14

Figure 2. Indications for treating patients listed for liver transplantation with the Molecular Adsorbent Recirculating System.

Table II. Parameters measured before, during, and after start of treatment with the Molecular Adsorbent Recirculating System (MARS).

	0–2 h before MARS	2 h after start MARS	p-Value^1	After last MARS treatment	p-Value^2
Hematology parameters
Hemoglobin (g/dL)	9.6 (8.9–10.9)	9.5 (8.8–10.2)	0.06	9.2 (8.7–10.2)	0.10
Platelet count (*10^9/L)	81 (58–131)	62 (38–122)	< 0.001	52 (42–75)	< 0.001
White blood cell count	8.6 (6.4–14)	7.9 (5.3–13.1)	0.28	7.5 (4.6–12.1)	0.13
Electrolytes
Na^+ (mmol/L)	141 (137–146)	142 (138–146)	0.03	143 (139–146)	0.02
K^+ (mmol/L)	4.0 (3.5–4.5)	3.9 (3.6–4.3)	0.53	4.0 (3.6–4.3)	0.43
Ca2^+ (mmol/L)	2.04 (1.86–2.32)	2.06 (1.90–2.27)	0.95	2.12 (2.00–2.40)	0.19
Phosphate (mmol/L)	1.2 (0.8–1.8)	1.0 (0.7–1.8)	0.001	1.0 (0.5–1.4)	0.002
Magnesium (mmol/L)	0.86 (0.76–1.01)	0.78 (0.70–0.87)	< 0.001	0.74 (0.69–0.84)	< 0.001
Toxicity parameters
Ammonium (µmol/L)	148 (104–213)	137 (99–196)	0.32	124 (85–174)	0.03
Bilirubin (µmol/L)	150 (74–353)	169 (73–280)	0.03	139 (72–242)	0.01
Enzyme activity
AST (U/L)	2147 (316–6293)	1857 (263–6137)	< 0.001	594 (173–2983)	< 0.001
ALT (U/L)	1576 (340–5029)	1355 (2665–3959)	< 0.001	834 (121–2565)	< 0.001
LDH (U/L)	958 (383–4981)	852 (381–4629)	< 0.001	518 (259–1506)	< 0.001
ALP (U/L)	121 (94–170)	110 (86–152)	0.02	103 (73–149)	0.002
Gamma-GT (U/L)	63 (37–98)	51 (26–90)	0.004	35 (20–75)	< 0.001
Renal parameters
Creatinine (µmol/L)	136 (74–288)	127 (54–208)	< 0.001	74 (44–146)	< 0.001
Urea (mmol/L)	8.2 (4.6–13.8)	7.2 (4.1–11.8)	< 0.001	5.4 (2.1–9.2)	< 0.001
Plasma proteins
Total protein (g/L)	47 (41–51)	46 (39–51)	0.93	46 (39–51)	0.10
Albumin (g/L)	30 (26–33)	30 (27–35)	0.16	31 (25–35)	0.24
Fibrinogen (g/L)	1.1 (0.9–1.5)	0.8 (0.6–1.2)	0.002	1.0 (0.5–1.3)	0.01
Coagulation
INR	2.4 (1.8–2.0)	2.7 (2.0–3.7)	0.04	2.5 (1.9–3.7)	0.004
APTT	63 (45–100)	70 (49–100)	0.77	72 (51–103)	0.33

Values obtained 2 hours after start of MARS (1) and after last MARS treatment (2) were compared to values obtained 0-2 hours before MARS with the Wilcoxon Signed Rank-test.

Note: Values are presented as median (quartiles).

ALP = Alkaline phosphatase; ALT = Alanine aminotransferase; APTT = Acivated partial thromboplastin time; AST = Aspartate aminotransferase; gamma GT = Glutamyl trans/ferase; INR = International normalized ratio; LDH = Lactate dehydrogenase.

Table III. Univariate logistic regression analyses of ability to predict survival without (n = 4) or until (n = 56) liver transplantation in 69 patients listed for liver transplantation. Baseline values minus values after treatment with the Molecular Adsorbent Recirculating System (MARS) are covariates.

	Odds ratio	95% Confidence interval	p-Value
Platelet count (*10^9/L)	1.01	0.99–1.03	0.33
Sodium (mmol/L)	0.94	0.84–1.05	0.30
Phosphate (mmol/L)	2.91	0.73–11.6	0.13
Magnesium (mmol/L)	1.83	0.01–461	0.83
Ammonium (µmol/L)	1.00	1.00–1.01	0.22
Bilirubin (µmol/L)	1.00	0.99–1.00	0.58
AST (U/L)	1.00	1.00–1.00	0.16
ALT (U/L)	1.00	1.00–1.00	0.53
LDH (U/L)	1.00	1.00–1.00	0.62
ALP (U/L)	1.00	0.99–1.01	0.82
Gamma-GT (U/L)	1.02	0.99–1.05	0.27
Creatinine (µmol/L)	1.02	1.00–1.05	0.050
Urea (mmol/L)	1.02	0.92–1.13	0.72
Fibrinogen (g/L)	0.64	0.18–2.30	0.49
INR	1.49	0.91–2.40	0.11

Note: Only parameters that changed significantly during MARS treatment according to Table II were tested.

Abbreviations: ALP = Alkaline phosphatase; ALT = Alanine aminotransferase; AST = Aspartate aminotransferase; gamma GT = Glutamyl transferase; INR = International normalized ratio; LDH = Lactate dehydrogenase.

Table IV. Cox regression analyses of parameters ability to predict 30-days post liver transplantation survival in Molecular Adsorbent Recirculating System treated patients that were subsequently liver transplanted (n = 56). Baseline values minus values after MARS treatment are covariates. Only parameters that changed significantly during MARS treatment according to Table II were tested.

	Univariate			Multivariate
	Hazard ratio	95% Confidence interval	p-Value	Hazard ratio	95% Confidence interval	p-Value
Platelet count (*10^9/L)	1.00	0.99–1.01	0.43
Sodium (mmol/L)	1.05	0.94–1.15	0.39
Phosphate (mmol/L)	0.05	0.00–0.76	0.03	0.20	0.01–7.93	0.39
Magnesium (mmol/L)	0.40	0.00–51	0.71
Ammonium (µmol/L)	1.00	0.99–1.00	0.50
Bilirubin (µmol/L)	1.00	0.99–1.01	0.46
ALT (U/L)	1.00	1.00–1.00	0.86
AST (U/L)	1.00	1.00–1.00	0.19
LDH (U/L)	1.00	1.00–1.00	0.89
ALP (U/L)	1.01	1.00–1.03	0.13
Gamma-GT (U/L)	1.03	1.01–1.4	< 0.001	1.02	0.99–1.04	0.26
Creatinine (µmol/L)	0.99	0.98–1.01	0.27
Urea (mmol/L)	0.99	0.91–1.08	0.82
Fibrinogen (g/L)	1.83	0.54–6.17	0.33
INR	0.95	0.54–1.67	0.85

Note: Only parameters that changed significantly during MARS treatment according to Table II were tested.

Abbreviations: ALP = Alkaline phosphatase; ALT = Alanine aminotransferase; AST = Aspartate aminotranesferase; gamma GT = Glutamyl transferase; INR = International normalized ratio; LDH = Lactate dehydrogenase.