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The role of molecular adsorbent recirculating system dialysis for extracorporeal liver support in children

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Abstract

The majority of children with acute, acute-on-chronic, and progressive chronic liver failure require liver transplantation. Since organ availability is limited, extracorporeal liver support systems are increasingly applied to bridge the time until transplantation. At present, four different devices are available: the molecular adsorbent recirculating system (MARS), Prometheus dialysis, plasma exchange combined with hemodialysis (PE/HD), and single-pass albumin dialysis (SPAD). Randomized trials in adults have demonstrated efficient toxin removal, improved portal hypertension, hemodynamic stability, and improved hepatic encephalopathy compared with standard medical therapy. None of the liver support systems has yet been evaluated systematically in children. Knowledge of the specific indications and technical features of the different devices is essential if applied in children. MARS combines albumin dialysis with conventional hemodialysis and allows for efficient removal of water and protein-bound toxins without exogenous protein delivery and the associated infectious and allergic risks. It has successfully been applied in children with otherwise intractable cholestatic pruritus and with liver failure. The benefits, however, need to be balanced against the costs and the risk of volume and nitrogen overload if repeated plasma infusion is required. In cases of active bleeding, plasma exchange in combination with hemodialysis should be preferred.

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Authors and Affiliations

  1. Division of Pediatric Nephrology, Center for Pediatric and Adolescent Medicine, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany

    Betti Schaefer & Claus Peter Schmitt

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  1. Betti Schaefer
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  2. Claus Peter Schmitt
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Correspondence to Claus Peter Schmitt.

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Answers

1. b

2. d

3. d

4. c

5. a

Multiple choice questions (answers are provided following the reference list)

Multiple choice questions (answers are provided following the reference list)

  1. 1.

    Which of the following situations represents an absolute indication for extracorporeal liver support?

    1. a)

      Chronic compensated liver disease

    2. b)

      Hepatic encephalopathy 3°

    3. c)

      INR above 1.6

    4. d)

      Increased blood pressure

    5. e)

      Intestinal bleeding

  2. 2.

    Which of the following statements regarding liver bridging is correct?

    1. a)

      Has been shown to improve survival in children with acute liver failure

    2. b)

      Cannot be performed in children below 10 kg body weight

    3. c)

      Induces significant liver regeneration owing to toxin removal

    4. d)

      Should not be initiated if liver Tx is not feasible or recovery unexpected

    5. e)

      RCTs are underway in children

  3. 3.

    Which of the following features of MARS is wrong?

    1. a)

      Set-up time is long

    2. b)

      Removes protein-bound toxins without exposure to exogenous proteins

    3. c)

      Is expensive

    4. d)

      Has no negative impact on coagulation

    5. e)

      Improves cholestatic pruritus

  4. 4.

    Plasma exchange in combination with hemodialysis for extracorporeal liver support is correctly described by which of the following statements?

    1. a)

      Is less efficient regarding toxin removal than MARS

    2. b)

      Requires special dialyzers to remove liver toxins

    3. c)

      Has a high detoxification capacity

    4. d)

      Must be performed sequentially

    5. e)

      Allows for continuous removal of protein-bound toxins

  5. 5.

    Which of the following statements regarding extracorporeal liver support (ELS) is correct?

    1. a)

      ELS is superior to standard medical treatment

    2. b)

      MARS removes bilirubin better than Prometheus

    3. c)

      ELS should not be applied in children with severe cholestatic pruritus

    4. d)

      SPAD in infants is inferior to the MARS mini-device

    5. e)

      ELS should not be performed with citrate anticoagulation

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Schaefer, B., Schmitt, C.P. The role of molecular adsorbent recirculating system dialysis for extracorporeal liver support in children. Pediatr Nephrol 28, 1763–1769 (2013). https://doi.org/10.1007/s00467-012-2348-9

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  • DOI: https://doi.org/10.1007/s00467-012-2348-9

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