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Molecular Absorbent Recirculating System therapy (MARS®) in pediatric acute liver failure: a single center experience

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Abstract

Background

Supportive care as a bridge to transplant or recovery remains challenging in children suffering from acute liver failure (ALF). We report our experience in children using the Molecular Absorbent Recirculating System (MARS®).

Methods

Retrospective data from children receiving therapy using MARS® from October 2009 to October 2012 were included in this single-center retrospective study. Patient characteristics, clinical presentation and complications of ALF, clinical and biological data before and after each MARS® session, technical modalities and adverse events were recorded.

Results

A total of six children underwent 17 MARS® sessions during the study period. Two adolescents were treated with the adult filter MARSFLUX® and four infants were treated with the MiniMARS® filter. The mean PEdiatric Logistic Dysfunction (PELOD) score at admission was 19 (range 11–33). All patients were mechanically ventilated, and four had acute kidney injury. The neurological course improved in one case, judged as stable in two cases and worsened in one case; data were unavailable in two cases. Mean serum ammonia levels decreased significantly following treatment with MARS® from an initial 89 ± 29 to 58 ± 35 mcmol/L (p = 0.02). No other significant biological improvement was observed. Hemodynamic status improved/remained unchanged in the adolescent group, but in the infants four of the seven sessions were poorly tolerated and two sessions were aborted. Three patients died, two were successfully transplanted and one recovered without transplantation.

Conclusion

In our experience, treatment with MARS® is associated with encouraging results in adolescents, but it needs modification for very sick infants to improve tolerance.

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References

  1. Devictor D, Tissieres P, Afanetti M, Debray D (2011) Acute liver failure in children. Clin Res Hepatol Gastroenterol 35:430–437

    Article  PubMed  Google Scholar 

  2. Psacharopoulos HT, Mowat AP, Davies M, Portmann B, Silk DB, Williams R (1980) Fulminant hepatic failure in childhood: an analysis of 31 cases. Arch Dis Child 55:252–258

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  3. Rivera-Penera T, Moreno J, Skaff C, McDiarmid S, Vargas J, Ament ME (1997) Delayed encephalopathy in fulminant hepatic failure in the pediatric population and the role of liver transplantation. J Pediatr Gastroenterol Nutr 24:128–134

    Article  PubMed  CAS  Google Scholar 

  4. Farmer DG, Venick RS, McDiarmid SV, Duffy JP, Kattan O, Hong JC, Vargas J, Yersiz H, Busuttil RW (2009) Fulminant hepatic failure in children: superior and durable outcomes with liver transplantation over 25 years at a single center. Ann Surg 250:484–493

    PubMed  Google Scholar 

  5. Lee WS, McKiernan P, Kelly DA (2005) Etiology, outcome and prognostic indicators of childhood fulminant hepatic failure in the United kingdom. J Pediatr Gastroenterol Nutr 40:575–581

    Article  PubMed  Google Scholar 

  6. Diamond IR, Fecteau A, Millis JM, Losanoff JE, Ng V, Anand R, Song C (2007) Impact of graft type on outcome in pediatric liver transplantation: a report From Studies of Pediatric Liver Transplantation (SPLIT). Ann Surg 246:301–310

    Article  PubMed Central  PubMed  Google Scholar 

  7. Azoulay D, Castaing D, Adam R, Savier E, Delvart V, Karam V, Ming BY, Dannaoui M, Krissat J, Bismuth H (2001) Split-liver transplantation for two adult recipients: feasibility and long-term outcomes. Ann Surg 233:565–574

    Article  PubMed Central  PubMed  CAS  Google Scholar 

  8. Vaid A, Chweich H, Balk EM, Jaber BL (2012) Molecular adsorbent recirculating system as artificial support therapy for liver failure: a meta-analysis. ASAIO J 58:51–59

    Article  PubMed  CAS  Google Scholar 

  9. Nevens F, Laleman W (2012) Artificial liver support devices as treatment option for liver failure. Best Pract Res Clin Gastroenterol 26:17–26

    Article  PubMed  Google Scholar 

  10. Blei AT, Cordoba J (2001) Hepatic encephalopathy. Am J Gastroenterol 96:1968–1976

    Article  PubMed  CAS  Google Scholar 

  11. Squires RH, Shneider BL, Bucuvalas J, Alonso E, Sokol RJ, Narkewicz MR, Dhawan A, Rosenthal P, Rodriguez-Baez N, Murray KF, Horslen S, Martin MG, Lopez MJ, Soriano H, McGuire BM, Jonas MM, Yazigi N, Shepherd RW, Schwarz K, Lobritto S, Thomas DW, Lavine JE, Karpen S, Ng V, Kelly D, Simonds N, Hynan LS (2006) Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr 148:652–658

    Article  PubMed Central  PubMed  Google Scholar 

  12. Merouani A, Kechaou W, Litalien C, Ducruet T, Jouvet P (2011) Impact of blood volume monitoring on fluid removal during intermittent hemodialysis of critically ill children with acute kidney injury. Nephrol Dial Transplant 26:3315–3319

    Article  PubMed  Google Scholar 

  13. Leteurtre S, Martinot A, Duhamel A, Proulx F, Grandbastien B, Cotting J, Gottesman R, Joffe A, Pfenninger J, Hubert P, Lacroix J, Leclerc F (2003) Validation of the paediatric logistic organ dysfunction (PELOD) score: prospective, observational, multicentre study. Lancet 362:192–197

    Article  PubMed  Google Scholar 

  14. Pollack MM, Patel KM, Ruttimann UE (1996) PRISM III: an updated Pediatric Risk of Mortality score. Crit Care Med 24:743–752

    Article  PubMed  CAS  Google Scholar 

  15. Lu BR, Gralla J, Liu E, Dobyns EL, Narkewicz MR, Sokol RJ (2008) Evaluation of a scoring system for assessing prognosis in pediatric acute liver failure. Clin Gastroenterol Hepatol 6:1140–1145

    Article  PubMed Central  PubMed  Google Scholar 

  16. Kamath PS, Wiesner RH, Malinchoc M, Kremers W, Therneau TM, Kosberg CL, D’Amico G, Dickson ER, Kim WR (2001) A model to predict survival in patients with end-stage liver disease. Hepatology 33:464–470

    Article  PubMed  CAS  Google Scholar 

  17. Barshes NR, Lee TC, Udell IW, O’Mahoney C, Karpen SJ, Carter BA, Goss JA (2006) The pediatric end-stage liver disease (PELD) model as a predictor of survival benefit and posttransplant survival in pediatric liver transplant recipients. Liver Transpl 12:475–480

    Article  PubMed  Google Scholar 

  18. Ferenci P, Lockwood A, Mullen K, Tarter R, Weissenborn K, Blei AT (2002) Hepatic encephalopathy—definition, nomenclature, diagnosis, and quantification: final report of the working party at the 11th World Congresses of Gastroenterology, Vienna, 1998. Hepatology 35:716–721

    Article  PubMed  Google Scholar 

  19. Teasdale G, Jennett B (1974) Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84

    Article  PubMed  CAS  Google Scholar 

  20. Fiser DH, Long N, Roberson PK, Hefley G, Zolten K, Brodie-Fowler M (2000) Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit Care Med 28:2616–2620

    Article  PubMed  CAS  Google Scholar 

  21. Brophy PD, Mottes TA, Kudelka TL, McBryde KD, Gardner JJ, Maxvold NJ, Bunchman TE (2001) AN-69 membrane reactions are pH-dependent and preventable. Am J Kidney Dis 38:173–178

    Article  PubMed  CAS  Google Scholar 

  22. Hassanein TI, Tofteng F, Brown RS, McGuire B, Lynch P, Mehta R, Larsen FS, Gornbein J, Stange J, Blei AT (2007) Randomized controlled study of extracorporeal albumin dialysis for hepatic encephalopathy in advanced cirrhosis. Hepatology 46:1853–1862

    Article  PubMed  CAS  Google Scholar 

  23. Merouani A, Flechelles O, Jouvet P (2012) Acute kidney injury in children. Minerva Pediatr 64:121–133

    PubMed  CAS  Google Scholar 

  24. Alper G, Jarjour IT, Reyes JD, Towbin RB, Hirsch WL, Bergman I (1998) Outcome of children with cerebral edema caused by fulminant hepatic failure. Pediatr Neurol 18:299–304

    Article  PubMed  CAS  Google Scholar 

  25. Schaefer B, Schmitt CP (2012) The role of molecular adsorbent recirculating system dialysis for extracorporeal liver support in children. Pediatr Nephrol 28:1763–1769

    Article  PubMed  Google Scholar 

  26. Adamovic T, Jouvet P, Vobecky S, Garel L, Rougemont AL, Alvarez F (2011) Hyperammonemia and neonatal cardiac failure. Minerva Anestesiol 77:554–557

    PubMed  CAS  Google Scholar 

  27. Schaefer B, Schaefer F, Wittmer D, Engelmann G, Wenning D, Schmitt CP (2012) Molecular Adsorbents Recirculating System dialysis in children with cholestatic pruritus. Pediatr Nephrol 27:829–834

    Article  PubMed  Google Scholar 

  28. Schaefer B, Schaefer F, Engelmann G, Meyburg J, Heckert KH, Zorn M, Schmitt CP (2011) Comparison of Molecular Adsorbents Recirculating System (MARS) dialysis with combined plasma exchange and haemodialysis in children with acute liver failure. Nephrol Dial Transplant 26:3633–3639

    Article  PubMed  CAS  Google Scholar 

  29. Novelli G, Rossi M, Morabito V, Pugliese F, Ruberto F, Perrella SM, Novelli S, Spoletini G, Ferretti G, Mennini G, Berloco PB (2008) Pediatric acute liver failure with molecular adsorbent recirculating system treatment. Transplant Proc 40:1921–1924

    Article  PubMed  CAS  Google Scholar 

  30. Ringe H, Varnholt V, Zimmering M, Luck W, Gratopp A, Konig K, Reich S, Sauer IM, Gaedicke G, Querfeld U (2011) Continuous veno-venous single-pass albumin hemodiafiltration in children with acute liver failure. Pediatr Crit Care Med 12:257–264

    Article  PubMed  Google Scholar 

  31. Sauer IM, Goetz M, Steffen I, Walter G, Kehr DC, Schwartlander R, Hwang YJ, Pascher A, Gerlach JC, Neuhaus P (2004) In vitro comparison of the molecular adsorbent recirculation system (MARS) and single-pass albumin dialysis (SPAD). Hepatology 39:1408–1414

    Article  PubMed  CAS  Google Scholar 

  32. Yokoi T, Oda S, Shiga H, Matsuda K, Sadahiro T, Nakamura M, Hirasawa H (2009) Efficacy of high-flow dialysate continuous hemodiafiltration in the treatment of fulminant hepatic failure. Transfus Apher Sci 40:61–70

    Article  PubMed  Google Scholar 

  33. Slonim AD, Joseph JG, Turenne WM, Sharangpani A, Luban NL (2008) Blood transfusions in children: a multi-institutional analysis of practices and complications. Transfusion 48:73–80

    Article  PubMed  Google Scholar 

  34. Davenport A, Will EJ, Davidson AM (1993) Improved cardiovascular stability during continuous modes of renal replacement therapy in critically ill patients with acute hepatic and renal failure. Crit Care Med 21:328–338

    Article  PubMed  CAS  Google Scholar 

  35. Davenport A (2009) Continuous renal replacement therapies in patients with acute neurological injury. Semin Dial 22:165–168

    Article  PubMed  Google Scholar 

  36. Schultheiss C, Saugel B, Phillip V, Thies P, Noe S, Mayr U, Haller B, Einwachter H, Schmid RM, Huber W (2012) Continuous venovenous hemodialysis with regional citrate anticoagulation in patients with liver failure: a prospective observational study. Crit Care 16:R162

    Article  PubMed Central  PubMed  Google Scholar 

  37. Sanchez MC, D’Agostino DE (2012) Pediatric end-stage liver disease score in acute liver failure to assess poor prognosis. J Pediatr Gastroenterol Nutr 54:193–196

    Article  PubMed  Google Scholar 

  38. Baliga P, Alvarez S, Lindblad A, Zeng L (2004) Posttransplant survival in pediatric fulminant hepatic failure: the SPLIT experience. Liver Transpl 10:1364–1371

    Article  PubMed  Google Scholar 

  39. Rhee C, Narsinh K, Venick RS, Molina RA, Nga V, Engelhardt R, Martin MG (2006) Predictors of clinical outcome in children undergoing orthotopic liver transplantation for acute and chronic liver disease. Liver Transpl 12:1347–1356

    Article  PubMed  Google Scholar 

  40. Prodhan P, McCage LS, Stroud MH, Gossett J, Garcia X, Bhutta AT, Schexnayder S, Maxson RT, Blaszak RT (2012) Acute kidney injury is associated with increased in-hospital mortality in mechanically ventilated children with trauma. J Trauma Acute Care Surg 73:832–837

    Article  PubMed  Google Scholar 

  41. Afonso RC, Hidalgo R, Zurstrassen MP, Fonseca LE, Pandullo FL, Rezende MB, Meira-Filho SP, Ferraz-Neto BH (2008) Impact of renal failure on liver transplantation survival. Transplant Proc 40:808–810

    Article  PubMed  CAS  Google Scholar 

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Acknowledgments

The authors thank Catherine Farrell MD for her help in the manuscript preparation.

Conflict of Interest Statement

None.

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Authors and Affiliations

  1. Pediatric Intensive Care Unit, Department of Pediatrics, Sainte-Justine Hospital, Montreal, QC, Canada

    Pierre Bourgoin, Catherine Litalien & Philippe Jouvet

  2. Pediatric Nephrology, Department of Pediatrics, Sainte-Justine Hospital, Montreal, QC, Canada

    Aicha Merouani & Véronique Phan

  3. Department of Surgery, Sainte-Justine Hospital, Montreal, QC, Canada

    Michel Lallier

  4. Pediatric Hepatology, Department of Pediatrics, Sainte-Justine Hospital, Montreal, QC, Canada

    Fernando Alvarez

  5. Soins Intensifs Pédiatriques, Hôpital Sainte Justine, 3175 chemin Côte Sainte Catherine, Montreal, Quebec, H3T 1C5, Canada

    Philippe Jouvet

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  1. Pierre Bourgoin
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Correspondence to Philippe Jouvet.

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Bourgoin, P., Merouani, A., Phan, V. et al. Molecular Absorbent Recirculating System therapy (MARS®) in pediatric acute liver failure: a single center experience. Pediatr Nephrol 29, 901–908 (2014). https://doi.org/10.1007/s00467-013-2691-5

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  • DOI: https://doi.org/10.1007/s00467-013-2691-5

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