Molecular adsorbent recirculating system in hepatic failure patients with a ventricular assist device

Introduction

The study we performed focuses on the removal of bilirubin in hepatic failure patients with a ventricular assist device (VAD). Bilirubin is a risk factor revealing the severe hepatic insufficiency and the alteration of the clinical status. The mortality rate of patients developing liver failure in the cardiac ICU is very high. The molecular adsorbent recirculating system (MARS) is the hepatic failure treatment in patients with no other therapeutic options. It is a liver support system that uses an albumin-enriched dialysate to facilitate the removal of albumin-bound toxins. Conventional hemodialysis techniques have little or no effect on liver detoxication and cannot improve these patients' prognosis. The study aims to prove the decrease of the mortality rate in hepatic failure patients with VAD as a result of using MARS.

Methods

We conducted a retrospective study of 55 patients with VAD. They were hospitalized in our cardiac ICU between January 2000 and November 2009. All patients had a hepatic check-up when admitted to the ICU. The patients with altered liver function had at least one check-up per day. We had seven patients with hyperbilirubinaemia >350 μmol/l (the threshold for starting hepatic dialysis). Five patients received MARS therapy. Hepatic check-ups were performed at the beginning and at the end of the session.

Results

Five patients were dialysed. Patient 1 - with a maximum serum bilirubin level of 350 μmol/l, needed four cycles of MARS therapy; the patient survived. Patient 2 - max bilirubin 390 μmol/l, 6 MARS; the patient survived. Patient 3 - max bilirubin 700 μmol/l, 3 MARS; the patient did not survive. Patient 4 - max bilirubin 680 μmol/l, 3 MARS; the patient survived. Patient 5 - max bilirubin 500 μmol/l, 15 MARS; the patient did not survive. The two patients that did not receive MARS therapy did not survive.

Conclusions

MARS is a viable option for the treatment of hepatic failure patients and, in particular, for those with VAD. We consider that without MARS a VAD patient cannot survive if his serum bilirubin level exceeds 350 μmol/l. Our hypothesis needs to be confirmed by multicenter randomized trials.