Improvement of systemic vascular resistance and arterial pressure in patients with acute on chronic liver failure during treatment with the molecular adsorbent recycling system (mars)

Background and purpose: Low arterial pressure and systemic vascular resistance in patients with acute on chronic liver failure (AOCLF) may be caused by an overload of albumin-bound endogenous vasodilatory substances that not are cleared by the failing liver. We aimed to determine if removal of albumin-bound as well as water-soluble substances from the blood stream by treatment with MARS improves arterial pressure and systemic vascular resistance in patients with AOCLF.

Patients and methods: Eight patients (median age 44, range 35-52 years) admitted with AOCLF due to alcoholic hepatitis (n = 6), bleeding from oesophageal varices (n = 1), and spontaneous peritonitis (n = 1). All patients were Child’s grade C. Five patients had hepatorenal syndrome type II. A single MARS treatment of 10 hours was performed and systemic haemodynamic variables were determined before and during treatment using radial artery and pulmonary artery catheters. Plasma-renin was monitored as a measure of renal perfusion, while creatinine and bilirubin were monitored as a measure of MARS’ capability of removing water-soluble and protein bound toxins. Non-parametric statistics (Wilcoxon) were applied for analysis.

Results: Four patients, including two with hepatorenal syndrome, recovered. During MARS treatment, mean arterial pressure increased from 67 (57-83) to 76 (68-84) mm Hg (p < 0.05), the systemic vascular resistance index (SVRI) from 757 (580-948) to 884 (595-1086) dyn s/cm⁵/m² (p < 0.05) (Figure 1), while cardiac index remained constant (5.9 (4.8-6.8) vs. 6.0 (4.1-7.7) L/min/m²). No change was demonstrated in oxygen delivery (465 (386-544) vs. 463 (311-559) mL/min/m²) or oxygen consumption (92 (57-160) vs. 93 (75-112) mL/min/m²). Creatinine decreased from 246 (66-764) to 119 (54-359) µmol/L (p < 0.05), bilirubin from 537 (324-877) to 351 (228-512) µmol/L (p < 0.05), and plasma-renin from 1236 (200-4400) to 499 (68-2000) mU/L (p < 0.05). In two cases with oliguria prior to MARS, increases in diuresis were noticed (260 to 2900 and 0 to 450 ml/24 hours, respectively).

Conclusions: MARS treatment of patients with AOCLF improves arterial blood pressure and systemic vascular resistance and efficiently reduces the plasma levels of water-soluble and protein-bound toxins and renin. These data show that liver dialysis with MARS is safe and may be of importance in stabilising central haemodynamics in patients with acute deterioration of chronic liver failure.

* This abstract was supported by a grant provided by Teraklin AG, Rostock, Germany.