Elsevier

Transplantation Proceedings

Volume 40, Issue 6, July–August 2008, Pages 1921-1924
Transplantation Proceedings

Liver transplantation
Candidate
Pediatric Acute Liver Failure With Molecular Adsorbent Recirculating System Treatment

https://doi.org/10.1016/j.transproceed.2008.05.075Get rights and content

Abstract

Background

The prognosis of pediatric acute liver failure (PALF) has been significantly improved by emergency orthotopic liver transplantation (OLT). Since 2004, the molecular adsorbent recirculating system (MARS) has been proposed as a bridging procedure. The aim of our study was to assess its efficacy in children with PALF.

Patients and Methods

Since 1999 we performed treatment of 39 fulminant hepatic failure (FHF) cases with MARS. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3–15 years) including 4 females and 2 males. In 3 cases the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and in 1, by acute hepatitis B virus. Inclusion criteria were: bilirubin >15 mg/dL; creatinine ≥2 mg/dL; encephalopathy grade >II; and International normalized ratio (INR) >2.5. Other estimated parameters were: AST and ALT serum levels, lactate, and urine volume. Neurological status was monitored using the Glasgow Coma Scale (GCS). Continuous MARS treatment was performed in all patients with a kit change every 8 hours. Intensive care unit (ICU) treatment was applied to optimize regeneration and to prevent cardiovascular complications.

Results

We observed a significant improvement among levels of bilirubin (P < .009), ammonia (P < .005), creatinine (P < .02), GCS (P < .002), and predictive criteria and as Sequential Organ Failure Assessment (SOFA) and Pediatric End-Stage Liver Disease (PELD). Three children underwent OLT: 1 died after 5 days due to primary nonfunction and 2 children are alive after a median follow-up of 14 months. In 2 children the MARS treatment led to resolution of clinical status without liver transplantation. One child died before OLT due to sepsis and multiorgan failure.

Conclusions

We concluded that application of the MARS liver support device in combination with experienced ICU management contributed to improve the clinical status in children with PALF awaiting liver transplantation.

Section snippets

Patients and Methods

Since 2000 we performed 2027 MARS treatments in 190 patients including 39 affected by FHF. Since September 2004 we treated 6 pediatric patients with FHF who were of mean age 10.6 years (range, 3–15 years) including 4 females and 2 males. In 3 cases, the cause of FHF was unknown; in 2 cases, it was induced by paracetamol overdose; and 1, by acute hepatitis B virus.

Inclusion criteria for MARS treatments were: bilirubin >15 mg/dL; creatinine >2 mg/dL; encephalopathy grade >II; International

Results

Since September 2004 we treated 6 pediatric patients with the MARS liver support device as a bridging procedure to liver transplantation. Median waiting time was 3 days (range, 2–4 days). Among 6 patients, 3 children were transplanted: 1 who had experienced paracetamol overdose (patient A); 1, acute hepatitis B (patient B); and 1, unknown causes (patient C). Patients A and B are alive at 14 months follow-up; patient C died after 5 days due to primary nonfunction. In 2 children the MARS

Discussion

Over the last 2 decades, many static and dynamic variables have been proposed to assess prognosis in patients with FHF. The 3 most important components of ALF management are (1) identification of causes requiring specific treatment; (2) institution of early monitoring and optimal intensive care for multiorgan involvement to improve chances of spontaneous recovery or of transplantation (deteriorating encephalopathy with cerebral edema relates to a systemic inflammatory response—infections need

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