Use of the Molecular Adsorbent Recirculating System in Acute Liver Failure: Results of a Multicenter Propensity Score-Matched Study.

Abstract

OBJECTIVES:

The molecular adsorbent recirculating system removes water-soluble and albumin-bound toxins and may be beneficial for acute liver failure patients. We compared the rates of 21-day transplant-free survival in acute liver failure patients receiving molecular adsorbent recirculating system therapy and patients receiving standard medical therapy.

DESIGN:

Propensity score-matched retrospective cohort analysis.

SETTING:

Tertiary North American liver transplant centers.

PATIENTS:

Acute liver failure patients receiving molecular adsorbent recirculating system at three transplantation centers (n = 104; January 2009-2019) and controls from the U.S. Acute Liver Failure Study Group registry.

INTERVENTIONS:

Molecular adsorbent recirculating system treatment versus standard medical therapy (control).

MEASUREMENTS AND MAIN RESULTS:

One-hundred four molecular adsorbent recirculating system patients were propensity score-matched (4:1) to 416 controls. Using multivariable conditional logistic regression adjusting for acute liver failure etiology (acetaminophen: n = 248; vs nonacetaminophen: n = 272), age, vasopressor support, international normalized ratio, King's College Criteria, and propensity score (main model), molecular adsorbent recirculating system was significantly associated with increased 21-day transplant-free survival (odds ratio, 1.90; 95% CI, 1.07-3.39; p = 0.030). This association remained significant in several sensitivity analyses, including adjustment for acute liver failure etiology and propensity score alone ("model 2"; molecular adsorbent recirculating system odds ratio, 1.86; 95% CI, 1.05-3.31; p = 0.033), and further adjustment of the "main model" for mechanical ventilation, and grade 3/4 hepatic encephalopathy ("model 3"; molecular adsorbent recirculating system odds ratio, 1.91; 95% CI, 1.07-3.41; p = 0.029). In acetaminophen-acute liver failure (n = 51), molecular adsorbent recirculating system was associated with significant improvements (post vs pre) in mean arterial pressure (92.0 vs 78.0 mm Hg), creatinine (77.0 vs 128.2 µmol/L), lactate (2.3 vs 4.3 mmol/L), and ammonia (98.0 vs 136.0 µmol/L; p ≤ 0.002 for all). In nonacetaminophen acute liver failure (n = 53), molecular adsorbent recirculating system was associated with significant improvements in bilirubin (205.2 vs 251.4 µmol/L), creatinine (83.1 vs 133.5 µmol/L), and ammonia (111.5 vs 140.0 µmol/L; p ≤ 0.022 for all).

CONCLUSIONS:

Treatment with molecular adsorbent recirculating system is associated with increased 21-day transplant-free survival in acute liver failure and improves biochemical variables and hemodynamics, particularly in acetaminophen-acute liver failure.

• Authors: Andrew J MacDonald, Ram M Subramanian, Jody C Olson, Jaime L Speiser, Valerie L Durkalski-Mauldin, Juan G Abraldes, David L Bigam, Mary M Flynn, Babusai Rapaka, Brianne M Shropshire, Ravi S Vora, Constantine J Karvellas, U.S. Acute Liver Failure Study Group
• Journal: Critical care medicine (Crit Care Med) Vol. 50 Issue 2 Pg. 286-295 (02 01 2022) ISSN: 1530-0293 [Electronic] United States
• PMID: 34259656 (Publication Type: Journal Article)
• Copyright: Copyright © 2021 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.

Topics

• Adult
• Alberta (epidemiology)
• Cohort Studies
• Female
• Humans
• Liver Failure, Acute (epidemiology, etiology, therapy)
• Liver Transplantation (methods, statistics & numerical data)
• Logistic Models
• Male
• Middle Aged
• Models, Molecular
• Propensity Score
• Retrospective Studies
• Tertiary Care Centers (organization & administration, statistics & numerical data)