Reviewed and revised 8th November 2013
- Molecular Adsorbent Recirculating System = MARS
- short-term extracorporeal hepatic support
- so-called ‘liver dialysis’
- acute liver failure
- acute-on-chronic liver failure
- albumin-bound toxins
- intractable pruritis due to cholestasis
- post hepatectomy and post-liver transplant support
- Severe alcoholic steatohepatitis
- Overdoses/intoxication with protein-bound substances
- active bleeding
- severe coagulopathy
- MARS® is a liver support system that uses an albumin-enriched dialysate to facilitate the removal of albumin-bound toxins
- The system has three different fluid compartments:
— a blood circuit
— a circuit containing 600 ml of 20% human albumin with a charcoal column and an anion exchange resin column
— dialysate circuit
METHOD OF USE
- patient’s blood is dialyzed against 20% human albumin solution across highly permeable membrane
- albumin acts as scavenging molecule to remove protein bound substances normally cleared by the liver
- the dialysate passes through the adsorbent columns and is recycled with regeneration of albumin binding sites
- similar to CRRT
- lowers platelet count and fibrinogen concentration
- High quality evidence is lacking — only underpowered controlled studies and case reports
- Case reports for acute liver failure due to hepatotoxic agents (e.g. acetaminophen, amanita phalloides, amphetamines, antibiotics, and allopurinol)
- Case reports for acute poisonings with highly bound protein substances (e.g phenytoin, lamotrigine, theophylline, calcium channel blockers, and heavy metals)
- MARS use is associated with improvement in hyperbilirubinemia, encephalopathy, and circulatory dysfunction; but no good RCT evidence and mortality data
- Randomized trial (n= 23) of standard medical therapy +/- MARS for acute-on-chronic liver failure (mostly due to alcohol) showed 30 day mortality reduction
- not available outside specialist centres
- effectiveness and role is still under investigation
Single pass albumin dialysis (SPAD)
- uses standard CVVHD system
- Diluted albumin solution (4.4%) added to dialysis solution
- Albumin rich dialysate is not recycled; discarded after “single pass,” with “clean” albumin continuously introduced to maintain binding site availability
- less well studied than MARS
References and Links
- Boyle M, Kurtovic J, Bihari D, Riordan S, Steiner C. Equipment review: the molecular adsorbents recirculating system (MARS). Crit Care. 2004 Aug;8(4):280-6. PMC522853.
- Collins K, Roberts E, Adeli K, et al. Single pass albumin dialysis (SPAD) in fulminant Wilsonian liver failure: a case report. Pediatr Nephrol 2009; 23: 1013-1016. PMID: 18299897
- Karvellas CJ, Gibney N, Kutsogiannis D, Wendon J, Bain VG. Bench-to-bedside review: current evidence for extracorporeal albumin dialysis systems in liver failure. Crit Care. 2007;11(3):215. PMC2206413.
- Laleman W, Wilmer A, Evenepoel P, Verslype C, Fevery J, Nevens F. Review article: non-biological liver support in liver failure. Aliment Pharmacol Ther. 2006 Feb 1;23(3):351-63. PMID: 16422994.
- Saliba F. The Molecular Adsorbent Recirculating System (MARS) in the intensive care unit: a rescue therapy for patients with hepatic failure. Crit Care. 2006 Feb;10(1):118. PMC1550821.
- Stange J. Extracorporeal liver support. Organogenesis. 2011 Jan-Mar;7(1):64-73. PMC3082035.
- Tan HK. Molecular adsorbent recirculating system (MARS). Ann Acad Med Singapore. 2004 May;33(3):329-35. PMID: 15175774.
- Wauters J, Wilmer A. Albumin dialysis: current practice and future options. Liver Int. 2011 Sep;31 Suppl 3:9-12. PMID: 21824276.