Treatment of split-liver recipients with poor graft function by albumin-dialysis (mars)

In the face of donor shortage, split-liver transplantation plays an increasing role in organ supply for patients in terminal chronic liver disease. However, occasionally grafts may be small for size or function uptake is delayed. In these critical situations, liver support is warranted to compensate for the not yet adequate graft function. A new dialysis treatment based on albumin dialysis (Molecular Adsorbents Recirculating System, MARS) was developed to selectively remove endogenous toxins from the patients.

Four split-liver recipients with poor graft function in the early phase were treated with this system at a total of 10 single treatments. Dialysis duration was 4,5-6 hours daily. Each treatment resulted in a substantial reduction of serum bilirubin level (average -29,5 %, pre-treatment level range 16,6-59,0 mg/dl). Adverse effects were not observed.

One patient was listed for high-urgency re-transplantation simultaneously to start of MARS and was transplanted the next day. The graft function of two other pients improved during treatment phase, leading to a spontaneous further decline of bilirubin levels and ongoing improvement of clinical status after discontinuation of treatment. These three patients survived and were discharged from hospital. The fourth patient also improved clinically during treatment as demonstrated by a decreased encephalopathy grade. After a 50 % reduction of serum bilirubin concentration during the course of three treatments, serum bilirubin remained stable for several days. However, the patient developed a fungal pneumonia and finally died in sepsis on post-operative day 22.

In conclusion, albumin-dialysis (MARS) offers new opportunities for the support of patients with poor graft function after liver transplantation in the early postoperative phase. Diminishing the toxic load of these patients may be favourable for liver regeneration and improvement of graft function. In the case of split-liver recipients, a temporary extracorporeal detoxification may be particularly valuable since grafts may initially be small for size and may increase their functional capacity by augmentation of liver mass. However, more cases are needed for a deeper evaluation of both the potential and safety of this new treatment modality.