Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure

Abstract

Introduction: Patients with acute-on-chronic liver failure show an aggravated hyperdynamic circulation. We evaluated, in a controlled manner, potential changes in systemic haemodynamics induced by the molecular adsorbent recirculating system (MARS) and the Prometheus system liver detoxification devices in a group of patients with acute-on-chronic liver failure.

Methods: Eighteen patients (51.2 +/- 2.3 years old; Child-Pugh score, 12.5 +/- 0.2; Maddrey score, 63.1 +/- 5.0; hepatic venous pressure gradient, 17.6 +/- 0.9 mmHg) with biopsy-proven alcoholic cirrhosis and superimposed alcoholic hepatitis were either treated with standard medical therapy (SMT) combined with MARS (n = 6) or Prometheus (n = 6) or were treated with SMT alone (n = 6) on three consecutive days (6 hours/session). Liver tests, systemic haemodynamics and vasoactive substances were determined before and after each session.

Results: Groups were comparable for baseline haemodynamics and levels of vasoactive substances. Both MARS and Prometheus decreased serum bilirubin levels (P < 0.005 versus SMT), the Prometheus device being more effective than MARS (P = 0.002). Only MARS showed significant improvement in the mean arterial pressure (Deltachange, +9 +/- 2.4 mmHg versus -0.3 +/- 2.4 mmHg with Prometheus and -5.2 +/- 2.1 mmHg with SMT, P < 0.05) and in the systemic vascular resistance index (Deltachange, +131.5 +/- 46.2 dyne x s/cm5/m2 versus -92.8 +/- 85.2 dyne x s/cm5/m2 with Prometheus and -30.7 +/- 32.5 dyne x s/cm5/m2 with SMT; P < 0.05), while the cardiac index and central filling remained constant. This circulatory improvement in the MARS group was paralleled by a decrease in plasma renin activity (P < 0.05), aldosterone (P < 0.03), norepinephrine (P < 0.05), vasopressin (P = 0.005) and nitrate/nitrite levels (P < 0.02).

Conclusion: The MARS device, and not the Prometheus device, significantly attenuates the hyperdynamic circulation in acute-on-chronic liver failure, presumably by a difference in removal rate of certain vasoactive substances. These findings suggest conspicuous conceptual differences among the albumin dialysis devices.

Figure 1

Schematic representation of both liver assist devices: (a) the molecular adsorbent recirculating system and (b) the Prometheus system. FPSA, fractionated plasma separation, adsorption, and dialysis.

Figure 2

Comparison of changes in levels of bilirubin and bile after treatment with standard medical therapy (SMT) alone, with the molecular adsorbent recirculating system (MARS) or with Prometheus (PROM). *P < 0.001, **P < 0.05.

Figure 3

Individual values for the mean arterial pressure (MAP) and systemic vascular resistance index (SVRI) before versus after treatment with (a), (d) standard medical therapy alone (SMT), (b), (e) the molecular adsorbent recirculating system (MARS) and (c), (f) the Prometheus (PROM) system. P value given when significant.

Figure 4

Comparison of changes in the mean arterial pressure (MAP), stroke volume and systemic vascular resistance index (SVRI) after treatment with standard medical therapy alone (SMT), with the molecular adsorbent recirculating system (MARS) or with the Prometheus (PROM) system. *P value given when significant.

Figure 5

Comparison of changes in (a) plasma renin activity, (b) aldosterone, (c) norepinephrine, (d) vasopressin and (e) nitric oxide metabolites (NOx) after treatment with standard medical therapy (SMT) alone (grey shading) shading), with the molecular adsorbent recirculating system (MARS) (black shading) or with the Prometheus (hatched shading) (PROM) system shading). *P value given when significant.