We thank Dr. Banares et al. for their comments to our editorial regarding the article by Hassanein et al.1 on the effect of the Molecular Adsorbents Recirculating System (MARS) in patients with hepatic encephalopathy (HE) in advanced cirrhosis. As mentioned in our editorial,2 studies in such patients are difficult to conduct, and the authors should be commended for their effort in carrying out the study. Nevertheless, there are weaknesses in the evaluation of the effects of MARS on HE, which limit the interpretation of the results. In fact, the primary outcome parameters (the “improvement proportion” [IP] and the “Hepatic Encephalopathy Scoring Algorithm” [HESA]) have never been described and validated before. This fact does not invalidate the findings, but calls for a very cautious interpretation of the results. We agree that the study was not powered to detect differences in survival. However, because this group of patients are not suitable candidates for liver transplantation, benefit of the improvement in HE remains questionable.

Finally, we agree that MARS should be further evaluated in prospective trials, possibly by using more conventional criteria with the focus on gains in survival rates and decreases in morbidity.


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  • 1
    Hassanein TI, Tofteng F, Brown RS Jr, McGuire B, Lynch P, Mehta R, et al. Randomized controlled study of extracorporeal albumin dialysis for hepatic encephalopathy in advanced cirrhosis. HEPATOLOGY 2007; 46: 18531862.
  • 2
    Ferenci P, Kramer L. MARS and the failing liver: any help from the outer space? HEPATOLOGY 2007; 46: 16821684.

Peter Ferenci*, Ludwig Kramer*, * Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.