Successful use of Molecular Absorbent Regenerating System (MARS) dialysis for the treatment of fulminant hepatic failure in children accidentally poisoned by toxic mushroom ingestion

Authors


Adrian Covic, MD, PhD, Associate Professor, Dialysis Center, ‘C.I. Parhon’ University Hospital, Blvd. Carol 1st, No. 50, Iasi 6600, Romania.
Fax: +40 232 210940.
e-mail: nefro@mail.dntis.ro, acovic@xnet.ro

Abstract:

Background: Acute liver failure (ALF) as a result of mushroom poisoning is associated with a high mortality (particularly in children), despite optimal medical therapy (OMT), including charcoal haemoperfusion and haemodiafiltration. MARS is a new, cell-free, extracorporeal liver assistance method utilizing an albumin dialysate for the removal of albumin-bound toxins.

Methods: We describe the first series in the literature (also first MARS treatments in Romania) with ALF because of mushroom poisoning in children (M/F = 2/4, age = 7–16 years). Liver function was evaluated pre-MARS and 15-min post-MARS, 24 h following each treatment and 30 days post-MARS.

Findings: All patients had severe hepatic dysfunction: hepatic encephalopathy (HE; four grade II, one grade III, one grade IV), ALT = 4082 (3400–5600) IU/L, bilirubin = 6.3 (2–10) mg/dL, prothrombin time (PT) = 52.5 (23–141) s. MARS was uneventful and well-tolerated. Two 6-h sessions per patient were performed with a similar immediate impact on liver tests: mean drop in ALT of −33 and −35%, respectively, and in bilirubin of −39 and −36%, respectively. ALT levels 24 h following MARS-1, remained unchanged but continued to drop by a further −28% following MARS-2. By contrast, all patients had a significant rebound in bilirubin (+39%) 24 h following MARS-1; however, following MARS-2 a rebound was seen only in two cases (+220%). PT improved by 37% after MARS-1 and normalized in four patients after MARS-2.

Outcome: Four patients survived and completely recovered the hepatic function. Negative prognostic markers: lack of complete correction of PT, continuous rebound and increase in bilirubin, and lack of improvement in HE post-MARS-1. Survival in six well-matched cases, treated by OMT = 0/6 (P < 0.05).

Conclusions: MARS is a safe and highly effective depurative therapy in children with ALF. Survival is predicted only by the impact/results of the initial MARS sessions and not by any of the baseline parameters.

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