Severe acute liver failure (ALF) is associated with high death rates if patients don’t receive timely treatment or a liver transplant. Unlike the heart or the kidneys, there is no established mechanical device to replace the liver’s function. Now, University of Maryland School of Medicine (UM SOM) researchers report that a device that removes toxins from the blood can also effectively provide a bridge to liver transplantation or buy time for a traumatically injured liver to heal, suggesting broader uses for the device than previously thought.

The researchers, writing in the journal Annals of Surgery, present the largest series of cases in the United States in which the Molecular Adsorbent Recirculating System, or MARS® (Baxter International Inc., Deerfield, IL), has been used as temporary liver replacement for ALF.

MARS can be likened to a dialysis machine for the liver. It essentially “washes” a patient’s blood with a solution containing albumin – normally produced by healthy livers – to remove toxins such as bile acids, ammonia, bilirubin, copper, iron and phenols from the blood.

“We’ve found in the use of MARS that we’re able to get trauma patients with massive liver injury to recovery and, in patients who are deemed good transplant candidates, get them to transplant with excellent survivals,” says lead researcher, Steven I. Hanish, MD, associate professor of surgery at UM SOM and a liver transplant surgeon at the University of Maryland Medical Center (UMMC).

UMMC began using MARS in 2013. A multidisciplinary team has tried MARS in a variety of cases – as an off–label bridge to transplant, as definitive therapy for toxic ingestion and in cases of severe liver trauma.

The study authors describe three cases that sparked their interest and formed their experience as they used MARS. In the first case, from years ago, a young man came to STC with a blunt injury that tore his liver from a major vein. His liver was removed, but he died waiting for a suitable donor liver. The writers concluded that a liver support device may have saved his life.

In a second case, gunshots severely damaged the liver of another young man. UMMC acquired the device on an emergency basis and he survived after MARS treatment and lengthy hospitalization. In the third case, a young football player suffered heat stroke causing liver cell death and severe ALF. MARS treatment kept him alive long enough to get a liver transplant.

The researchers began recording data that could help determine the impact of extending the MARS technology, including patient demographics, etiology of ALF and laboratory values. End–points were patient survival with– and without liver transplant and/or recovery of liver function.

The report details the outcomes of 27 critically patients with severe ALF who received MARS therapy between January 2013 and December 2016. Overall, the group displayed multisystem organ impairment and had liver disease more severe than that of patients in the total liver transplant program at UMMC.

Three of five patients with severe liver trauma survived, with recovery of liver and kidney function. Thirteen patients received MARS as a bridge–to–transplant. Nine received liver transplantation with a one year survival of 78 percent (the transplant program’s overall survival at one year is 85 percent). Four patients died who were not transplanted due to overall medical condition, the presence of additional disorders, or lack of a suitable donor.

Additionally, nine patients with ALF from toxic ingestion received MARS, with liver recovery and survival in 67 percent. Other measures of liver function, including blood clotting tests and ammonia levels significantly improved during MARS therapy. No one suffered a type of brain injury known as cerebral herniation during MARS therapy.