Liver Dysfunction Supportive Therapies - From Therapeutic Plasmapheresis to Molecular Adsorbent Recirculating System

Background: Because of the scarcity of donor organs, liver support strategies are being developed with the aim of either supporting patients with borderline functional liver cell mass until an appropriate organ becomes available for transplantation. Up until ten years ago Therapeutic Plasmapheresis (TPE) and Continuous Renal Replacement Therapy (CRRT) were the main treatment used. Currently, non-biological systems include Molecular Adsorbent Recirculating System (MARS) which is not only used as “bridging therapy” but also until liver recovery without necessity of liver transplantation (LT). Methods: This report focus on TPE in the form of Plasma-Exchange (PE) that was introduced in our clinical activity since 1987, and MARS utilized since 1999. The above systems were used as bridging therapy either to optimize the clinical status for LT or resolution without necessity to LT with acceptable results. Results: 1326 procedures of TPE on 101 patients with liver dysfunction were carried out from 1987 to 1999. Liver function impairment was related to Acute on Chronic Hepatic Failure (AoCHF) (#76), Fulminant Hepatitis (FH) (#23), Intractable Pruritus (IP) (#2).Since 1999, 2866 treatments on 269 patients were performed with MARS for ACLF [acute-on-chronic liver failure] (#140), FH (#46); Delayed Function (#22), Primary No Function (#18), Acute Hepatic Failure (AHF) after surgery (#25), and IP (#17). The most recent data relative to treatment in our departments in the last 12 months (2009-2010) of patients with TPE (#5 patients) and with MARS (#10 patients) has been reported. Conclusion: According to our clinical experience TPE can lower efficaciously bilirubin and hepatic enzymes. MARS detoxifies great volumes of blood and eliminates pro-inflammatory molecules. TPE daily performed may be helpful in AoCHF patients until transplantation takes place. MARS shows significant improvement above all in AoCHF and in FH.