molecular absorbents recirculating system (mars ® ) “albumin dialysis” marco maggiorini...
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Molecular Absorbents Recirculating System (MARS®)
“Albumin Dialysis”
Marco MaggioriniIntensive Care Unit
Department of Internal Medicine
University Hospital Zurich
Toxins:• Bile acids• Bilirubin• Prostacyclins• Nitric oxide• Indol / Phenol-• Metabolites• Toxic fatty acids• Thiols• Digoxin/Diazepam-
like subs.• ...• Ammonia• Lactate
Further liver damagevia vicious cycle:necrosis/apoptosis !!!
• Brain Function• Kidney Function• Cardiovascular Tone• Bone Marrow Activity
Liver failure - endogenous intoxication
Ongoing Ongoing
ImbalanceImbalance ofof water-solublewater-soluble and and non-soluble non-soluble substancessubstances
Transport of protein bound substances
Plasma albumin
Intracellular transport protein Biotransformation
Toxin
Bile
Accumulation of non-water-soluble substances
Klammt et al., 3rd ISAD 2001
Albumin binding capacity in liver failure
0
20
40
60
80
100
120
140
Healthy volunteers Patients with Acute-on-Chronic LF
Alb
um
in b
ind
ing
cap
acit
y
%
Accumulation of non water-soluble substances
MARS® Therapy
Balance of water-solublesubstances
Balance ofprotein bound
substances
Dialysis Albumin Dialysis
Water based human body
Diffusion
Plasma exchange(unselective)
Binding siterelated distribution
Filtration(unselective)
water-solubletoxins
(free)
non water-solubletoxins
(protein bound)
Toxin removal
* n=287, 51 centers
51% Decompensated chronic liver disease
26% Acute liver failure / dysfunction
13% Liver failure post LTx
5% LF post liver surgery
5% Others
Main indication groups*International MARS Registry
*critical functioning liver cell mass years
Liv
er f
un
ctio
n
Acute liver failure (5%)
Acute on chronicliver failure (95%)
100%
*
MARS
MARS
Liver Failure
MARS® therapy - currently investigated in
Decompensated chronic liver disease Acute-on-Chronic Liver Failure
Decompensated end-stage cirrhosis
Acute liver failure / liver dysfunction Acute liver failure
Acute drug induced cholestasis
Hypoxic liver failure
Liver failure / dysfunction post liver transplantation Primary graft dysfunction
Primary graft non function
Liver failure / dysfunction post liver surgery
Intractable pruritus in chronic cholestatic syndromes
Multi organ failure
The MARS® and PRISMA
The MARS® principle
The MARS® membrane
®®
The MARS® membrane
The MARS® membrane
from the patient
to the patient
AlbuminAlbumincircuitcircuit
Blo
od
cir
cuit
Blo
od
cir
cuit
The DiaFLUX® filterA
lbu
min
cir
cuit
Alb
um
in c
ircu
it Dialysate circu
itD
ialysate circuit
MARS® Absorber cartridges
Activated charcoal
column
(diaMARS® AC250)
Anion-exchanger resin
column
(diaMARS® IE 250)
Intermittent MARS® treatment strategy
Albumin circuit
600 ml 20% human albumin
Flow 150-250 ml/min (~ 20% less then blood flow)
Patient circuit
Blood flow 150-250 ml/min
Dialysate flow intermittent strategy 300-500 ml/min
Dialysate flow CRRT strategy 2l/h
Duration of treatment
Liver dysfunction: 6-8h MARS®
Liver and renal dysfunction: 6-8h MARS® + 16-18h CRRT
MARS® circuit anticoagulation
Unfractioned heparinWash MARS® circuit with 10’000 IU heparin
200-800 IU heparin infusion before MARS® filter
ACT optimal range 150-180 s
MARS® associated alteration of coagulation factors
Retrospective analysis of coagulopathy/ bleeding complications observed during 83 consecutive MARS sessions in 21 patients (11 men)
INR 1.7 1.8 (n=81, p<0.0001)
fibrin D-dimers 1.54 2.46 mg/l (n=61, p<0.0001)
platelet counts 68 50 x 109/l (n=82, p<0.0001)
Fibrinogen 1.9 1.6 g/l (n=80, p<0.0001)
Schüppbach et al (sumbitted)
MARS® associated alteration of coagulation factors
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
1 2
INR
Prior MaximalduringMARS
p<0.0001
0
100
200
300
400
500
1 2
Platelets(x109/l)
Prior MinimalduringMARS
p<0.0001
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
1 2
Fibrinogen(g/l)
Prior MinimalduringMARS
p<0.0001
0
5
10
15
20
1 2
Fibrin D-Dimers
(mg/l)
Prior MaximalduringMARS
p<0.0001
Retrospective analysis of coagulopathy/ bleeding complications observed during 83 consecutive MARS sessions in 21 patients (11 men)
- median age 46 y.- median 3 sessions/pat.- median duration/session 8 hours.
Schüppbach et al (sumbitted)
MARS® associated alteration of coagulation factors
pre-treatment values of bleeding vs. non-bleeding sessions
bleeding non-bleedingmedian INR 2.1 vs. 1.6 (p=0.001)
platelet count (x109/l) 40 vs. 68 (p=0.042)
plasma fibrinogen (g/l) 0.8 vs. 2.0 (p=0.008)
fibrin D-dimer (mg/l) 5.75 vs. 1.38 (p=0.044)
Schüppbach et al (sumbitted)
Univariate/Multivariate analysis of factors associated with bleeding
Odds Ratio
95% Confidence Limits
Lower Upper
p-value
INR* 6.591 1.611 26.958 0.005
Fibrin D-Dimer Level (mg/l)* 1.252 1.016 1.542 0.033
Activated Partial Thromboplastin Time (sec)
1.013 0.999 1.028 0.096
Platelet Count (x109/l) 0.981 0.956 1.007 0.056
Plasma Fibrinogen Concentration (g/l) 0.195 0.056 0.676 0.003
Circulatory Support (no vasopressors) 0.131 0.025 0.683 0.007
Age (<50 years)* 0.121 -3.762 -0.464 0.005
* Independent predictors in multivariate analysis Schüppbach et al (sumbitted)
MARS® associated alteration of coagulation factors
Faybik et. al Crit Care 2006, 10 R24
61 MARS treatment in 33 patientsPG I2 in all + Heparin (ACT 120-150) in 17FFP given in 37 MARS treatments (17 patients)
MARS® circuit anticoagulation
Prostacyclin I2 (Epoprostenol)
Rational: Reversible inhibition of platelet activation by decreasing the expression of platelet fibrinogen receptor and P-selectin, and reduction of the heterotypic platelet-leukocyte aggregation.
Prior to treatment: up-titration (1ng/kg/min) to reach 5 ng/kg/min within 30 min.
Treatment start: 3-5ng/kg/min before MARS® filter
Ev. add heparin to reach an ACT between 120-150 s
Thromboelastography (TEG®)
Normal thromboelastograph
R = reaction time; K = coagulation time; = angle alpha = cloth growth; MA = maximal amplitude
Thromboelastography (TEG®)
Normal trace
Hyper-coagulable trace
Hyper-fibrinolytic trace
Hypo-coagulable trace
Substitution of Factor VIIa
Improvement in terms of a shortened CT, and increased angle and MCF can be seen postinfusion
Thromboelastography (TEG®)
Variable (n) Time TEG reaches mm
Coagulation
R (3-13 mm) 2 mm Initial fibrin formation
Factors, inhibitors activity
K (1-9 mm) 20 mm Clot firmness Factors, fibrinogen, platelets
Angle (55-62 mm)
Slope R to K Rate of clot growth
Platelets and factors on platelet surface
MA (45-53 mm) - Strength of the clot
Function of platelets and plasma factors
CL30 (100%) - Clot lyses
Clot index (CI) (-3 to 3 mm)
- Hypo/hyper coagul. state
Modified thromboelastography (TEG®)
Variable (n) Coagulation Inhibitor
Coagulation
R (3-13 mm) - Initial fibrin formation
Factors, inhibitors activity
RHEP Heparinase = R - (R+Hpase) Effect of endogeneous/ exogeneous heparin
MA (45-53 mm) - Strength of the clot
Function of platelets and plasma factors
MAPLT GP iib/IIIa inhib. (abciximab)
= MA - (MA+ abciximab)
Contribution of platelets
Thromboelastography (TEG®)
Faybik et. al Crit Care 2006, 10 R24
(45-53 mm)
(9-13 mm)
(1-9 mm)
(55-62 degree)
(-3/+3)
(100%)
61 MARS treatment in 33 patientsPG I2 in all + Heparin (ACT 120-150) in 17FFP given in 37 MARS treatments (17 patients)
Before 30 min. Within 1h of end
Thromboelastography (TEG®)
Faybik et. al Crit Care 2006, 10 R24
(45-53 mm)
(9-13 mm)
(1-9 mm)
(55-62 degree)
(45-53 mm)
(9-13 mm)
(1-9 mm)
(55-62 degree)
Patients with FFP administration in 37 (46%) MARS treatments (17/33 patients) later than 30 min
Before 30 min. Within 1h of end
FFP
MARS® associated alteration of coagulation factors
Safety considerations Anticoagulation regimen:
Prostaglandin I2 is preferred (transitory platelets inhibition)
Add heparin if necessary (ACT 120-150 s)
Monitoring: TEG preferred to standard coagulation parameters
Substitution with FFP in high risk patients
Contraindication: Overt DIC
Fibrinogen < 1.0 g/l
Platelet < 30’000 /µl
MARS® associated alteration of coagulation factors
TEG in Patients at high risk of bleeding
Doria et al. Clin Transp
2004, 18:365
MARS® associated alteration of coagulation factors
Safety considerationsPatients at high risk of bleeding
Platelets < 50’000 /µl
TEG reaction time > 800 s
TEG constant time > 1500 s
TEG angle < 30 degree
TEG maximal amplitude < 45 mm
Doria et al. Clin Transp 2004, 18:365