Molecular Absorbent Recirculating System therapy (MARSA®) in pediatric acute liver failure: a single center experience

Supportive care as a bridge to transplant or recovery remains challenging in children suffering from acute liver failure (ALF). We report our experience in children using the Molecular Absorbent Recirculating System (MARSA (R)). Retrospective data from children receiving therapy using MARSA (R) from October 2009 to October 2012 were included in this single-center retrospective study. Patient characteristics, clinical presentation and complications of ALF, clinical and biological data before and after each MARSA (R) session, technical modalities and adverse events were recorded. A total of six children underwent 17 MARSA (R) sessions during the study period. Two adolescents were treated with the adult filter MARSFLUXA (R) and four infants were treated with the MiniMARSA (R) filter. The mean PEdiatric Logistic Dysfunction (PELOD) score at admission was 19 (range 11-33). All patients were mechanically ventilated, and four had acute kidney injury. The neurological course improved in one case, judged as stable in two cases and worsened in one case; data were unavailable in two cases. Mean serum ammonia levels decreased significantly following treatment with MARSA (R) from an initial 89 A +/- 29 to 58 A +/- 35 mcmol/L (p = 0.02). No other significant biological improvement was observed. Hemodynamic status improved/remained unchanged in the adolescent group, but in the infants four of the seven sessions were poorly tolerated and two sessions were aborted. Three patients died, two were successfully transplanted and one recovered without transplantation. In our experience, treatment with MARSA (R) is associated with encouraging results in adolescents, but it needs modification for very sick infants to improve tolerance.