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


RESULTS
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.


RESULTS
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.
Covic
Adrian
A
Dialysis Center, University Hospital, Iasi, Romania. acovic@xnet.ro
Goldsmith
David J A
DJ
Gusbeth-Tatomir
Paul
P
Volovat
Carmen
C
Dimitriu
Alexandru G
AG
Cristogel
Florin
F
Bizo
Aurel
A
D000293:Adolescent; D000410:Alanine Transaminase / Q000097:blood; D000545:Amanita; D000641:Ammonia / Q000097:blood; D001663:Bilirubin / Q000097:blood; D002648:Child; D005260:Female; D015600:Glasgow Coma Scale; D006801:Humans; D017093:Liver Failure / Q000097:blood / Q000209:etiology / Q000628:therapy*; D008297:Male; D009145:Mushroom Poisoning / Q000097:blood / Q000150:complications / Q000628:therapy*; D006435:Renal Dialysis; D016060:Sorption Detoxification; D016896:Treatment Outcome
D000641:Ammonia; D000410:Alanine Transaminase; D001663:Bilirubin