Liver support for fulminant hepatic failure: Is it time to use the Molecular Adsorbents Recycling System in children?*

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Abstract
To describe the main liver support devices used for fulminant hepatic failure (FHF) and to review data on the Molecular Adsorbents Recycling System (MARS) and assess its efficiency in children. Studies were identified through selected readings and a MEDLINE search from 1975 and 2004 using fulminant hepatic failure, acute liver failure, primary graft dysfunction, liver support, MARS, and extracorporeal liver assist device as key words. All original studies, including case reports, relating to the use of the MARS or albumin dialysis system were included. Additional attention was put on prognosis criteria of FHF severity in children. Study design, numbers and diagnoses of patients, definite or bridging treatment, outcome measures, and complications were extracted and compiled. Results of individual trials were combined on the risk ratio scale. Nine randomized trials including 354 patients were identified. However, liver support failed to significantly affect mortality when compared with standard medical therapy. Albumin dialysis, and particularly MARS, emerges as an easily applicable technique for temporary liver support. Some well-designed studies have characterized its efficiency in a few indications, such as in intractable pruritus in chronic liver disease, in acute or chronic liver diseases, and in decompensated cirrhosis with hepatorenal syndrome. In adults and children with FHF, anecdotal reports suggest that MARS may stabilize the patient. However, no randomized controlled study has validated its use in this indication. A randomized controlled study is ongoing in adults with FHF. Such a trial seems to be unfeasible in children for several methodologic reasons. Although promising preliminary results suggest that MARS may have a significant position in the therapeutic arsenal for FHF, no sufficient data exist to justify its use in children. For as long as the results of the ongoing adult trial are not available, the indications of this expensive technique in children with FHF are limited.