Molecular Adsorbent Recirculating System (MARS®) in Hypoxic Hepatitis

Phase 2

Conditions: Shock Liver
Hypoxic Hepatitis
Hypoxic Liver Injury
Acute Liver Failure
Ischemic Hepatitis

Brief Summary: Hypoxic hepatitis (HH) is reported to be the most frequent cause of elevated aminotransferase levels in hospital. Up to 10 % of critically ill patients develop HH during the course of their intensive care unit (ICU) stay. Occurrence of HH is a life threatening event and ICU-mortality is reported to be up to 60%. Early therapeutic intervention is of central prognostic importance in patients with HH to improve the hemodynamic impairment as early as possible, to reduce hyperammonemia and hepatic encephalopathy, to avoid progression of organ failure and to improve outcome. Studies reported that Molecular Adsorbent Recirculating System (MARS®) therapy improved the hemodynamic situation in patients with acute and acute on chronic liver failure. The study hypothesis is that MARS® therapy in critically ill patients with severe HH improves hepatic hemodynamics and function and consecutively the course of the disease. 40 patients with suffering of severe HH with aminotransferase levels \> 40 times the upper limit of normal of more than 12 hours will be randomized 1:1 to MARS® therapy (n=20) or conventional therapy (n=20). 4 MARS®-sessions will be performed on three consecutive days, each for at least 12 hours. Treatment will be continued under special circumstances. The maximum duration of the treatment phase is 7 days. The primary endpoint is the difference of the indocyanine plasma disappearance rate at day 7. The expected duration of the study is 2 years.

Recruitment & Eligibility

Inclusion Criteria

presence of severe hypoxic hepatitis with aminotransferase levels > 40 times the upper limit of normal
duration of hypoxic hepatitis more than 12 hours
age >/= 18 years

Exclusion Criteria

age < 18 years
pregnancy
DNR - order
liver cirrhosis
Cardiopulmonary resuscitation with unknown neurological outcome and/or hypoxic brain damage
Expected survival of less than 24 hours

Arm && Interventions

Group	Intervention	Description
MARS-Group	MARS	20 patients will be allocated by randomization to the MARS arm. Additionally to standard medical therapy they will receive 4 MARS sessions on three consecutive days, MARS® therapy will be applied for at least 12 hours per session. Thereafter, MARS® treatment will be continued if the patient still has increasing aminotransferase levels, requires vasopressor support or suffers from cholestasis (defined as serum bilirubin levels \> 5 mg/dL) for 3 sessions again. There will be a maximum of 7 MARS ® sessions per patient.

Primary Outcome Measures

Name	Time	Method
difference of the indocyanine plasma disappearance rate (ICG-PDR)	Days 1-7	The primary endpoint will be the difference of the indocyanine plasma disappearance rate (ICG-PDR) at day 7. Only in case of major differences in baseline values of ICG-PDR we will use the change from baseline to day 7 of ICG-PDR (delta ICG-PDR) as outcome. Assuming normal distribution of ICG-PDR, we will formally test the null-hypothesis of no difference between intervention group and control using an independent sample t-test. The assumption of a normal distribution will be founded on visually inspecting a histogram and using the Shapiro Wilks test for normal distribution. If the assumption of normality does not hold data will be compared using the Mann-Whitney U-test. A p-level of \< 0.05 will be considered statistically significant. Furthermore a linear random coefficient model will be used to incorporate daily measurements of ICG-PDR during the course of the study in terms of a repeated measures design.

Secondary Outcome Measures

Name	Time	Method
hospital - length of stay	1-90
28 day mortality	28 days
number of organ failure on day 7	7 days
duration of vasopressor support	1-28
ICU - length of stay	1-28
7-day mortality	7 days
number of organ failure on day 28	28 days
markers of liver function	1-28	especially occurrence of jaundice (defined as total bilirubin levels \> 3 mg/dL) will be documented
systemic hemodynamics	7 days	systemic blood pressure, heart rate, cardiac index, central venous oxygen saturation, systemic vascular resistance index, global enddiastolic volume index, stroke volume variation, extravascular lung water index, pulse pressure variation, intrathoracic blood volume index, cardiac function index, central venous pressure
number of complications of HH	1-28	following complications will be encountered: cholestasis, secondary sclerosing cholangitis, hepatic encephalopathy grade 3 \& 4, hypoglycemia, intraabdominal hypertension, new onset of infections, renal failure, hepatopulmonary syndrome
biomarkers	0-28	blood samples will be collected the assess markers of inflammation, markers of endothelial function, markers of cardiac function, markers of cholestasis, markers of liver cell necrosis etc
duration of mechanical ventilation	1-28
duration of renal replacement therapy	1-28
number of vasopressor free days	28 days
necessity of renal replacement therapy	1-28
90 days mortality	90 days

Locations (2): University Medical Center Hamburg-Eppendorf
🇩🇪
Hamburg, Germany
Medical University Vienna, Dpt. of Internal Medicine 3, Div. of Gastroenterology and Hepatology
🇦🇹
Vienna, Austria