SHORT REPORTS

Albumin Dialysis and Molecular Adsorbents Recirculatiig System (MARS) for Acute

Wilson’s Disease Sambit Sen, * Marie Felldin,’ Christian Steiner, * Bo Larsson,’ Godfiey T Gillett,’

Micbael Olausson, ’ Roger Williams, * and Rajiv Jalan *

Wilson’s disease presenting as acute liver failure (ALF) is potentially fatal, and liver transplantation (LTx) is the only option. We report two patients with Wdson’s disease and ALF treated with the Molecular Adsorbents Recircu- lating System (MARS). Both patients fulfilled criteria for poor prognosis. Because LTx was not available immedi- ately in either case, MARS was used as a bridge to LTx. In Case 1, serum bilirubin decreased from 803 to 425 pmol/L after 3 treatments, but increased to 656 pmol/L during a break, decreasing again to 457 pmol/L with further treatment. Serum copper decreased from 53.7 pmol/L, to 35.8 pmol/L after first treatment session, and 17.4 pmol/L at treatment completion. In Case 2, MARS treatment over 2 weeks reduced serum bilirubin from 1200 to 450 pmollL and copper from 35 to 13 pmol/L with marked improvement in encephalopathy and reduc- tion in ammonia (59 to 34 pmol/L). Both patients were successfully bridged to LTx (days 9 and 28, respectively). Analysis of albumin-dialysate from the MARS circuit sug- gested that copper removal occurred mostly in the first few hours of treatment, partly being adsorbed by albumin and partly by the MARSFlux membrane (Teraklin AG, Ros- tock, Germany). These data suggest that M A R S removes copper efficiently and can be used to bridge patients with Wilson’s disease and ALF to LTx. (Liver Transpl2002;8: 962-3671

W ilson’s disease is an autosomal recessive heredi- tary disease of copper metabolism in which cop-

per transport from the liver is impaired,’ resulting in its accumulation in the liver. The commonest modes of presentation are either as a chronic liver disease, or as a neurologic dis0rder.~,3 Acute liver failure is one of the

From the *Liver Failure Group, Institute of Hepatolog, University College London Hospitals, London, UK the ?Division of Transpkznta- tion and Liver Surgery and the $Intensive Care Unit, Sahlgenska Uni- versity Hospital, Goteborg, Sweden; and the $Clinical Chemisty, North- ern General Hospital, Shefield, UK

Address reprint requests to Rajiv Jakzn, MD, Institute ofHepatolog, University College London Hospitals Q Medical School, 69-75 Chenies Mews, London W C l E 6HX, UK Telephone: 44-207-679-6552; FAX. 44-207-380-0405; E-mail: r.jakzn@ucl.ac. uk

Liver Diseases Copyright 0 2002 by the American Association for the Study of

1527-6465/02/0810-0017$35.00/0 doi:lO. I O53/jtss.20O2.3554G

rarer presentations of Wilson’s disease, and is poten- tially fatal. It is often accompanied by acute renal failure and hemolytic anemia,*,5 which is thought to be caused by the massive release of copper into the circulation. Liver transplant (LTx) often might be the only thera- peutic option, and has a good l-year survival (about 90%), whereas cases in which LTx cannot be performed have about 90% mortality.6 However, frequently donor organs become available too late to be of benefit. There- fore, some form of liver support system that can keep a patient alive until a donor organ becomes available would be potentially life-saving.

The Molecular Adsorbents Recirculating System (MARS) (Teraklin AG, Rostock, Germany) is an extra- corporeal liver support system7 using a hollow-fiber dialysis module in which the patient’s blood is dialyzed across an albumin-impregnated membrane (MARS- Flux; Teraklin AG) while maintaining a constant flow of albumin-rich (20%) dialysate in the extracapillary compartment. The albumin molecule subserves impor- tant transport and detoxification functions through availability of a large number of binding sites. Toxins from the albumin in the patient’s blood are adsorbed onto the membrane, and then pass to the albumin in the dialysate. This is then perfused over an activated charcoal column and an anion exchange resin column, which take up the toxins from the albumin to regener- ate the dialysate. Substances with a molecular weight of more than 50 kD, such as essential hormones bound to carrier proteins, growth factors, and albumin are not removed from the perfused blood. The system includes an additional hemodialysis/hemofiltration module, which removes the water-soluble toxins.

Although copper is predominantly and tightly bound to ceruloplasmin in the blood, about 20%* is transported by albumin in an exchangeable form and released to other carriers for actual cell-specific uptake.9 It has been hypothesized that this albumin-bound pool is greatly increased with release of copper into the cir- culation in acute liver failure. This is the basis on which albumin dialysis, using a continuous veno-venous hemodiafiltration (CVVH) technique, has been used to

962 Liver Transplantation, Vol8, No l 0 (October), 2002:pp 962-967

MARS in Wilson j Disease 963

treat one such case.1° The present paper reports two cases of acute liver failure caused by Wilson’s disease that were successfully bridged to LTx with MARS alone in one, and MARS with albumin-CVVH in the other.

Case Report

Case 1

A 23-year-old woman, a foreign tourist to the United Kingdom, without any significant past medical history, was admitted with severe upper abdominal pain and vomiting after a week of jaundice. At presentation, she had grade 1 hepatic encephalopathy (HE) (West Haven criteria’ l), with mild ascites and with evidence of devel- oping hepatic and renal failure (serum bilirubin, 725 pmol/L; International Normalized Ratio [INRI, 3.75; serum albumin, 24g/L; serum lactate, 5.27 mmol/L; serum creatinine, 329 pmol/L; diminishing urine out- put). Liver enzymes were normal (alanine aminotrans- ferase, 16 IU/L; alkaline phosphatase, 10 IU/L). The high bilirubin level was caused partly by, and main- tained by hemolysis (hemoglobin, 5.6g/dL; hematocrit, 0.16; reticulocytes, 13.9%; haptoglobulin < O.lg/L). There was associated leucocytosis (white blood cell count W C ] , 52 X lO9/L) (without any clinical evi- dence of infections, and with negative blood cultures) as well as thrombocytopenia (platelet count decreasing from 186 to 8 1 X lO9/L in the first 24 hours after admission).

A Kayser-Fleischer ring was detected on slit-lamp examination, and serum copper was found to be ele- vated (53.7 pmol/L). A transjugular liver biopsy revealed the presence of cirrhosis with evidence of inflammation. There was bile duct proliferation with cholestasis and rosetting. Hepatocytes showed fatty change, balloon degeneration, and occasional Council- man bodies. Glycogenation of nuclei was present. There was evidence also of portal tract inflammation and interface hepatitis (the inflammatory infiltrate including neutrophils). Rhodamine staining showed hepatocytes positive for copper-associated protein in a patchy distribution. O n the basis of presence of a Kay- ser-Fleischer ring, a high serum copper and a compati- ble liver biopsy, she was confirmed to have Wilson’s disease on day 7 of the illness and subsequently started on D-penicillamine.

By day 3, she had developed grade 3 HE with oligo- anuria, in addition to worsening coagulopathy and thrombocytopenia. Because of the patient’s foreign nationality, it was unclear initially whether she was eli- gible for LTx in the United Kingdom. To buy time, on

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Figure 1. Time course of serum bilirubin in Case 1 (dura- tion of MARS treatment marked by horizontal double- headed arrow).

day 4 she was started on treatment with MARS linked with hemofiltration (Hospal BSM 22c, Lyon, France). Both blood and albumin circuits were run at 150 mL/min. Three treatment sessions were performed in succession, separated by only 1 to 2 hours for a change of the filters, which essentially was a continuous treat- ment for 46 hours. A significant reduction of serum bilirubin (from 803 to 425 pmol/L) was observed over this period (Fig. l). Subsequently, when a break of half a day (14 hours) was given, the bilirubin increased again to 656 pmol/L, but responded well to another contin- uous treatment session of 26 hours, decreasing to 457 pmol/L. INR ranged between 2.01 and 3.61 through this period. Oligo-anuria persisted, but the serum cre- atinine decreased to 79 pmol/L. Serum lactate decreased to 1.51 and 1.28 mmol/L at the end of the first and second MARS sessions, respectively. Serum copper decreased from 53.7 pmol/L, at the start of MARS, to 35.8 pmol/L after the first treatment session (16 hours) and 17.4 pmol/L at treatment completion. The severity of HE fluctuated between grades 2 and 3 (with a tendency toward improvement over the course of the MARS treatments), with a computed tomogram of the brain revealing early cerebral edema. Four days after initiating MARS treatment, her eligibility for LTx was confirmed, and she was listed for superurgent LTx. She successfully underwent transplantation the next day, 9 days after presentation. After a follow-up of 13 months, she is maintaining good health (Fig. 1).

The albumin dialysate was sampled for copper con- centration from the four ports on the MARS circuit, which are 1. between blood and hemofilter columns, 2. between hemofilter and charcoal columns, 3. between charcoal and anion exchange columns, and 4. between

964 Sen et al

anion exchange and blood columns. These samples were taken at the end of the first 16-hour long MARS session during each of the two spells of continuous treatment (at which time the disposable filters were changed). This did not reveal any significant difference or gradient of copper concentration between different segments of the circuit (around 45 pmol/L and 7 pmol/L during the first and second treatments respec- tively) (Fig. 2).

Case 2

A 25-year-old woman was admitted with a week's his- tory of fatigue, epigastric pain and jaundice, starting 3 weeks after an intramuscular injection of contraceptive progesterone. At presentation, there was evidence of hepatic dysfunction (serum bilirubin, 100 pmol/L; ala- nine aminotransferase, 144 IU/L; INR, 2.4; serum albumin, 22g/L) without any HE or associated renal dysfunction (serum creatinine, 71 pmol/L; normal urine output). Serum lactate level was 8.1 mmol/L. Hemoglobin was 12.4 g/dL, dropping to 7.4 g/dL by day 10 with a high reticulocyte count (240 X lO9/L) and undetectable serum haptoglobulin levels, indicat- ing hemolysis. The serum ceruloplasmin was low (0.12 g/L) and a Kayser-Fleischer ring was detected on slit- lamp examination. The diagnosis of Wilson's disease was confirmed by genetic testing (the ATP7B gene was sequenced and shown to be homozygous for the His1069Gln mutationlz). Liver biopsy revealed cirrho-

sis with moderate inflammation, with some hepatocytes positive for copper-associated protein on rhodamine staining. D-penicillamine (1000 mg/d) was started on day 3 and continued up to day 13. She continued to deteriorate clinically, with rising serum bilirubin (370 pmol/L) and worsening INR (3.6), and was placed on the waiting list for LTx, with the highest priority, on day 8. However, no donor liver was available. The hepatic failure progressed, with appearance of HE (on day 13) which worsened to grade 2 by day 16, associ- ated also with the development of oliguria (on day 13).

MARS, in conjunction with hemodialysis (AK100, Gambro, Sweden), with a portable water cleaning equipment unit (WRO 200, Gambro, Sweden) was started on day 14, when she received an 8-hour treat- ment session. Both blood and albumin circuits were run at 150 mL/min, whereas the dialysate was run at 500 mL/min. At the start of MARS treatment, hemoglobin was 9.2 g/dL, serum bilirubin 1,200 pmol/L, INR 4.2, platelet count 42 X lO9/L and arterial ammonia 38 pmol/L. The patient was stable throughout the session and serum bilirubin fell substantially post-MARS (Fig. 3).

Directly after the first MARS treatment, she was started on albumin-CVVH (as has previously been reported by Kreymann et allo), which essentially is a conventional CVVH (Prisma CFM, Gambro, Sweden with AN69 filter [with an acrylonitrile and sodium

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Blood 18': 43.5 Hemofiltration Circuit l&: 52.3 MARS

2nd: 7.3 Circuit 2nd: 6.8 Albumin

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Figure 2. The MARS circuit, with copper concentrations (pmollL) in the albumin dialysate in different parts of the circuit, during the first and second treatment sessions in Case 1. No significant difference or gradient of copper concentration between different segments of the circuit can be seen.

MARS in Wilson 2 Disease 965

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A 1200 2

10 15

T 40

1 0 20 25 30

Hospital Days

Figure 3. Time course of serum bilirubin and copper (Cu) in Case 2 (duration of MARS treatment and albu- min-CVMI marked by headed arrow and dotted line respectively).

methallyl sulfonate copolymer membrane]) performed with a modified dialysate (a 4.5-L bag of dialysate, with l L removed and replaced by 1 L of 20% human albu- min, resulting in a 44 g/L albumin concentration), and continued for 36 hours. There was no significant improvement of either serum bilirubin or copper levels (Fig. 3), though there was a total removal of 233 pmol of copper (calculated by measuring the dialysate volume and copper concentration in each of the dialysate waste bags). This was followed by the second MARS session (l 0 hours), which achieved a satisfactory reduction of both serum bilirubin and copper levels, but after a sub- sequent 7 hours of albumin-CVVH, the HE had wors- ened to grade 3 to 4, with an arterial ammonia of 59 pmol/L. MARS therapy was then intensified, with effectively a continuous session for the next 4 days, interrupted only by l to 2 hours for change of filters (each being used for a maximum of 12 hours). The response was favorable, with improvement of HE (to grade l) , reduction of arterial ammonia (43 pmol/L) and stabilization of serum bilirubin (between 500 and 650 pmol/L) after this 4-day period of intense M A R S . From day 20, daily sessions of MARS treatment (for 8 to 12 hours) were resumed, with conventional CVVH in between (Fig. 3).

D-penicillamine (250 mg/d) was reintroduced from day 23; however, the patient's clinical status remained largely unchanged. Serum bilirubin decreased slowly to 450 pmol/L (day 27), and arterial ammonia was reduced to 34 pmol/L. Serum copper decreased too, from a maximum of 35 pmol/L on day 16 to 13 pmol/L on day 23. Eventually, 28 days after admission, she underwent LTx. The postoperative period was complicated by delayed graft function and a cytomeg-

alovirus infection, but after a follow-up of 6 months, she remains in good health.

During the second treatment sessions with MARS, copper concentrations were measured every 2 hours in the serum and in the albumin dialysate from the port between anion exchange and blood columns (Fig. 4). A rapid drop of serum copper (from 34 to 22 p,mol/L) was matched by a corresponding rise of copper concen- tration in the dialysate (from 3 [as fresh human albumin preparations contain traces of copper] to 22 pmol/L) over the first 4 hours, followed by relatively little change in either level for the rest of the treatment (Fig. 4).

Discussion

Acute liver failure is one of the potentially fatal modes ofpresentation of Wilson's disease and an indication for urgent LTx. A recent study has shown that a serum lactate level above 3.5 mmol/L in paracetamol-induced acute liver failure is a marker for poor prognosis.13 Higher levels were observed in both cases. Moreover, both the patients described in the present paper fulfilled the King's College Hospital criteria for LTx in acute liver failure.'* Therefore, without a transplant, both would have been expected to have a very poor out- corne.l5 However, as in the cases presented here, an

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Figure 4. Copper concentration, in serum and albumin dialysate, during a MARS-sessions in Case 2. A rapid drop of serum copper was matched by a corresponding rise of copper concentration in the dialysate over the first 4 hours, followed by relatively little change in either level for the rest of the treatment.

966 Sen et al

organ may not be available immediately. Whereas LTx was performed on the ninth day of illness in Case 1, Case 2 had to wait for a much longer period (28 days). In such cases a liver-support system, which can keep the patient alive for a few days, is potentially life-saving. This has been attempted in the past, with methods such as albumin dialysiss and plasma exchange.16 Our data suggests that MARS can be used effectively to bridge such patients to LTx, even over several weeks. More- over, the clinical improvement brought about by MARS, as was clearly evident in Case 2, means that the patient is in a better condition to undergo LTx.

Kreymann et all0 preferred to do albumin dialysis rather than MARS in a similar case based on the hypothesis that the latter would not be effective in removing copper as it did not have any cation-filtering column. However, at least from the point of view of removal of liver toxins, MARS would seem to be more effective than simple albumin dialysis, because the potential capacity for a finite volume of albumin to adsorb toxins is increased by adding the activated char- coal and anion-exchange resin columns, which allow the system to recirculate and function for a longer period. More importantly, it appears from the cases reported here that MARS does remove copper from the blood effectively. This is the only reasonable explana- tion for the substantial reduction of serum copper observed in Case 1, who was oligo-anuric, and in whom D-penicillamine had not been started, which makes the possibility of other routes of copper loss unlikely.

In Case 2, whereas albumin-CWH was effective in removing a substantial amount of copper, there was no significant reduction of either serum copper or bilirubin levels. More importantly, the patient clinically deterio- rated with further worsening HE while on albumin- CVVH. With MARS, as in Case 1, there was a satisfac- tory reduction of serum copper and serum bilirubin in Case 2. However, it is important to note that albumin- CVVH was used for a much shorter duration than MARS, and, therefore, could actually have proved to be of greater benefit (as was seen in a case reported ear- lierlO) if it was persisted. Our view is that both forms of therapy would probably be effective in removal of serum copper in Wilson’s disease patients. However, MARS probably would be a more appropriate therapy from the point of view of treating liver failure, in that encephalopathy improves, as does renal failure.

The mechanism of copper removal by the MARS system is not absolutely clear. However, no significant gradient of copper concentration was observed between different segments of the MARS circuit in Case 1 , indi- cating that copper entering the dialysate was not being

removed by any filter column, but just circulating around the circuit. This interpretation is supported by the kinetics of copper removal seen in Case 2, which showed saturation of the MARS system over the first few hours, and little copper removal thereafter. How- ever, the MARS treatment did result in a significant reduction of serum copper. This observation indicates that copper, although being removed effectively from the blood by the MARS circuit, was not being cleared by any of the filters, which leaves only the 20% albumin itself, the MARSFlux membrane, or both, in the blood/ albumin column as the possible sites of copper removal. In Case 1, the first treatment session with MARS reduced the serum copper level by about 18 pmol/L. However, calculations showed a removal of only 27 pmol into the albumin dialysate (a total of 600 mL, with a copper concentration of around 45 pmol/L throughout), without any other significant route of copper loss (the patient being oligo-anuric, and not on treatment with D-penicillamine). Similarly, with the patient in Case 2, who too was oligo-anuric, and off D-penicillamine before the start of MARS therapy, the corresponding figures would be a reduction of serum copper level by 12 pmol/L and removal of only 12 pmol into the dialysate during MARS session. The amount of copper removed into the albumin dialysate appears to be inadequate to explain the substantial reduction of serum levels. We suggest that whereas albumin obviously removes some amount of copper, the difference may be attributable to adsorption of cop- per onto the binding sites present on the MARSFlux membrane.

Interestingly, D-penicillamine was stopped in the patient in Case 2 from day 13 to day 23 because she was oligo-anuric (meaning that excretion would be mini- mal) and was not responding to the drug. However, in retrospect, continuing it might have been beneficial, as MARS itself would have probably provided a route of excretion for the chelated copper.

The critical role for removal of copper in improving outcome in patients with Wilson’s disease is supported by data showing that administration of D-penicilla- mine in Wilson’s disease patients with severe hepatic insufficiency and without renal failure or hepatic encephalopathy can lead to improved survival.17 The cases presented here show that MARS can be used suc- cessfully as an effective bridge to LTx in acute liver failure caused by Wilson’s disease presenting with hepatic encephalopathy and renal failure. Treatment with MARS resulted in a substantial reduction of serum copper, probably by adsorption to the MARSFlux membrane in addition to that adsorbed to the albumin

M R S in Wilson ? Disease 967

in the dialysate. This system would become more effec- tive by the addition of a suitable cation exchange resin to the MARS circuit that is specific for copper, and with greater removal might actually raise the possibilities of spontaneous recovery. Our preliminary data provide the pathophysiologic basis to suggest that a controlled clinical trial of MARS in acute liver failure caused by Wilson’s disease is justified.

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