Early Liver Support With MARS in Post-hepatectomy Liver Failure

Study Overview
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Brief Summary
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This is a prospective, randomized, open-label, multicentre study involving European centers with experience in the management of PHLF to assess the impact of early liver support with MARS on survival in patients with post-hepatectomy liver failure (PHLF).

Detailed Description
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PHLF is a major risk factor for mortality in patients who underwent major hepatectomy. A specific treatment is yet not available. In a primary proof-of-concept study, it was shown that it is safe and feasible to use MARS in patients with PHLF early after hepatectomy. Survival was superior to a historical control group. This study will include patients with early, primary PHLF (based on the 50:50 criteria) after major liver surgery. Patients will be randomized 1:1 to receive standard treatment alone or standard treatment + liver dialysis using the Molecular Adsorbent Recirculating System (MARS). Relevant outcome along with several physiological parameters will be assessed.

Official Title
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Early Liver Support With MARS in Post-hepatectomy Liver Failure: a Randomized, Multicentre Trial

Conditions
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Liver Failure as A Complication of Care

Intervention / Treatment
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* Device: Molecular Adsorbent Recirculating System
* Other: Standard medical treatment (SMT)


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Patients subjected for major liver surgery (4 or more Couinaud segments) or patients undergoing a 2nd, 3rd or 4th hepatic resection. Pre-operative chemotherapy and/or biological agents are allowed. Primary PHLF occurring early after surgery defined by the 50:50 criteria (from PO day 5 to day 14) or by the presence of hepatic encephalopathy grade 2 or more and the 50:50 criteria (from PO day 3 to 4). Written informed consent. Exclusion Criteria: ALPPS (Associating Liver Partition and Portal vein Ligation for Staged hepatectomy) procedure. In patients with chronic liver disease presence of significant portal hypertension (hepatic venous pressure gradient ≥ 10 mmHg and/or Fibroscan ≥ 21kPa) prior to surgical intervention. Any contraindication for MARS therapy such as uncontrolled active bleeding, platelet counts <20.000 /µl or uncontrolled infection (presence of fever or adequate antibiotic therapy for less than 48h), septic shock, haemodynamic instability requiring inotropic support (noradrenaline > 1mg/h). PHLF occurring after post operative day 14. Secondary PHLF: post-operative liver failure secondary to vascular (outflow or inflow thrombosis) or septic problems. Persistant biliary complications (infected biloma, main biliary tree damage). Inability or unwilling of the patient or family to give informed consent.

Ages Eligible for Study
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Minimum Age: 18 Years
Maximum Age: 80 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Standard medical treatment + MARS<br>Patients assigned to the control arm will receive standard medical treatment (SMT) and liver dialysis using Molecular Adsorbent Recirculating System (MARS). | Device: Molecular Adsorbent Recirculating System<br>* MARS therapy will start within 24-48 h after randomization and be given on 3 consecutive days in sessions of 8-12 h. The patients are observed for 2 days following the last session, with focus on bilirubin INR and signs of encephalopathy, and can thereafter receive 3 additional sessions in case of no or partial response to treatment.<br>* Other names: MARS 1116/1 - X-MARS;|
| Active Comparator: Standard medical treatment<br>Patients assigned to the control arm will receive standard medical treatment (SMT) as specified in the study protocol. | Other: Standard medical treatment (SMT)<br>* Patient management and standard medical treatment (SMT) as specified in the study protocol.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 60 day survival | Overall survival rate from time of randomization to death from any cause | From randomization to death from any cause, assessed up to 60 days postop | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| 28 day survival | Overall survival rate from time of randomization to death from any cause. | From randomization to death from any cause, assessed up to 28 days post-op | 
| 90 day survival | Overall survival rate from time of randomization to death from any cause. | From randomization to death from any cause, assessed up to 90 days postop | 
| 6 month survival | Overall survival rate from time of randomization to death from any cause. | From randomization to death from any cause, assessed up to 6 months postop | 
| 1 year survival | Overall survival rate from time of randomization to death from any cause. | From randomization to death from any cause, assessed up to 1 year. | 
| Impact of MARS therapy on liver function | Impact of MARS therapy on liver function according to Child Pugh score (grade A, B and C) | From randomization up to 1 year. | 
| Impact of MARS therapy on liver function | Impact of MARS therapy on liver function according to the Model for End-stage Liver Disease (MELD) score (5 groups: < 9, 10-19, 20-29, 30-39 and >40 points, lower points indicate improvement of liver function). | From randomization up to 1 year. | 
| Impact of MARS therapy on extra-hepatic function (APACHE-II scoring) | Impact of MARS therapy on extra-hepatic function assessed by the Acute Physiology And Chronic Health Evaluation II (APACHE II) scoring system (range 0-71 points, lower points indicate less severe disease). | From randomization up to 1 year. | 
| Impact of MARS therapy on extra-hepatic function (SOFA scoring) | Impact of MARS therapy on extra-hepatic function assessed by the Sequential Organ Failure Assessment (SOFA) scoring system (0-24 points, higher points indicate more severe disease). | From randomization up to 1 year. | 
| Impact of MARS therapy on extra-hepatic function (CLIF-SOFA scoring) | Impact of MARS therapy on extra-hepatic function assessed by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) scoring system (0-24 points, higher points indicate more severe disease). | From randomization up to 1 year. | 
| Impact of MARS therapy on splanchnic hemodynamics assessed by direct estimation of portal blood flow. | Impact of MARS therapy on splanchnic hemodynamics assessed by direct estimation of portal blood flow (ml/min). | At randomization (day 0) and on day 10. | 
| Impact of MARS therapy on splanchnic hemodynamics assessed by indirect estimation of portal blood flow using ultrasonography. | Impact of MARS therapy on splanchnic hemodynamics assessed by indirect estimation of portal blood flow using ultrasonography (ml/min). | At randomization (day 0) and on day 10. | 
| Impact of MARS therapy on splanchnic hemodynamics assessed by portal pressure measuring. | Impact of MARS therapy on splanchnic hemodynamics assessed by portal pressure measuring. | At randomization (day 0) and on day 10. | 
| Impact of MARS therapy on liver regeneration assessed by volumetric liver analysis using combined Computed Tomography (CT) and Magnetic Resonance Imaging (MR). | Impact of MARS therapy on liver regeneration assessed by volumetric liver analysis using combined Computed Tomography (CT) and Magnetic Resonance Imaging (MR). | At randomization (day 0) and on days 5, 10 and 30 . | 
| Impact of MARS therapy on liver regeneration assessed by serum levels of phosphate. | Impact of MARS therapy on liver regeneration assessed by serum levels of phosphate. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver regeneration assessed by serum levels of alphafetoprotein. | Impact of MARS therapy on liver regeneration assessed by serum levels of alphafetoprotein. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver regeneration assessed by serum levels of hepatocyte growth factor. | Impact of MARS therapy on liver regeneration assessed by serum levels of hepatocyte growth factor. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver performance status. | Impact of MARS therapy on liver performance status estimated using indocyanine green (ICG) clearance. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver toxins (bile acids) in serum and dialysate. | impact of MARS therapy on liver toxins (ammonia, bile acids and cytokines (IL-6 and TNF-alpha)). Determinations in serum and in the dialysate. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver toxins (ammonia) in serum and dialysate. | impact of MARS therapy on liver toxins (ammonia). Determinations in serum and in the dialysate. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver toxins (IL-6) in serum and dialysate. | impact of MARS therapy on liver toxins (IL-6). Determinations in serum and in the dialysate. | At randomization (day 0) and on days 5 and 10. | 
| Impact of MARS therapy on liver toxins (TNF-alpha) in serum and dialysate. | impact of MARS therapy on liver toxins (TNF-alpha). Determinations in serum and in the dialysate. | At randomization (day 0) and on days 5 and 10. | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Molecular Adsorbent Recirculating System, post-hepatectomy liver failure, liver dialysis, post-hepatectomy liver dysfunction