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Technology Insight: artificial extracorporeal liver support—how does Prometheus® compare with MARS®?

Nature Clinical Practice Nephrology volume 3, pages 267–276 (2007)Cite this article

Abstract

Artificial extracorporeal liver support or 'liver dialysis' has been used in patients with severe liver failure with increasing frequency since the Molecular Adsorbents Recirculating System (MARS®), a variant of albumin dialysis, was introduced in 1999. Nevertheless, liver dialysis must still be thought of as experimental because its contribution to improved patient survival has not been proven in large randomized trials. Prometheus® is a novel device for fractionated plasma separation via an albumin-permeable filter that was developed to improve removal of albumin-bound toxins. Initial studies have proven clinical use of Prometheus® to be feasible and safe. Head-to-head comparisons of Prometheus® and MARS® have shown treatment with the former to be more efficient with respect to removal of most albumin-bound and water-solved markers. As controlled studies with clinical end points are lacking, it is not known whether the observed greater detoxification capacity of Prometheus® will translate into clinical benefit; two small studies indicate that there might be a beneficial effect in hepatic encephalopathy and pruritus. In a recent randomized comparison of MARS® and Prometheus®, however, hemodynamic improvement was observed in response to MARS®, but not Prometheus®, treatment. A large randomized controlled trial investigating the effect of Prometheus® on survival—the HELIOS study—has been initiated. First results are expected in 2008 and will be crucial to establishing a role for Prometheus® in the field of extracorporeal liver support.

Key Points

  • Artificial extracorporeal liver support or 'liver dialysis' is being used in patients with acute or acute-on-chronic liver failure with increasing frequency

  • The Molecular Adsorbents Recirculating System (MARS®) is a variant of albumin dialysis developed by Gambro (Lund, Sweden)

  • Prometheus® is a fractionated plasma separation device developed by Fresenius Medical Care (Bad Homburg, Germany) for superior removal of albumin-bound toxins

  • Preliminary data from small studies support the safety and efficacy of MARS® and Prometheus®

  • Until large, controlled, randomized trials show a survival benefit, use of Prometheus® and MARS® must be considered experimental

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Figure 1: Prometheus® is based on the principles of fractionated plasma separation and adsorption
Figure 2: The Molecular Adsorbents Recirculating System (MARS®) is based on the principles of albumin dialysis and adsorption, using a secondary circuit prefilled with 20% albumin solution
Figure 3: Fractionated plasma separation versus albumin dialysis
Figure 4: Effects of 6-hour treatments with MARS® or Prometheus® on serum albumin levels
Figure 5: Course of changes in mean arterial pressure during 16 Prometheus® and 16 MARS® treatments in eight patients

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Acknowledgements

This work would not have been possible without the collegiality within the Extracorporeal Liver Support Study Group at the Medical University of Graz. Special thanks to the nursing staff of our dialysis unit for their dedication to patient care. We thank D Schneditz and M Trauner for fruitful discussions during preparation of this manuscript.

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Authors and Affiliations

  1. P Krisper is Senior Physician in the Division of Nephrology, and RE Stauber is Chief of the Liver Clinic in the Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University Graz, Graz, Austria.,

    Peter Krisper & Rudolf E Stauber

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  2. Rudolf E Stauber
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Correspondence to Peter Krisper.

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Competing interests

The authors' research projects on extracorporeal liver support were supported in part by Fresenius Medical Care.

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Krisper, P., Stauber, R. Technology Insight: artificial extracorporeal liver support—how does Prometheus® compare with MARS®?. Nat Rev Nephrol 3, 267–276 (2007). https://doi.org/10.1038/ncpneph0466

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