1. Sesión 3: Cirrosis hepática Soporte hepático artificial Rafael Bañares Hospital General Universitario Gregorio Marañón Madrid

2. Acute-on-chronic LF and Liver Support Sepsis Bleeding Alcohol DILI InflammationOxidative stressHemodynamic changes Pathophysiological changes MOF and death Circulatory failure HRS Encephalopathy Precipitating event Stable clinical condition Liver Failure

3. Liver support systems Requirements and characteristics of liver support systems Pathophysiological effects of liver support systems Effect of liver support systems on clinical outcomes

4. Acute-on-chronic LF and artificial support Sepsis Bleeding Alcohol DILI InflammationOxidative stressHemodynamic changes Pathophysiological changes MOF and death Circulatory failure HRS Encephalopathy Precipitating event Stable clinical condition Liver Failure

5. Requirements of the “ideal” ALS system Detoxification by neutralizing or removing toxins Synthesis of clinically important proteins Facilitation of regeneration of native hepatocytes To restore normal health and/or to provide clinical stability To restore normal health and/or to provide clinical stability Provide support to patients with liver failure (including other organ failures) Provide support to patients with liver failure (including other organ failures) No major safety concerns

6. Combination of “Therapeutic units” Carpentier et al. Gut 2009

8. Biological systems –PROS Potential to provide synthetic function –CONS Difficulty of having an adequate cell source Need for a critical bioactive mass Complex technology Risk of xenotransmission Non-biological systems –PROS Relatively easy to use Provide detoxifying functions –Water-soluble –Protein-bound More advanced clinical development –CONS Do not provide synthetic functions Comparison between biological and non-biological systems

9. Differences between albumin dialysis systems FPSA (Prometheus) Based on plasma separation including albumin (large size pore MW cut-off 250 kD) Molecular adsorbent recirculating system MARS Adsorption Dialysis Based on removal of protein-bound and water-soluble toxins (MW cut-off 50 kD) against albumin-enriched dialysate Undergo continuous recirculation and adsorption

10. Liver support systems Requirements and characteristics of liver support systemsRequirements and characteristics of liver support systems Pathophysiological effects of liver support systems Effect of liver support systems on clinical outcomesEffect of liver support systems on clinical outcomes

11. Acute-on-chronic LF and artificial support Sepsis Bleeding Alcohol DILI InflammationOxidative stressHemodynamic changes Pathophysiological changes MOF and death Circulatory failure HRS Encephalopathy Precipitating event Stable clinical condition Liver Failure

12. Removal of toxins Hemodynamic effects

13. Substances cleared during albumin dialysis Albumin-bound substancesWater-soluble substances BenzodiazepinsAmmonia BilirubinAromatic amino acids Cytokines, TNF alphaCreatinine Bile acidsInterleukin 6, TNF alpha Copper, manganeseTryptophan Middle-chain and short-chain fatty acids Urea Nitric oxide, vasoactive substances GABA FPSA (Prometheus) seems to be more effective in clearance capacity as compared with MARS

14. Effect of albumin dialysis (MARS) on systemic hemodynamics Catalina et al. Liver Int 2003 0 20 40 60 80 100 120 140 BaselineEnd of session MAP 76 ± 1387 ± 19 p=0.009 mmHg 0 2 4 6 8 10 12 14 BaselineEnd of session CO 10.2 ± 2.49 ± 2.5 L/ min p=0.015 0 200 400 600 800 1000 1200 1400 BaselineEnd of session SVRI 612± 295 750± 347 Dyn.seg.cm -5 p=0.008 PCP 22 ± 421 ± 8 mmHg NS 0 5 10 15 20 BaselineEnd of session 12.5± 412.7± 5 NS

15. Effect of albumin dialysis (MARS) on vasoactive mediators Catalina et al. Liver Int 2003 MARS albumin dialysis attenuates hyperdinamic circulation in AAH

16. Laleman et al. Critical Care 2006 Effect of albumin dialysis on systemic hemodynamics. MARS Vs. PROM

17. Effect of albumin dialysis (MARS) on portal pressure 0 5 10 15 20 25 30 35 40 45 Baseline 4 hEnd of session mmHg HVPG change during MARS therapy 22.3±6 mmHg17.5±7.3 mmHg Mean decrease 23±18 % Baseline End first session WHVPFHVP p = 0.04 5 10 15 20 25 30 35 40 45 NS 2,4 2,2 2,0 1,8 1,6 1,4 1,2 1,0 0,8 0,6 Baseline ADMA Final ADMA μMμM P = 0,01 P = 0,02 MARS effect on portal pressure may be associated to a decrease in intrahepatic resistance Catalina et al. Liver Int 2003

18. Sen S et al. J Hepatol 2005 The effect of albumin dialysis on portal pressure is independent of extracorporeal circulation

19. Effect of albumin dialysis on inflammatory profile CytokineEffectNº of patientsAuthor/year IL 18, caspase 1Unaffected10/ACLFRoth/Dig Liv Dis 2009 IL6, TNFαUnaffected5 /HRSWong/ Gut 2010 IL6, IL1, IL10, TNFα, HGF Improvement15/ACLFNovelli/ Transp Proc 2009 IL6, IL8, IL10, TNFα, TNFαR Unaffected9/ACLF RCT Stadlbauer/ Crit Care 2006 IL6, IL8, IL10, TNFα, TNFαR Unaffected9/ACLF RCT Sen/ Liv Transpl 2004 TNF α, IL8, IL10, IL6Unaffected32/ACLFIloeni/ Transp Proc 2006 IL6, TNFαImprovementAmbronio/ Acta Biomed, 2003 TNFα, IL1 β, IL6, IL10Improvement13Dicampli/ Transp Proc 2005 TNFα, IL6, IL8, IFNγImprovement24Ho/ Liv Int 2003 No solid conclusion may be obtained about the role of albumin dialysis on cytokine profile

20. Lack of effect of albumin dialysis in improving albumin function in ACLF Jalan et al. Hepatology 2009

21. Pathophysiological effects: Summary Improve systemic hemodynamics (humans) –Increase arterial pressure –Decrease cardiac output –Decrease vasoactive systems –Decrease NO levels Decrease portal pressure (humans) No clear effect in inflammatory mediators or ammonia levels No improvement in deteriorated albumin function

22. Acute-on-chronic LF and artificial support Sepsis Bleeding Alcohol DILI InflammationOxidative stressHemodynamic changes Pathophysiological changes MOF and death Circulatory failure HRS Encephalopathy Precipitating event Stable clinical condition Liver Failure

23. Liver support systems Requirements and characteristics of liver support systemsRequirements and characteristics of liver support systems Pathophysiological effects of liver support systemsPathophysiological effects of liver support systems Effect of liver support systems on clinical outcomes

24. Quality of evidence Stutchfield et al British Journal of Surgery 2011 ALF: 198 patients ACLF: 157 patients

25. HELIOS study: FPSA (Prometheus) in ACLF RELIEF study: MARS in ACLF Meta-Analysis of Liver Support Systems in ACLF Stutchfield et al British Journal of Surgery 2011

26. Type I Hepatorenal syndrome n=13 MARS albumin dialysis n=8 Hemodiafiltration n=5 Primary end-point 30-day survival Mitzner et al. Liver Transplantation 2000 Albumin dialysis (MARS) in hepatorenal syndrome Small sample size (n=13) SMT not appropriate (terlipressin+albumin)

27. Albumin dialysis (MARS) in HRS refractory to vasoconstrictor therapy No changes in GFR, RPF, cytokine profile nor neurohormones No apparent impact on survival Wong F et al; Gut 2010 Pilot, observational, pathophysiological study HRS-1 refractory to vasoconstrictors + albumin n=6 GFR, RPF, Neurohormones, NO, TNF α, IL6

28. MARS in acute-on-chronic liver failure Cirrhosis with “superimposed” liver injury Serum bilirubin > 20 mg/dL Exclusion criteria; n=8 ALF (1) Sepsis (1) Active bleeding (1) HRS (4) Screened patients n=46 Spontaneous decrease in Br n=12 Included patients n=24 SMT n=12 SMT + MARS n=12 Primary end-point Bilirubin< 15 mg/dL (3 days) Secondary end-point In-hospital mortality 2/12 (17 %)5/12 (42 %) 6/12 (50 %) 1/12 (8 %) Heeman et al. Hepatology 2002

29. Albumin dialysis (MARS) in acute-on-chronic liver failure Heeman et al. Hepatology 2002 Cons –Small sample size –End-point different to mortality –Patient selection No differences in adverse events between groups

30. Screened patients n=82 Included patients n=70 MARS n=39 Albumin dialysis (MARS) in encephalopathy Absence of inclusion criteria n=10 Exclusion criteria n=2 Cirrhosis with severe HE (grade III or IV) SMT n=31 Primary end-point: Two grade improvement in HE 0.00 0.50 1.00 1.50 2.00 2.50 3.00 3.50 4.00 0122436486072849610 8 120 hours mean cum num of improvements/person MARS SMT 0% 10% 20% 30% 40% 50% 60% 70% 80% 01224364860728496108120 hours percent with 1st improvement MARS SMT Effect of albumin dialysis in severe HE Time to improvement

31. Predictors of response: MARS therapy (adjusted OR: 3.8) Child-Pugh score Glasgow Coma Scale Survival rate was greater in patients with rapid recovery of encephalopathy MARS in hepatic encephalopathy No significant adverse events Hassanaien et al. Hepatology 2007

32. HELIOS study ACLF patients N=145 Mean MELD 27 Mean CPS 12 SMT N=68 SMT + FPSA N=77 30 days survival: 66% 90 days survival: 47 %90 days survival: 38 % 30 days survival: 63%P=0.70 P=0.38 Subgroup analysis 90 days survival benefit under FPSA therapy in Hepatorenal syndrome type I (p = 0.04) MELD score >30 (p = 0.02) Subgroup analysis 90 days survival benefit under FPSA therapy in Hepatorenal syndrome type I (p = 0.04) MELD score >30 (p = 0.02) Liver transplantation: 19.5 %Liver transplantation: 19.1 % Rifai, K et al. Gastro 2012 28 days therapy Cirrhotic patients Acute decompensation HRS/EH/Severe Jaundice

33. Extracorporeal liver support with the Molecular Adsorbent Recirculating System (MARS) in patients with acute-on-chronic liver failure (ACLF). The RELIEF Trial.

34. Methods: Design of RELIEF trial Multicenter prospective randomized trial – SMT Vs. SMT + MARS Main end-point –Intention-to-treat 28 days transplant-free survival –Per protocol 28 days transplant-free survival Secondary end-points –Evolution of biochemical parameters –Evolution of hepatic encephalopathy

35. Methods: Inclusion Criteria Acutely decompensated liver cirrhosis –Presumed cirrhosis –Triggering event Bilirubin >5 mg/dl (without evidence of extrahepatic origin) –AND… at least one of: HRS (International Ascites Club) and/or Hepatic encephalopathy > or equal º II and/or Progressive hyperbilirubinemia (Bilirubin > 20 mg/dl or >340 µmol/l) Sample size calculation –“20 % reduction in mortality in experimental arm” (from 40 % to 20 %).

36. Methods: Exclusion Criteria Progressive jaundice as a consequence of the natural course of cirrhosis or extrahepatic colestasis Platelet count less than 50000/mm 3 INR >2.3 or DIC Need for renal replacement or intrinsic renal disease Uncontrolled infection Active bleeding HCC> 4 cm or tumoral and non-tumoral portal vein thrombosis Severe cardiopulmonary disease Hemodynamic instability Major surgical procedure within the last 4 weeks HIV infection

37. Methods: Sample size and study populations Sample size calculation –“20 % reduction in mortality in experimental arm” (from 40 % to 20 %). Intention-to-treat population –All patients enrolled into the trial without major violation of the inclusion and exclusion criteria Per-Protocol population: – ITT population excluding drop-outs (withdrawal of informed consent, surgical procedures, major violations of the protocol)

38. Day -2 Day Day 0 N=189 Day 4Day 7Day 14Day 21Day 28 SMT SMT+MARS Check for elegibility Check for inclusion and exclusion criteria Screened patients N=397 (19 centers) Pre-Rx phase Patients not eligible for the trial N=208 Main reasons for no inclusion No inclusion criteria n=68 INR>2.3 n=43 Platelet count< 50000/mm 3 n=34 No consent n=23 Mean (SD) number of sessions: 6.5 (3.1) sessions/patient Duration of MARS sessions: 6-8 h RELIEF: Study flow Cirrhotic patients Acute decompensation HRS/EH/Severe Jaundice Bañares R et al. Hepatology 2013

39. VariableSMT (n=85)SMT+ MARS (n=71)P Age (years)50 (11)51.8 (10.4)NS Sex (male (%))61 (71.8 %)46 (64.8 %)NS Etiology of liver disease Alcohol Viral hepatitis Others *more than one cause is possible 80 (94.1 %) 7 (8.2 %) 6 (7.1 %) 64 (90.1 %) 5 (7 %) 9 (12.6 %) NS Alcohol abuse (n (%))66 (77.6 %)55 (77.5 %)NS Infection (n (%))26 (30.6 %)20 (28.2 %)NS GI Bleeding (n (%))12 (14.1 %)8 (11.3 %)NS Dehydration (n (%))8 (9.4 %)6 (8.5 %)NS Others (n (%))5 (5.9 %)1 (1.4 %)NS More than one precipitating event (n (%)) 32 (37.6 %)29 (40.8 %)NS Number of precipitating events (median (range)) 1 (1-4)1 (1-3)NS SBP (n (%))6 (7.1 %)12 (16.9 %)P=0.055 Baseline characteristics (PP population)

40. VariableSMT (n=85)SMT+MARS (n=71)P Progressive hyperbilirubinemia (n (%)) 60 (70.6 %)46 (64.8 %)NS HRS (n (%))45 (52.9 %)37 (52.1 %)NS Encephalopathy ≥ grade II (n (%)) 37 (43.5 %)28 (39.4 %)NS SOFA score (n=95)7.7 (3.3)8.1 (2.8)NS Glasgow (n=140)13.05 (3.23)13.06 (3.61)NS Bilirubin (mg/dl)27.0 (12.3)26.8 (11.8)NS Albumin (g/L)28.1 (9.9)27.3 (6.3)NS Serum creatinine2.27 (2.07)2.50 (2.20)NS INR1.78 (0.33)1.74 (0.31)NS Hematocrit29.3 (6.0)28.4 (4.8)NS Leucocytes15.6 (11.0)16 (9.6)NS Platelet count120.3 (72.3)130.9 (75.2)NS MELD > 20 (n(%))59 (69.4 %)58 (81.7 %)P=0.078 Baseline characteristics (PP population)

41. % change p=0.02p=0.0001 Changes in baseline parameters: day 4 p=0.0001p=0.098p=0.009

42. Effects on renal function in patients with HRS (PP population) at day 4; n=72 16/34 47.1 % 10/38 26.3 % OR: 2.49; IC 95 %: 0.93-6.68; p=0.06

43. Effects on Hepatic Encephalopathy (PP population) at day 4; n=58 % decrease 15/24 62.5 % 13/34 38.2 % OR 2.69 IC 95 %: 0.91-7.90; p=0.07

44. SMT +MARSSMT ITT population Overall 28 days mortality: SMT: 39.3 % SMT + MARS: 41.4 % Log-rank test: P=0.79 PP population Overall 28 days mortality: SMT: 40 % SMT + MARS: 41.2 % Log-rank test: P=0.88 SMT +MARSSMT Effect of MARS on 28 days transplant-free survival ITT populationPP population

45. 28-days mortality according risk groups SubgroupSMT (%)MARS (%)P value HRS53.3 %54 %NS HE ≥ grade 2 at randomization 48.6 %50 %NS Progressive Hyperbilirubinemia 31.7 %39.7 %NS MELD>2047.5 %44.8 %NS SubgroupSMT (%)MARS (%)P value HRS53.2 %52.2 %NS HE ≥ grade 2 at randomization 48.7 %50 %NS Progressive Hyperbilirubinemia 30.6 %36.4 %NS MELD>2047.9 %41.4 %NS ITT population PP population

46. Variables influencing mortality VariableORP value Assigned therapy (MARS Vs. SMT) 0.87 (0.44-1.72)0.694 MELD score>202.52 (1.07-5.91)0.034 SBP at admission1.74 (0.63-4.80)0.289 VariableDeath n=63Alive n=93p Age (years)55.6 (10.8)47.6 (9.5)P<0.0001 SBP (n (%))10 (15.9 %)8 (8.6 %)P=0.1 HRS (n (%))44 (69.8 %)38 (40.9 %)P<0.001 HE greater than grade 2 (n (%))32 (50.8 %)33 (35.5 %)P=.057 Child-Pugh score11.4 (1.4)10.6 (1.4)P=0.001 MELD score28.3 (8.6)22.7 (8.8)P< 0.001 VariableReferenceOR IC 95 %P value HE greater than grade 2 (n (%)) Yes Vs No2.16 (1.01-4.58)P= 0,045 Increase in serum bilirubin at day 4 Per 10 % increase1,26 (1,08-1,47)P=0.003 MELD scorePer point increase1,08 (1,03-1,13)P< 0.001

47. Adverse events

48. SMTSMT+MARSp value Overall SAE63,8 %66,3 %NS SAE related death6,4 %12,6 %NS Infection11,7 %18,9 %NS Worsening of coagulation parameters0 %5.3 %0.06 Severe bleeding9,6 %17,9 %0.09 Worsening of liver failure20,2 %9,5 %0.04 Worsening of hemodynamics7,4 %3,2 %NS MOF13,8 %12,6 %NS Worsening of renal failure7,4 %8,4 %NS

49. Updated meta-analysis Meta-analysis of ELS systems in ACLF Stutchfield et al British Journal of Surgery 2011

50. Summary and Conclusions Liver support devices induce relevant changes in pathophysiological variables in patients with ACLF Liver support devices improve severe encephalopathy and renal function These beneficial effects are not translated to an improvement in short-term survival

51. The future Related to devices –Improvement of overall efficacy of ALS devices –Improvement of applicability –Potential contribution of Stem Cells technology –Use of new tissue matrix (scaffolds)

52. The future Related to devices –Improvement of overall efficacy of ALS devices –Improvement of applicability –Potential contribution of Stem Cells technology –Use of new tissue matrix (scaffolds) Improve therapeutic schedule –Mean time under therapy in MARS RELIEF trial 42 hours during the 21 days period of observation

53. The future Risk stratification: –CANONIC study Influence of number of organ-failures Influence of inflammatory activation Definition of new end-points –Bridging to liver transplantation?

54. Related to clinical end-points: Influence of Liver Transplantion Acute Liver Failure Candidates to liver transplantation Well defined diagnostic criteria Proven impact of LT on mortality Well defined criteria to list patients Well defined priority policies Non-Candidates to liver transplantation Survival increase Decrease on-list mortality Decrease complications (i.e renal failure, ICP control) Improvement of in-hospital outcomes Avoid unnecessary transplantation procedures?

55. Related to clinical end-points: Influence of Liver Transplantion Acute-on-chronic Potential candidates to liver transplantation No clearly defined diagnostic criteria No clear prognostic information Frequent comorbidities precluding LT Absence of well defined criteria to list patients Absence of well defined priority policies Non-Candidates to liver transplantation Survival increase Tailored therapy according risk stratification Bridge to transplantation