Reversal of Cerebral Edema in Acute Liver Failure after MARS Therapy

Introduction: Acute liver failure (ALF) is characterized by the presence of impaired synthetic function and encephalopathy in the setting of an acute liver injury. Cerebral edema is a potentially fatal complication of ALF and can lead to marked neurologic compromise secondary to brainstem herniation. The molecular adsorbent recirculating system (MARS) has historically been used to remove albumin-bound toxins from the body while patients await definitive liver transplant. Here we present a case of acute liver failure complicated by cerebral edema that was resolved using MARS. Case Description/Methods: A 42-year-old woman with no past medical history presented to an emergency department with complaint of nausea and vomiting. She was found to have markedly elevated liver function tests in the thousands. Her total bilirubin was 1.5 mg/dl, INR was 3.8, and platelet count was 74,000. Her hospital course was complicated by new-onset hepatic encephalopathy (HE) and shock. Initial computed tomography (CT) of the head revealed no acute intracranial abnormalities. She was subsequently transferred to an acute liver transplant center in fulminant hepatic failure. A repeat CT head was obtained that revealed new cerebral edema and effacement of the cerebral sulci; the patient was started on hypertonic saline and mannitol. The patient was placed on MARS therapy for three cycles. Mannitol was held for serum hyperosmolarity, and another head CT performed on hospital day 5 revealed persistent cerebral edema. A brain MRI was performed on hospital day 11 to evaluate for potential encephalitis. MRI revealed a complete resolution of cerebral edema and normal appearing cerebral sulci. Her mental status gradually began to improve during her stay. She was downgraded from the intensive care unit on hospital day 20 and discharged to a long-term acute care facility in stable condition. Discussion: Studies exploring the use of MARS in ALF are scarce and have provided mixed results. A multi-center, non-blinded, randomized controlled trial by Saliba et al failed to demonstrate a mortality benefit or improvement in HE using MARS in patients with ALF. There have been scattered uncontrolled studies using MARS in ALF that demonstrated improvement in HE and intracranial pressure. While our patient demonstrated resolution of cerebral edema following 3 cycles of MARS, further large-scale clinical trials are required before MARS can be recommended as a consensus treatment modality for patients with cerebral edema secondary to ALF (see Figure 1).Figure 1.: A: Initial non-contrast CT scan of the head that revealed new onset cerebral edema. B: Repeat non-contrast CT scan of the head obtained on hospital day 5 that demonstrated persistent cerebral edema C: MRI of the brain with contrast obtained on hospital day 11 that revealed resolution of cerebral edema.