Sandbox:Dildar

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [2]

Overview

MARS
SPAD
CVVHDF

Comparison between MARS, SPAD and CVVHDF
Device	Detoxification capacity				Cost effectivenss
	Ammonia	Bilirubin	Bile acids	Water soluble substances
MARS	Significantly lower reduction	Significantly lower reduction	No significant differences	No significant differences	More Expensive,approximately € 2165
SPAD	Significantly greater reduction	Significantly greater reduction	No significant differences	No significant differences	Less Expansive,approximately € 656 - 30%
CVVHDF	Significantly greater reduction	Significantly lower reduction	No significant differences	No significant differences	Cheap

Comparing SPAD, MARS and CVVHDF[edit | edit source] SPAD, MARS and continuous veno-venous haemodiafiltration (CVVHDF) were compared in vitro with regard to detoxification capacity.[21] SPAD and CVVHDF showed a significantly greater reduction of ammonia compared with MARS. No significant differences could be observed between SPAD, MARS and CVVHDF concerning other water-soluble substances. However, SPAD enabled a significantly greater bilirubin reduction than MARS. Bilirubin serves as an important marker substance for albumin-bound (non water-soluble) substances. Concerning the reduction of bile acids no significant differences between SPAD and MARS were seen. It was concluded that the detoxification capacity of SPAD is similar or even higher when compared with the more sophisticated, more complex and hence more expensive MARS.

As albumin dialysis is a costly procedure, financial aspects are important: For a seven-hour treatment with MARS, approximately € 300 for 600 ml human serum albumin solution (20%), € 1740 for a MARS treatment kit and € 125 for disposables used by the dialysis machine have to be spent. The cost of this therapy adds up to approximately € 2165. Performing SPAD according to the protocol by Sauer et al., however, requires 1000 ml of human albumin solution (20%) at a cost of € 500. A high-flux dialyzer costing approximately € 40 and the tubings (€ 125) must also be purchased. The overall costs of a SPAD treatment is approximately € 656 - 30% of the costs of an equally efficient MARS therapy session. The expenditure for the MARS monitor necessary to operate the MARS disposables is not included in this calculation

Circuit	Components	Function
Circuit 1	Human serum albumin	Circuit one is connected to the patient's blood through a semipermeable membrane which contains two special filters to cleanse the albumin after it absorbs toxins from the patient's blood such as ammonia, aromatic amino acids, merceptans, bilirubin, bile acids, cytokines and nitric oxide.
Circuit 2	Hemodialysis machine	Circuit two cleanses the albumin from the first circuit before its re-circulation though the semipermeable membrane before it comes in contact with the patient's blood.

Extracorporeal liver support has been a much studied topic throughout the last 50 years. Albumin dialysis as a therapeutic option for patients with acute liver failure or acute decompensation of chronic liver disease was introduced in the mid-nineties. The Molecular Adsorbent Recirculating System (MARS) is based on the concept of albumin dialysis and allows for the removal of protein-bound as well as water-soluble toxins. Besides its role as a sufficient volume expander human serum albumin is an important scavenger for molecules with pathophysiological relevance in liver failure. Albumin dialysis enables the selective regeneration of patient's albumin resulting in an increase of albumin binding capacity. Clinically, an improvement of central and local hemodynamics as well as liver-, brain-, and kidney-functions were observed. Thus, the treatment can contribute to liver regeneration and stabilization of vital organ functions and thus help to bridge patients to liver transplantation or to recovery of native liver function. Proper patient selection is critical for clinical success. Aggressive treatment of infections and sepsis seems to be a decisive pre-requisite for its safe and efficient use. Cautious anticoagulation with heparin is the common standard. Citrate use is recommended for patients prone to bleeding. Today, albumin dialysis MARS is among the best studied liver support methods. It appears as a valuable therapeutic tool for the treatment of various complications of of liver failure, especially hemodynamic instability and hepatic encephalopathy. Further studies will need to help defining the optimal patient selection and technical process parameters such as session length and frequency of treatment. he aim of extracorporeal albumin dialysis (ECAD) is to reduce endogenous toxins accumulating in liver failure. To date, ECAD is conducted mainly with the Molecular Adsorbents Recirculating System (MARS). However, single-pass albumin dialysis (SPAD) has been proposed as an alternative. http://www.webaisf.org/media/12203/09_angeli.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4699252/ survival 28 days

Indication acute liver ailure acute on chronic liver ailure fulminant hepatic failure sub fulminant hepatic failure hepatic encaphalopathy gade 2 or above acutely decmpensated liver cirrhosis hyperbilirubinemia >5 hrs progssive hperbilrubinemia contraindications platelets count<50,000 DIC INR.2.3 uncontrolled infection https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4128463/

• The second circuit consists of a hemodialysis machine and is used to clean the albumin in the first circuit, before it is recirculated to the semipermeable membrane in contact with the patient's blood.

The MARS system can remove a number of toxins, including ammonia, bile acids, bilirubin, copper, iron and phenols.

MARS development started at the University of Rostock in Germany. It has 510 (k) approval from the Food and Drug Administration (FDA) for drug overdoses and poisoning as of June 2005 and is available in the USA since the end of 2005.[3] Canada's first MARS unit arrived at the Toronto General Hospital in 2005.

The Molecular Adsorbents Recirculation System (MARS), is the best known extracorporal liver dialysis system and has existed for approximately ten years. It consists of two separate dialysis circuits. The first circuit consists of human serum albumin, is in contact with the patient's blood through a semipermeable membrane and has two filters to clean the albumin after it has absorbed toxins from the patient's blood. The second circuit consists of a hemodialysis machine and is used to clean the albumin in the first circuit, before it is recirculated to the semipermeable membrane in contact with the patient's blood.

Causes

Common casuses

The most common Cause of the splenic rupture remains blunt trauma to the abdomen.The other common causes of splenic rupture includes.

• Neoplasms
• Infections
• Non Infectious
• Therapy related
• Mechanical Causes

Less common causes

The less common causes of splenic rupture are difficult to diagnose and can be threatening. Some less common causes of splenic rupture are as follows:

• Autologus stem cell transplantation in AL Amyloidosis patients

Algorithms

Major molecular events in the pathogenesis of HCC

Genomic alterations

Epigenetic modifications

Growthfactor pathway alterations

Gene Mutations

Gene Amplification

DNA methylation micro RNA

Micro RNA

LNC RNA

Major Signaling pathways

•TERT promoter •TP53 •CTNNB1 •AXIN1 •AXIN2 •ATM •RPS6KA3 •JAK1 •IL6R •IL6ST •ARID1 •ARID2

•CCND1 •FGF19 •CDKNA2A •CDKNA2B •AXIN1 •IRF2 •MET

GSTP1 •E-Cadherin •CDKNA2 •RASSF1A •SOCS-3 •MIGMT

•MiR-155 •Mir-122 •Mir-224 •Mir-21

•HULC •HEIH •Dreh •MVIH •HOTAIR •MDIG •LINE1

•Wnt/β –catenin •Tyrosine kinase pathways EGF HGF/c-MET FGF VEGF •IGF •HIF •TGF β •Hedgehog

Elderly Male with jaundice from pancreatic cancer, By James Heilman, MD (Own work) [CC BY 3.0 (http://creativecommons.org/licenses/by/3.0)], via Wikimedia Commons

The incidence of HCC has almost tripled since the early 1980s in the United States where it is the fastest rising cause of cancer-related deaths1. According to population based Surveillance Epidemiology and End Results registry data, the overall HCC age adjusted incidence rates for liver and intrahepatic ducts cancer is as high as 8 per 100,000 underling population in 2010 (Fig. 1) of which at least 6 per 100,000 related to HCC. Men are at approximately three times higher risk than women. Asian men (i.e., Chinese, Korean, Filipino, and Japanese) have the highest age-adjusted incidence rates. However, the largest proportional increases have occurred among Hispanics followed by blacks and non-Hispanic whites, whereas the lowest proportional increases have occurred among Asians. In contrast to Asians/Pacific Islanders, HCC incidence rates are reported to be higher among Hispanics born in the United States than among foreign-born Hispanics2. HCC incidence rates have increased in each successive birth cohort born between 1900 and 19593 (Fig. 2). In addition, the age distribution of HCC patients has shifted to younger ages, with the greatest proportional increases among individuals 45–60 years old (Fig. 2). There is a south to north gradient in the incidence and mortality of HCC; Southern states including Texas, Louisiana, and Mississippi have some of the highest HCC incidence rates in the nation (Fig. 3). In one study, Texas Latino and especially South Texas Latinos had the highest age-adjusted HCC incidence rates (as high as 10.6/100,000)4.