Predictive Criteria for the Outcome of Patients With Acute Liver Failure Treated With the Albumin Dialysis Molecular Adsorbent Recirculating System Gilnardo Novelli, 1 Massimo Rossi, 1 Giancarlo Ferretti, 2 Francesco Pugliese, 3 Franco Ruberto, 3 Quirino Lai, 1 Simone Novelli, 4 Vincenzo Piemonte, 5 Luca Turchetti, 5 Vincenzo Morabito, 1 Maria C Annesini, 5 and Pasquale B Berloco 1 1 “Paride Stefanini” Department of General Surgery and Organ Transplantation, and Departments of 2 Infectious and Tropical Diseases, 3 Anesthesiology, Critical Care Medicine and Pain Therapy, 4 Clinical Engineering, and 5 Chemical, Material and Environmental Engineering, La Sapienza University, Rome, Italy Abstract: The aim of this study was to evaluate the improvement of prognostic parameters after treatment with the molecular adsorbent recirculating system (MARS) in patients with fulminant hepatitis (FH). The parameters conducive to a positive prognosis include: Glasgow Coma Scale (GCS) score 11, intracranial pres- sure (ICP) <15 mm Hg or an improvement of the systolic peak flow of 25–32 cm/s via Doppler ultrasound in the middle cerebral artery, lactate level <3 mmol/L, tumor necrosis factor-a <20 pg/mL, interleukin (IL)-6 <30 pg/mL, and a change in hemodynamic instability from hyper- kinetic to normal kinetic conditions, and so define the timing (and indeed the necessity) of a liver transplant (LTx). From 1999 to 2008 we treated 45 patients with FH with MARS in the intensive care unit of our institution. We analyzed all the parameters that were statistically signifi- cant using univariate analysis and considered the patients to be candidates for inclusion in a multivariate logistic regression analysis. Thirty-six patients survived: 21 were bridged to liver transplant (the BLT group) and 15 contin- ued the extracorporeal method until native liver recovery (the NLR group) with a positive resolution of the clinical condition. Nine patients died before transplantation due to multi-organ failure.We stratified the entire population into three different groups according to six risk factors (the percentage reduction of lactate, IL-6 and ICP, systemic vas- cular resistance index values, GCS <9, and the number of MARS treatments): group A (0–2 risk factors), group B (3–4 risk factors), and group C (5–6 risk factors). Analyzing the prevalence of these parameters, we noted that group A perfectly corresponded to the NLR group, group B corre- sponded to the BLT group, and group C was composed of patients from the non-survival group; thus, we were able to select the patients who could undergo a LTx using the predictive criteria. For patients with an improvement of neurological status, cytokines, lactate, and hemodynamic parameters, LTx was no longer necessary and their treatment continued with MARS and standard medical therapy. Key Words: Acute liver failure, Artificial organ, Cytokine, Molecular adsorbent recirculating system, Pre- dictive criterion. Fulminant hepatic failure (FHF) is a devastating disease that, despite recent therapeutic advances, remains associated with significant morbidity and mortality (1). FHF results from the loss of hepatic metabolic and synthetic function, rapidly leading to encephalopathy and multiple organ dysfunction with mortality rates nearing 90% (2).The major problems in the management of FHF are the lack of criteria outcome predictors and an inexact definition of the role and the timing of liver transplantation (LTx). The King’s College Criteria (KCC) are probably the best validated tools currently available (3); however, the predictive value of KCC has been questioned in the USA (4) because the encephalopathy grade and etiology are the only predictors of outcome (5). Fur- thermore, KCC has not been sufficiently evaluated in Received June 2009; revised July 2009. Address correspondence and reprint requests to Dr Vincenzo Morabito, Dipartimento “Paride Stefanini”, Chirurgia Generale e Trapianti d’Organo, La Sapienza Università di Roma, Viale del Policlinico 155, I-00161 Roma, Italia. Email: vinmor11@libero.it Presented in part at the 10th International Symposium on Albumin Dialysis in Liver Disease held 12–14 September 2008 in Rostock, Germany. Therapeutic Apheresis and Dialysis 13(5):404–412 doi: 10.1111/j.1744-9987.2009.00759.x © 2009 The Authors Journal compilation © 2009 International Society for Apheresis 404