Molecular Adsorbent Recirculating System Treatment for Acute Hepatic Failure in Patients With Hepatitis B Undergoing Chemotherapy for Non-Hodgkin’s Lymphoma G. Novelli, M. Rossi, G. Ferretti, F. Nudo, A. Bussotti, G. Mennini, L. Novelli, S. Ferretti, F. Antonellis, S. Martelli, and P.B. Berloco ABSTRACT Hepatitis B virus (HBV) is a serious cause of morbidity and mortality in hepatitis B surface (HBsAg) antigen–positive patients treated with chemotherapy. Because the hepatitis is related to HBV virological reactivation, application of effective antiviral therapy, such as Lamivudine, has been attempted. Despite the use of these antiviral agents at the time of clinical hepatitis, some HBsAg-positive patients still develop hepatic failure and die. We used the Molecular Adsorbent Recirculating System (MARS) (MARS Monitor; Teraklin AG, Rostock, Germany) to treat 5 HBsAg-positive lymphoma patients with acute hepatic failure due to chemotherapy despite lamivudine treatment. Before and after each treatment we monitored the parameters of neurological status (EEG, cerebral CT and Glasgow coma score), hemodynamic parameters, acid-base equilibrium and blood gases as well as hepatic and renal function. The inclusion criteria were these of the King’s College Hospital. Statistical analysis by Student t method showed significant results (P  .01). Three of 5 patients are alive without signs of reactivation of viral or hematological diseases at 1 year follow-up. The 2 patients died because MARS treatment was started too late, with Glascow coma score grade IV, hemodynamic instability, and mechanical ventilator assistance. Despite the limited number of cases, we believe that MARS can be applied to patients with a high tolerance and yield good results, but the treatment has to start at the first signs of hepatic failure. T HE ASSOCIATION of hepatitis viruses with non- Hodgkin’s lymphomas (NHL) is not rare. Reactiva- tion of hepatitis B virus (HBV) infection is associated with increased serum HBV DNA and alanine aminotransferase (ALT) levels. The risk of HBV reactivation is particularly high in areas endemic for chronic hepatitis B, namely, where the Hepatitis B surface antigen (HBsAg) carrier rate in the general population ranges from 10% to 20%. In patients with NHL, the risk of reactivation has been esti- mated from several previous reports to range from 20% to 50% of HBV carriers undergoing cancer chemotherapy. In most cases, flares of hepatitis are asymptomatic, with mild and transient elevation of ALT levels, but some patients have more severe flares with jaundice and even hepatic decompensation and death. 1 The mechanism of hepatitic injury in patients undergoing HBV reactivation either dur- ing or following chemotherapy remains unknown. For patients experiencing hepatic dysfunction during adminis- tration of chemotherapy, the mechanism is presumed to be suppression of immune function leading to enhanced HBV replication, resulting in increased hepatocyte injury. In contrast, hepatic dysfunction has also occured below with- drawal of cytotoxic or immunosuppressive therapy; the mechanism of this type of hepatic injury has been postu- lated to be restoration of immune function associated with rapid immune-mediated destruction of hepatocytes in- fected with HBV. 2 Glucocorticoids have been implicated to promote HBV From the Dip. Malattie Infettive (G.F., S.F.), Centro Trapianti di Organ, (G.N., M.R., F.N., A.B., G.M., L.N., S.F., F.A., S.M., P.B.B.), and Terapia Intensiva Post-trapianto, Azienda Policlinico Umberto I, Università degli Studi “La Sapienza” Roma, Rome, Italy. Address reprint requests to G. Novelli, Centro Trapianti di Organo Policlinico Umberto I, Viale del Policlinico 155, 00100 Roma, Italy. 0041-1345/05/$–see front matter © 2005 by Elsevier Inc. All rights reserved. doi:10.1016/j.transproceed.2005.06.051 360 Park Avenue South, New York, NY 10010-1710 2560 Transplantation Proceedings, 37, 2560 –2562 (2005)