MARS vs DPMAS Cartridge: Key Differences
The evidence provided does not contain any information about DPMAS (Direct Plasma Membrane Absorption System) cartridge, making a direct comparison impossible. The available guidelines and research discuss only MARS (Molecular Adsorbent Recirculating System) and Prometheus® as artificial liver support systems, with no mention of DPMAS technology 1.
What We Know About MARS
Mechanism of Action
- MARS uses albumin dialysis where patient blood is dialyzed across an albumin-impregnated membrane against a recirculated albumin-containing dialysate that is continuously regenerated through charcoal and anion-exchanger columns 2, 3, 4.
- This system selectively removes albumin-bound toxins including bilirubin, bile acids, and fatty acids 2, 4.
Clinical Evidence for MARS
- EASL guidelines (2018) state that MARS showed "promising beneficial effects" in type 1 HRS patients in two controlled studies, but requires further investigation 1.
- A prospective randomized controlled trial demonstrated that MARS treatment significantly prolonged 30-day survival in patients with type I HRS and high bilirubin (≥15 mg/dL): mortality was 62.5% at day 7 and 75% at day 30 in the MARS group versus 100% at day 7 in controls (P <0.01) 3.
- MARS treatment improved hepatic encephalopathy, hemodynamic stability, hepatic and kidney function, and pruritus in multiple center reports 2.
Current Guideline Recommendations
- Neither MARS nor any artificial liver support system is included in the standard treatment algorithm for HRS-AKI in the most recent 2024 AASLD guidance 1.
- The 2020 French guidelines suggest artificial liver support systems may provide a "bridge to transplant" in ACLF patients with multiple organ failure, but emphasize that indications need further exploration and patients should be referred to expert centers early 1.
- Two large European multicenter randomized trials (MARS and Prometheus) in patients with acute decompensation did NOT demonstrate survival benefit at 28 or 90 days compared to standard medical therapy 1.
Clinical Context and Limitations
- The negative multicenter trials included heterogeneous populations (ACLF grade 0 to grade 3) with vastly different mortality rates (4% to 80%), which may have obscured benefits in specific subgroups 1.
- Post-hoc analysis showed significant improvement in hepatic encephalopathy and hepatorenal syndrome with albumin dialysis using MARS 1.
- An observational study and meta-analysis suggested improved short-term survival (14-day and 28-day) in ACLF patients with multiple organ failure, potentially allowing bridge to transplantation 1.
Critical Clinical Guidance
Since DPMAS is not mentioned in any available evidence, no recommendation can be made regarding its use. For patients with cirrhosis and HRS-AKI:
First-Line Treatment (Not Artificial Liver Support)
- Withdraw diuretics, beta-blockers, and nephrotoxic drugs immediately 1.
- Administer albumin 1 g/kg (maximum 100 g) on day 1, followed by 20-40 g daily 1.
- Initiate vasoconstrictors (terlipressin preferred, or norepinephrine) for Stage 2 or greater HRS-AKI 1.
- Treat any precipitating infections with appropriate antibiotics 1.
Role of Artificial Liver Support
- MARS should only be considered in specialized centers as a potential bridge to liver transplantation in highly selected ACLF patients with multiple organ failure 1.
- MARS is NOT part of standard HRS-AKI management and should not delay definitive therapy 1.
- Liver transplantation remains the definitive treatment for HRS-AKI 1.
Common Pitfall
Do not pursue artificial liver support systems like MARS as primary therapy for HRS-AKI when standard pharmacological treatment (vasoconstrictors plus albumin) has proven mortality benefit and should be initiated immediately 1, 3.