Cost-utility of molecular adsorbent recirculating system treatment in acute liver failure

Table 1 MARS treatment protocols for acute liver failure in Finland

Etiology	MARS treatment initiation criteria	Treatment protocol
Acute liver failure	Rapid deterioration of hepatic synthetic function and clinical condition despite conservative standard medical therapy	22-h sessions daily until:
	And one of the following criteria:	(1) Native liver recovers
	(1) Ingestion of a lethal dose of a known hepatotoxin (e.g. Amanita, paracetamol)	(2) Suitable transplant organ is found
	(2) The patient fulfills the criteria for highly urgent liver transplantation	(3) Irreversible multi-organ damage occurs

MARS: Molecular adsorbent recirculating system.

Table 2 Mean pre-treatment 15D scores in different encephalopathy grade groups (mean ± SD)

Pre-treatment encephalopathy grade	15D score
0	0.532 ± 0.151
1	0.461 ± 0.188
2	0.403 ± 0.177
3	0.079 ± 0.077
4	0.016

The average age-matched 15D score of the Finnish population is 0.92, and the standardized 15D score for unconscious/intubated patients is 0.016[22].

Table 3 Baseline data for the MARS and control groups

	MARS group	Historical control group	P value
Pre-treatment demographic & clinical data
Number of patients	90	17
Age (yr)	45 (14-81)	42 (21-72)	0.714
Sex (male)	37 (41%)	7 (41%)	0.996
Body mass index (kg/m2)	26 (17-40)	26 (21-37)	0.372
MARS sessions/patient	2 (1-9)	0
Mechanically ventilated	30 (33%)	6 (35%)	0.875
Vasoactive infusion used	27 (30%)	9 (56%)	0.041
Renal insufficiency	29 (32%)	7 (41%)	0.474
MELD-score	31 (5-50)	30 (19-51)	0.225
Mean encephalopathy grade	1.7 ± 1.6	2.1 ± 1.7	0.335
Contra-indication to Ltx prior to treatment	11 (12%)	4 (24%)	0.253
Became untransplantable during treatment	7 (8%)	3 (18%)	0.195
Number of transplanted patients	26 (29%)	8 (47%)	0.162
Pre-treatment key laboratory values
Platelets (× 109/L)	138 (11-410)	142 (51-448)	0.919
NH4 ion (μmol/L)	68 (8-512)	90 (14-241)	0.559
Bilirubin (μmol/L)	215 (4-761)	381 (38-880)	0.057
Creatinine (μmol/L)	75 (35-1318)	78 (38-275)	0.946
FV (%)	32 (5-142)	38 (7-71)	0.865

All values are expressed as median (range) or as number of patients (%). Hepatic encephalopathy grade is presented as mean ± SD. MELD score: Mean end-stage liver disease score; Ltx: Liver transplantation; FV: Coagulation factor V.

Table 4 The survival, cost, and HRQoL data of MARS-treated and control patients

	Subgroups according to outcome	3-yr survival			Cost (€)				HRQoL
		n	%	Mean (d)	n	Mean	Min	Max	n	Pre-treatment mean	Post-treatment mean
MARS group	All ALF patients	90	78		31	79 745	11 961	370 573	90	0.30	0.70
	Alive at 3 yr	70			24	78 724	11 961	370 573	70	0.34	0.89
	Dead	20		63	7	83 243	32 496	171 157	20	0.15	0.00
	Contraindication to Ltx	18	39
	Alive at 3 yr	7			4	52 492	30 325	112 585	7	0.38	0.85
	Dead	11		14	5	64 414	32 496	95 666	11	0.13	0.00
	No contraindication - no Ltx	46	85
	Alive at 3 yr	39			15	41 957	11 961	137 235	39	0.40	0.93
	Dead	7		110	1	89 471			7	0.09	0.00
	Transplanted	26	92
	Alive at 3 yr	24			5	210 012	96 984	370 573	24	0.22	0.84
	Dead	2		169	1	171 157			2	0.47	0.00
Control group	All ALF patients	17	41		16	105 820	16 862	262 481	17	0.27	0.36
	Contraindication to Ltx		0
	Dead	7		9	7	45 089	17 591	105 917	7	0.27	0.00
	No contraindication - no Ltx		100
	Alive at 3 yr	2			2	77 162	16 862	137 462	2	0.27	0.85
	Transplanted		63
	Alive at 3 yr	5			4	170 578	117 444	262 481	5	0.32	0.87
	Dead	3		28	3	180 285	129 120	250 772	3	0.19	0.00

HRQoL: Health-related quality of life; ALF: Acute liver failure.

Table 5 Base case results for MARS

	Cost (€)	Incremental cost (€)	QALYs	Incremental QALYs	Cost per QALY (€)	Incremental cost per QALY
MARS	93 214		1.44	0.66	64 732	MARS dominates SMT
Control group (SMT only)	104 142	10 928	0.78		133 858

SMT: Standard medical therapy; QALY: Quality-adjusted life year.