Krisper Peter, Stauber Rudolf E
Universitaetsklinik für Innere Medizin, Abteilung für Nephrologie und Hämodialyse, Graz, Austria.
Nat Clin Pract Nephrol. 2007 May;3(5):267-76. doi: 10.1038/ncpneph0466.
Artificial extracorporeal liver support or 'liver dialysis' has been used in patients with severe liver failure with increasing frequency since the Molecular Adsorbents Recirculating System (MARS), a variant of albumin dialysis, was introduced in 1999. Nevertheless, liver dialysis must still be thought of as experimental because its contribution to improved patient survival has not been proven in large randomized trials. Prometheus is a novel device for fractionated plasma separation via an albumin-permeable filter that was developed to improve removal of albumin-bound toxins. Initial studies have proven clinical use of Prometheus to be feasible and safe. Head-to-head comparisons of Prometheus and MARS have shown treatment with the former to be more efficient with respect to removal of most albumin-bound and water-solved markers. As controlled studies with clinical end points are lacking, it is not known whether the observed greater detoxification capacity of Prometheus will translate into clinical benefit; two small studies indicate that there might be a beneficial effect in hepatic encephalopathy and pruritus. In a recent randomized comparison of MARS and Prometheus, however, hemodynamic improvement was observed in response to MARS, but not Prometheus, treatment. A large randomized controlled trial investigating the effect of Prometheus on survival--the HELIOS study--has been initiated. First results are expected in 2008 and will be crucial to establishing a role for Prometheus in the field of extracorporeal liver support.
自1999年引入分子吸附循环系统（MARS）（一种白蛋白透析的变体）以来，人工体外肝支持或“肝透析”在重症肝衰竭患者中的应用频率越来越高。然而，肝透析仍应被视为实验性的，因为其对提高患者生存率的贡献尚未在大型随机试验中得到证实。Prometheus是一种通过白蛋白可渗透滤器进行分级血浆分离的新型装置，其开发目的是改善对白蛋白结合毒素的清除。初步研究已证明Prometheus的临床应用是可行且安全的。Prometheus与MARS的直接比较表明，在清除大多数白蛋白结合和水溶性标志物方面，前者的治疗效率更高。由于缺乏具有临床终点的对照研究，尚不清楚Prometheus观察到的更大解毒能力是否会转化为临床益处；两项小型研究表明，在肝性脑病和瘙痒方面可能存在有益效果。然而，在最近一项MARS与Prometheus的随机比较中，观察到MARS治疗可改善血流动力学，但Prometheus治疗则不然。一项调查Prometheus对生存率影响的大型随机对照试验——HELIOS研究——已经启动。预计2008年将得出初步结果，这对于确定Prometheus在体外肝支持领域的作用至关重要。
