Use of extra-corporeal liver support therapies in acute and acute on chronic liver failure

Abstract

Artificial (non-biological) extracorporeal liver support (ECLS) devices aim to remove albumin-bound and water soluble toxins in order to restore and preserve hepatic function and mitigate or limit the progression of multiorgan failure while either hepatic recovery or liver transplant occurs. Current artificial ECLS devices differ primarily in selectivity of the membrane utilized; dialysis based techniques such as the molecular adsorbent recirculating system (MARS®) combine renal replacement therapy with albumin dialysis and a highly selective (<50 kDa) filter in contrast to plasmapheresis (HVP)/plasma separation and filtration (Prometheus) techniques which are less selective (~250 kDa). Artificial ECLS devices have been used to support patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). These devices have been shown to be safe. The following beneficial effects have been documented: improvement of jaundice, amelioration of haemodynamic instability, reduction of portal hypertension, and improvement of hepatic encephalopathy. However, the only randomized prospective multicenter controlled trial to show an improvement in transplant-free survival was for HVP. Biological (cell based) extracorporeal liver support systems (B-ECLS) aim to support the failing liver both through detoxification and synthetic function and warrant further study for safety and benefit.