[Extracorporeal therapies in hepatic diseases]

Acute and acute-on-chronic liver failure have different underlying causes and are associated with hepatic or extrahepatic organ failure. Depending on etiology, up to 20% of critically ill patients suffer from hepatic dysfunction, which contributes to increased morbidity and mortality. A variety of extracorporeal procedures including renal replacement therapies, artificial and bioartificial liver support, and plasma exchange are used in the management of patients with liver diseases. Several randomized controlled studies of artificial liver support and plasma exchange proved the safety of these procedures and demonstrated improvement of hepatic encephalopathy and hemodynamics. A survival benefit could be observed in some of the randomized, controlled trials. In contrast, renal replacement therapy in critically ill patients with liver diseases has been assessed in retrospective case series and was associated with high mortality rates in liver cirrhosis. In summary, extracorporeal therapies are a cornerstone of therapeutic options in critically ill patients with hepatic failure. In addition to the comparison of different procedures, future studies should assess the timing of initiation as well as duration, and identify criteria of therapeutic futility of extracorporeal therapies in this population.