Artificial Liver Support Systems in Acute Liver Failure and Acute-on-Chronic Liver Failure: Systematic Review and...

Area of Science:

• Hepatology
• Critical Care Medicine
• Biomedical Engineering

Background:

• Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are life-threatening conditions requiring advanced therapeutic interventions.
• Extracorporeal liver support systems, including nonbiological (NBAL) or biological artificial liver support systems (BAL) and whole-organ extracorporeal liver perfusion (W-ECLP), aim to support liver function during critical illness.

Purpose of the Study:

• To systematically review the safety and efficacy of NBAL/BAL and W-ECLP systems in adult patients with ALF and ACLF.
• To evaluate the impact of these systems on survival, adverse events, transplantation rates, and hepatic encephalopathy.

Main Methods:

• Systematic review of randomized controlled trials (RCTs) for NBAL/BAL systems (2000-2023) and observational studies for W-ECLP (1990-2023).
• Data extraction included study characteristics, patient demographics, interventions, and outcomes.
• Meta-analysis was performed for mortality and serious adverse events (SAEs) for NBAL/BAL systems.

Main Results:

• NBAL/BAL systems did not show a statistically significant association with reduced 28-30 day mortality (RR, 0.85; p=0.169) or SAEs (RR, 1.15; p=0.059) compared to standard medical treatment.
• Subgroup analysis suggested a potential mortality benefit for NBAL/BAL in ALF patients (RR, 0.67; p=0.069).
• W-ECLP systems, in a small cohort (12 patients), successfully bridged over half of severe patients to transplantation with survival and no porcine retrovirus transmission.

Conclusions:

• Current evidence does not demonstrate significant pooled effects of NBAL/BAL devices on mortality or SAEs in ALF/ACLF patients.
• The findings highlight the need for further research, including larger RCTs and optimized protocols, for extracorporeal liver support systems.
• Improvements in patient selection, perfusion durability, and treatment strategies are crucial for advancing these technologies.