Advances in extracorporeal liver support for acute and acute-on-chronic liver failure

Liver failure, either acute (ALF) or acute-on-chronic (ACLF), is characterized by hepatocellular dysfunction, systemic inflammation, and multiorgan failure, leading to high mortality without liver transplantation (LT). However, LT is limited by organ shortages and medical contraindications, necessitating alternative therapeutic strategies. Biological liver support systems, incorporate functional hepatocytes to partially restore hepatic metabolic functions, though clinical trials have not demonstrated a survival benefit. Artificial systems, such as albumin dialysis (MARS, Prometheus), facilitate toxin removal, though evidence remains limited. Continuous renal replacement therapy, while not specific for liver failure, is essential in patients with severe hyperammonemia or acute kidney injury, aiding in ammonia clearance and fluid balance control. Plasma exchange (PE) has promising detoxification and immunomodulatory effects, improving survival in ALF. In ACLF, PE may reduce systemic inflammation, though evidence remains limited. Further studies are needed to optimize ECLS therapies, refine patient selection, and establish their role in ALF and ACLF management.