Extracorporeal Albumin Dialysis (OPAL) as Novel Therapeutic Bridging Option in Posthepatectomy Liver Failure

Posthepatectomy liver failure (PHLF) remains a major cause of mortality after liver resection, with limited therapeutic options. PHLF can be categorized into primary (small-for-size) and secondary forms, the latter resulting from complications such as sepsis or hemorrhage. Extracorporeal albumin dialysis (ECAD), including open albumin dialysis (OPAL), may support hepatic detoxification by removing albumin-bound toxins. While most studies focus on primary PHLF, data on secondary PHLF are scarce.

This retrospective cohort study includes all patients receiving OPAL after liver surgery until February 2026 at the Medical Center of the University of Freiburg, Germany. A detailed chart review was performed. The primary endpoint was bilirubin reduction per filter cycle. Survival and changes in laboratory parameters were analyzed as secondary endpoints.

Eighteen patients were included, predominantly with secondary PHLF (15/18, 83.3%). Sepsis was the leading cause of secondary liver failure (8/15, 53.3%), followed by hemorrhage (6/15, 40.0%). Median bilirubin reduction per filter cycle was 1.52 mg/dL (relative reduction 14.64%; p < 0.0001), with greater reductions at higher prefilter levels (p < 0.0001). Relative reductions were also observed in creatinine (16.84%) and urea (14.75%; both p < 0.0001). Platelet count and hemoglobin showed minor decreases, while MELD 3.0 scores improved modestly. Multiple consecutive filters did not increase overall bilirubin reduction. Thirty-day survival after surgery was 66.7% and 38.9% after OPAL initiation.

OPAL effectively reduces bilirubin levels and improves related parameters in PHLF. It may provide temporary detoxification support, particularly in secondary PHLF. Prospective studies are needed to assess its impact on patient survival.