A systematic review on extracorporeal liver support for liver failure

AbstractPaediatric acute liver failure (PALF) is a rare but devastating condition with high mortality. An exaggerated inflammatory response is now recognised as pivotal in the pathogenesis and prognosis of ALF, with cytokine spill from the liver to systemic circulation implicated in development of multi-organ failure associated with ALF. With advances in medical management, especially critical care, there is an increasing trend towards spontaneous liver regeneration, averting the need for emergency liver transplantation or providing stability to the patient awaiting a graft. Hence, research is ongoing for therapies, including extracorporeal liver support devices, that can bridge patients to transplant or spontaneous liver recovery. Considering the immune-related pathogenesis and inflammatory phenotype of ALF, plasma exchange serves as an ideal liver assist device as it performs both the excretory and synthetic functions of the liver and, in addition, works as an immunomodulatory therapy by suppressing the early innate immune response in ALF. After a recent randomised controlled trial in adults demonstrated a beneficial effect of high-volume plasma exchange on clinical outcomes, this therapy was incorporated in European Association for the Study of Liver (EASL) recommendations for managing adult patients with ALF, but no guidelines exist for PALF. In this review, we discuss rationale, timing, practicalities, and existing evidence regarding the use of plasma exchange as an immunomodulatory treatment in PALF. We discuss controversies in delivery of this therapy as an extracorporeal device, and practicalities of use of plasma exchange as a ‘hybrid’ therapy alongside other extracorporeal liver assist devices, before finally reviewing outstanding research questions for the future.

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The Fire from Within: Multiorgan Failure with Bimodal Rhabdomyolysis from Exertional Heat Stroke

Case Reports in Hepatology ◽

10.1155/2020/1305730 ◽

2020 ◽

Vol 2020 ◽

pp. 1-7 ◽

Cited By ~ 2

Author(s):

Onion Gerald V. Ubaldo ◽

Khia Quiwa ◽

Rohana Elise Rollan ◽

Edhel Tripon ◽

Elizabeth Sebastian

Keyword(s):

Liver Transplantation ◽

Liver Failure ◽

Liver Transplant ◽

Core Body Temperature ◽

Multiorgan Failure ◽

Heat Stroke ◽

Exertional Heat Stroke ◽

Liver Support ◽

Central Nervous System Dysfunction ◽

Extracorporeal Liver Support

Heat stroke (HS) is a condition characterized by a rise in core body temperature and central nervous system dysfunction. It is divided into two types: classical and exertional. Exertional heat stroke (EHS) is accompanied by organ failure. Liver injury, presenting only with a rise in liver enzymes, is common but in rare conditions, acute liver failure (ALF) may ensue, leading to a potentially lethal condition. Most cases of EHS-induced ALF are managed conservatively. However, liver transplantation is considered for cases refractory to supportive treatment. Identifying patients eligible for liver transplantation in the context of an EHS-induced ALF becomes a medical dilemma since the conventional prognostic criterion may be difficult to apply, and there is paucity of literature about these specific sets of individuals. Recently, extracorporeal liver support has been gaining popularity for patients with liver failure as a bridge to liver transplant. In this case report, we present a young Filipino athlete with symptoms and clinical course consistent with EHS that developed multiorgan failure, initially considered a candidate for liver transplant and total plasma exchange, but clinically improved with supportive management alone. This patient was also found to have bimodal rhabdomyolysis during the course of his hospital stay as manifested by the bimodal rise in his creatine kinase enzymes.

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Single-Pass Albumin Dialysis in the Treatment of Children with Liver Failure

Blood Purification ◽

10.1159/000502938 ◽

2019 ◽

Vol 49 (1-2) ◽

pp. 55-62

Author(s):

Johannes Holle ◽

Alexander Gratopp ◽

Sophie Balmer ◽

Verena Varnholt ◽

Stephan Henning ◽

...

Keyword(s):

Liver Failure ◽

Pediatric Patients ◽

Serum Levels ◽

Albumin Dialysis ◽

Liver Support ◽

Single Pass ◽

Medical Chart Review ◽

Extracorporeal Liver Support ◽

Life Threatening ◽

Catecholamine Therapy

Background and Aims: Acute and acute on chronic liver failure are life-threatening conditions, and bridging to transplantation is complicated by a paucity of suitable organs for children. While different modalities of extracorporeal liver support exist, their use in children is complicated by a large extracorporeal volume, and data on their use in children is limited. The aim of this analysis was to investigate the efficacy and safety of single-pass albumin dialysis (SPAD) in children with liver failure. Methods: Retrospective medical chart review of pediatric patients with liver failure treated with SPAD. The decrease in hepatic encephalopathy (HE) and the serum levels of bilirubin and ammonia were measured to determine efficacy. Adverse events were documented to assess safety. Results: Nineteen pediatric patients with a median age of 25.5 months and a median body weight of 11.9 kg were treated with SPAD between January 2011 and March 2018. Total bilirubin (p < 0.001) and ammonia (p = 0.02) significantly decreased after treatment with SPAD. As clinical outcome parameter, HE significantly improved (p = 0.001). Twelve patients were bridged successfully to liver transplantation. In all patients, 71 SPAD sessions were run. Clotting in the dialysis circuit was observed in 49% of all sessions. Heparin and citrate were used for anticoagulation and were significantly superior to dialysis without any anticoagulation (p= 0.03). Transfusion of packed blood cells (57%) and catecholamine therapy (49%) were frequently necessary. Conclusions: Treatment with SPAD was effective in detoxification, as measured by significant improvement of HE and clearance from surrogate laboratory parameters.

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