From the Guidelines
There is no liver dialysis equivalent to kidney dialysis because the liver performs numerous complex functions that cannot be easily replicated by an external machine. The liver has over 500 different functions, including protein synthesis, detoxification, bile production, metabolism of carbohydrates, fats, and proteins, and storage of vitamins and minerals [ 1 ]. These diverse biochemical processes involve intricate cellular mechanisms that current technology cannot fully replicate outside the body.
Current Management of Liver Failure
Instead of dialysis, liver failure is managed through supportive care to maintain function until the liver regenerates (in acute failure) or through liver transplantation for end-stage disease [ 1 ]. Some temporary liver support systems like MARS (Molecular Adsorbent Recirculating System) and Prometheus can provide limited detoxification but cannot replace the liver's synthetic and metabolic functions [ 1 ]. These devices serve as bridges to transplantation or recovery rather than true replacements for liver function.
Importance of Liver Transplantation
Liver transplantation (LT) is an established life-saving procedure, and the field of LT has changed in the past 10 years with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, and evolution of transplant oncology [ 1 ]. The purpose of the EASL guidelines is to focus on developments since the previous EASL guidelines published in 2016, highlighting the importance of LT in the management of liver failure [ 1 ].
Future Directions
The development of hepatic regenerative therapies and artificial/bioartificial liver support devices that will serve as a bridge to LT or even as destination therapy for patients with liver failure is of critical importance [ 1 ]. Advanced care planning in patients listed for LT occurs infrequently, and engaging palliative care in all listed patients who develop ACLF is necessary [ 1 ].
Key Points
- The liver's complex functions cannot be replicated by an external machine.
- Liver failure is managed through supportive care or liver transplantation.
- Temporary liver support systems can provide limited detoxification but are not a replacement for liver function.
- Liver transplantation is a life-saving procedure with expanding indications.
- Development of new therapies and devices is crucial for the management of liver failure.
From the Research
Liver Dialysis
- There is no established liver dialysis treatment for acute liver failure, as the current systems, such as MARS and Prometheus, have failed to show survival benefits in patients with acute-on-chronic liver failure 2.
- The development of newer devices with improved functionality is underway, but larger randomized trials are needed to prove their effectiveness in enabling restoration of the complex dysregulated immune system and impacting organ failure and mortality in these patients 2.
Acute Liver Failure Treatment
- The treatment for acute liver failure is mainly focused on preventing complications and treating associated organ dysfunctions, with liver transplantation being the only life-saving measure in progressive cases 3, 4.
- N-acetylcysteine (NAC) has been used in the treatment of non-acetaminophen-induced acute liver failure, but the evidence is inconclusive, and its use is not supported by robust clinical evidence 5, 4, 6.
- The use of extracorporeal artificial liver devices in clinical practice is yet to be supported by evidence, and their effectiveness in treating acute liver failure is still being researched 4.
Challenges in Liver Dialysis
- The development of an effective liver dialysis system is challenging due to the complexity of liver functions and the need for a system that can provide temporary functional support until the donor liver becomes available or the failing liver regenerates 2.
- The removal of hepatotoxic metabolites and inhibitors of hepatic regeneration by liver dialysis is crucial in providing a suitable microenvironment and supporting the failing liver, but the current systems have failed to achieve this goal 2.