From the Guidelines
Liver dialysis is available but not commonly used due to its limitations in replicating all liver functions and the lack of strong evidence supporting its effectiveness in improving long-term survival. The most recent and highest quality study, published in 2020 1, suggests that liver dialysis systems like MARS and Prometheus can be used as bridge therapies for patients awaiting liver transplantation or those with acute liver failure expected to recover. These systems can temporarily remove toxins from the blood, but their use is restricted due to their high cost, limited availability, and the need for specialized expertise.
The primary indications for liver dialysis include:
- Allowing the liver to regenerate (bridge to recovery)
- Use of supportive therapy until liver transplantation (bridge to transplant) However, the evidence supporting their effectiveness is limited, with most studies showing no significant decrease in mortality 1. A post-hoc analysis of albumin dialysis with MARS versus standard medical therapy showed a significant improvement in hepatic encephalopathy and hepatorenal syndrome, but the overall benefit on survival is still unclear.
The use of liver dialysis is generally recommended in specialized centers with expertise in liver disease management, and patients should be referred to these centers at an early stage after decompensation of their cirrhosis. The decision to use liver dialysis should be made on a case-by-case basis, taking into account the individual patient's condition, the availability of liver transplantation, and the potential benefits and risks of the treatment. Ultimately, liver transplantation remains the definitive treatment for end-stage liver disease, and liver dialysis should be considered a temporary measure to support patients until transplantation can be performed.
From the Research
Liver Dialysis Overview
- Liver dialysis, also known as liver support systems, is a treatment option for patients with liver failure, including acute liver failure and acute-on-chronic liver failure 2, 3.
- The goal of liver dialysis is to remove hepatotoxic metabolites and inhibitors of hepatic regeneration, providing a suitable microenvironment for the failing liver to recover or until a donor liver becomes available 2.
Types of Liver Dialysis
- There are different types of liver dialysis systems, including molecular adsorbent recirculating system (MARS) and Prometheus, which combine haemodialysis with albumin dialysis or plasma separation and filtration 3.
- Other devices, such as BioLogic-DT and extracorporeal liver assist device (ELAD), have also been developed and are being studied for their efficacy and safety in treating liver failure 4, 5.
Efficacy and Safety of Liver Dialysis
- Studies have shown that liver dialysis can improve jaundice, ameliorate haemodynamic instability, reduce portal hypertension, lower intracranial pressure, and improve hepatic encephalopathy 3, 4.
- However, multicentre controlled trials have failed to show a beneficial effect on transplant-free survival, and the use of these devices is currently only justified as a bridge to liver transplantation 3, 4.
Limitations and Controversies of Liver Dialysis
- The high cost and limited availability of liver dialysis systems, as well as the potential complications and side effects associated with immunosuppression, are significant limitations to their use 2, 5.
- Further research is needed to determine the efficacy and safety of liver dialysis systems and to develop new therapeutic modalities for the treatment of liver failure 4, 5.