From the Guidelines
Liver dialysis should only be considered as a bridge therapy to liver transplantation or as a means to allow the liver to recover naturally in patients with acute liver failure or acute-on-chronic liver failure, as it has not consistently shown to improve long-term survival without transplantation. The most common liver dialysis systems include Molecular Adsorbent Recirculating System (MARS), Prometheus system, and Single-Pass Albumin Dialysis (SPAD) 1. These systems work by removing toxins that accumulate when the liver fails, such as ammonia, bilirubin, bile acids, and certain medications.
The procedure involves circulating the patient's blood through an external device containing albumin or other substances that bind to toxins, effectively filtering them out before returning the blood to the patient. Liver dialysis is generally reserved for severe cases where conventional medical management has failed, and patients typically require intensive care monitoring during treatment. While these therapies can temporarily improve clinical symptoms and laboratory values, they haven't consistently shown to improve long-term survival without transplantation, which remains the definitive treatment for end-stage liver disease 1.
Some studies have shown that liver support systems, such as MARS and Prometheus, may improve short-term survival in patients with acute-on-chronic liver failure (ACLF) and multiple organ failure 1. However, the indications for these systems need to be explored further, and new research protocols are required to determine their effectiveness 1. The most recent guidance from the American Association for the Study of Liver Diseases (AASLD) suggests that liver dialysis may be considered as a bridge to liver transplantation or as a means to allow the liver to recover naturally, but emphasizes the need for development of hepatic regenerative therapies and artificial/bioartificial liver support devices 1.
In terms of specific patient populations, liver dialysis may be considered for patients with ACLF who are awaiting liver transplantation or who have failed conventional medical management 1. However, the decision to initiate liver dialysis should be made on a case-by-case basis, taking into account the individual patient's clinical status and prognosis.
Overall, while liver dialysis may have a role as a bridge therapy to liver transplantation or as a means to allow the liver to recover naturally, it is not a substitute for liver transplantation, which remains the definitive treatment for end-stage liver disease 1. The use of liver dialysis should be guided by the most recent and highest-quality evidence, and patients should be referred to an expert center at an early stage after decompensation of their cirrhosis.
From the Research
Liver Dialysis Overview
- Liver dialysis, also known as liver support therapy, is a treatment used to support patients with liver failure.
- The molecular adsorbent recirculating system (MARS) is a type of liver dialysis that uses albumin dialysis to remove toxins from the blood 2, 3.
- MARS has been shown to improve biochemical profiles, resolve encephalopathy, correct hemodynamics, and reduce intracranial pressure in patients with liver failure 2, 3.
Indications for Liver Dialysis
- Liver dialysis is used to treat patients with acute liver failure, acute-on-chronic liver failure, and fulminant hepatic failure 3, 4.
- It is also used as a bridge to liver transplantation in patients with liver failure 3, 4.
- In addition, liver dialysis has been used to treat severe cholestatic drug-induced liver injury 5.
Types of Liver Dialysis
- MARS is a type of artificial liver support device that uses albumin dialysis to remove toxins from the blood 2, 3.
- Other types of liver dialysis include Prometheus dialysis, plasma exchange combined with hemodialysis (PE/HD), and single-pass albumin dialysis (SPAD) 4.
- Bioartificial liver support devices are also available, but their effects on patient survival have not been conclusively shown 6.
Benefits and Limitations of Liver Dialysis
- Liver dialysis has been shown to improve biochemical profiles, resolve encephalopathy, and correct hemodynamics in patients with liver failure 2, 3.
- However, the timing of initiation of therapy, duration of treatment, and frequency of sessions are still unresolved issues 2, 3.
- Large multicentric trials are needed to optimize the potential of liver dialysis and to compare its efficacy with other treatments 2, 3.