Artificial Liver Support System Combined with Liver Transplantation in the Treatment of Patients with Acute-on-Chronic Liver Failure

Abstract

BackgroundThe search for a strategy to provide temporary liver support and salvage the patients with acute-on-chronic liver failure (ACLF) remains an important issue. This study was designed to evaluate the experience in artificial liver support system (ALSS) combined with liver transplantation (LT) in the treatment of ACLF.Methodology/Principal FindingsOne hundred and seventy one patients with HBV related ACLF undergoing LT between January 2001 and December 2009 were included. Of the 171 patients, 115 received 247 sessions of plasma exchange-centered ALSS treatment prior to LT (ALSS-LT group) and the other 56 received emergency LT (LT group). The MELD score were 31±6 and 30±7 in ALSS-LT group and LT group. ALSS treatment resulted in improvement of liver function and better tolerance to LT. The average level of serum total bilirubin before LT was lower than that before the first time of ALSS treatment. The median waiting time for a donor liver was 12 days (2–226 days) from the first run of ALSS treatment to LT. Compared to LT group, the beneficial influences of ALSS on intraoperative blood loss and endotracheal intubation time were also observed in ALSS-LT group. The 1-year and 5-year survival rates in the ALSS-LT group and LT group were 79.2% and 83%, 69.7% and 78.6%.Conclusions/SignificancePlasma exchange-centered ALSS is beneficial in salvaging patients with ACLF when a donor liver is not available. The consequential LT is the fundamental treatment modality to rescue these patients and lead to a similar survival rate as those patients receiving emergency transplantation.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL) 2014

“…However, contrary results were shown by systematic review by Kjaergard et al where it was seen that ALS reduced mortality by 33 % in patients with ACLF as compared to SMT [131]. More recently, studies have shown that ALS could be an effective form of bridging therapy in patients with ACLF with high MELD scores awaiting liver transplantation and many believe it is a futile exercise in the absence of liver transplant [119,120]. These results have been substantiated by the recently published two large European randomized multicentric controlled trials, i.e., HELIOS (for Prometheus) [125] and RELIEF trial (for MARS) [124], that failed to show any benefit with these modalities on short-term transplant-free survival, which was the primary end point of these studies.…”

“…Whether these could be considered for transplant and what is the outcome when compared with those without organ failure is not clear. Ling et al and Xu et al found that downgrading MELD (to \ 30) in ACLF using an artificial liver support system as bridging therapy improved outcomes in the responders to levels similar to those who had upfront liver transplant [119,120].…”

Dysregulated iron homeostasis is strongly associated with multiorgan failure and early mortality in acute‐on‐chronic liver failure

“…From the 1 Departments of Research and 3 Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India; 2 Institute of Bioinformatics, International Technology Park, Bangalore, India; Departments of 4 Biological Chemistry, 5 Pathology, and 6 Oncology, McKusick-Nathans Institute of Genetic Medicine, Johns Hopkins University School of Medicine, Baltimore, MD; and 7 Department of Pathology, ILBS, New Delhi, India.…”

“…5 Dysregulated iron homeostasis has been reported in patients with CLD, particularly with alcohol-related liver disease, wherein iron overload is directly correlated with alcohol consumption 6 and labile iron pool (LIP), which promotes formation of oxygen radicals and increases oxidative stress in hepatocytes. 7,8 Increased iron levels in the liver and macrophages also contribute to liver damage and apoptosis.…”

Hepatitis E virus infection results in acute graft failure after liver transplantation: a case report

“…For patients who developed massive necrosis of hepatocytes and lost ability of liver regeneration, several times of ALSS and sequential timely LT were needed [15].…”