Extracorporeal Liver Support Systems in Paediatric Liver Failure

Abstract

Extracorporeal liver support systems (ELSS), encompassing artificial and bioartificial devices, have been used for decades, with the aim of supporting patients with acute liver failure and acute-on chronic liver failure, as a bridge to recovery (acute liver failure only) or liver transplantation, in an era of organ donation shortage. Although biochemical efficacy has been consistently demonstrated by these devices, translation into clinical and survival benefits has been unclear, due to study limitations and lack of reliable prognostic scoring in liver failure. Consequently, extracorporeal devices are not widely accepted as routine therapy in adult liver failure. Recent large multicentre trials using artificial liver systems have not revealed beneficial outcomes associated with albumin dialysis but plasma exchange practices have shown some potential. In paediatric liver failure, data on extracorporeal systems is scarce, comprising few reports on albumin dialysis (namely, Molecular Adsorbent Recirculating System; MARS) and plasma exchange. When extrapolating data from adult studies differences in disease presentation, aetiology, prognosis and the suitability, and safety of such devices in children must be considered. The aim of this review is to critically appraise current practices of extracorporeal liver support systems to help determine efficacy in paediatric liver failure.

A child with acute liver failure associated with influenza A and resolved with plasma exchange treatment

“…In PE or plasmapheresis, the patient’s plasma is filtered to be replaced by fresh frozen plasma or albumin in order to remove various toxins, including protein-bound toxins, as well as to improve coagulopathy. 18…”

Efficacy of albumin dialysis as a bridge to transplantation in children with end-stage liver disease

“…A.G. Strokov 1,2 1,2 Liver transplantation is the only effective treatment modality for end-stage liver disease. However, donor organs are not always available.…”

“…В таких случаях применение искусственных систем поддержки функции печени позволяет подготовить пациента к трансплантации. За последние десятилетия разработано большое количество таких систем -биологических, содержащих гепатоциты, и полностью искусственных [1][2][3]. Из последних наибольшее распространение в клинической практике получили системы, основанные на альбуминовом диализе с использованием мембран с высокой, до 250 кДА, точкой отсечения, и кроме того, содержащие блок стандартного гемодиализа для выведения водорастворимых веществ [4].…”

Falla hepática aguda en pediatría

“…La terapia MARS (Molecular Adsorbent Recirculating System) consiste en un circuito primario por el que fluye la sangre del paciente a través de un filtro (de menos de 60 KDa) y un circuito secundario con un dializado rico en albumina en contracorriente. Las sustancias unidas a albúmina en el primer circuito se disocian, atraviesan el filtro y se adhieren a la albúmina del segundo circuito, se dializan para remover partículas hidrosolubles y la albúmina del dializante se reactiva por adsorción con carbón activado y una resina aniónica 29 .…”