Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials

• Published in: Intensive care medicine Vol. 46; no. 1; pp. 1 - 16
• Main Authors: Alshamsi, Fayez, Alshammari, Khalil, Belley-Cote, Emilie, Dionne, Joanna, Albrahim, Talal, Albudoor, Budoor, Ismail, Mona, Al-judaibi, Bandar, Baw, Bandar, Subramanian, Ram M., Steadman, Randolph, Galusca, Dragos, Huang, David T., Nanchal, Rahul, Al Quraini, Mustafa, Yuan, Yuhong, Alhazzani, Waleed
• Format: Journal Article
• Language: English
• Published: Berlin/Heidelberg Springer Berlin Heidelberg 01.01.2020; Springer; Springer Nature B.V
• Subjects: Analysis; Anesthesiology; Bleeding; California; Canada; Care and treatment; Clinical trials; Critical Care Medicine; Emergency Medicine; Extracorporeal Circulation - instrumentation; Extracorporeal Circulation - methods; Extracorporeal Circulation - trends; Failure analysis; Health aspects; Hepatic encephalopathy; Humans; Hypotension; Intensive; Intensive care; Liver; Liver failure; Liver Failure - physiopathology; Liver Failure - therapy; Liver transplantation; Medicine; Medicine & Public Health; Meta-analysis; Morbidity; Mortality; Pain Medicine; Pediatrics; Pharmaceutical industry; Pneumology/Respiratory System; Randomization; Randomized Controlled Trials as Topic - standards; Randomized Controlled Trials as Topic - statistics & numerical data; Safety; Saudi Arabia; Systematic Review; Thrombocytopenia; Transplantation; United States; Saudi Arabia; Canada; California; United States; Hemoperfusion; Acute liver failure; Exchange transfusion; Extracorporeal liver support; Acute on chronic liver failure; Albumin dialysis
• ISSN: 0342-4642; 1432-1238; 1432-1238
• DOI: 10.1007/s00134-019-05783-y

Purpose Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support (ECLS) devices have been used as a bridge to liver transplant; however, the efficacy and safety of ECLS are unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of ECLS in liver failure. Methods We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from inception through March 13, 2019. RCTs comparing ECLS to usual care in ALF or ACLF were included. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. Results We identified 25 RCTs (1796 patients). ECLS use was associated with reduction in mortality (RR 0.84; 95% CI 0.74, 0.96, moderate certainty) and improvement in hepatic encephalopathy (HE) (RR 0.71; 95% CI 0.60, 0.84, low certainty) in patients with ALF or ACLF. The effect of ECLS on hypotension (RR 1.46; 95% CI 0.98, 2.2, low certainty), bleeding (RR 1.21; 95% CI 0.88, 1.66, moderate certainty), thrombocytopenia (RR 1.62; 95% CI 1.0, 2.64, very low certainty) and line infection (RR 1.92; 95% CI 0.11, 33.44, low certainty) was uncertain. Conclusions ECLS may reduce mortality and improve HE in patients with ALF and ACLF. The effect on other outcomes is uncertain. However, the evidence is limited by risk of bias and imprecision, and larger trials are needed to better determine the effect of ECLS on patient-important outcomes.