Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials
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 system...
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| Published in | Intensive care medicine Vol. 46; no. 1; pp. 1 - 16 |
|---|---|
| Main Authors | , , , , , , , , , , , , , , , , |
| Format | Journal Article |
| Language | English |
| Published |
Berlin/Heidelberg
Springer Berlin Heidelberg
01.01.2020
Springer Springer Nature B.V |
| Subjects | |
| Online Access | Get full text |
| ISSN | 0342-4642 1432-1238 1432-1238 |
| DOI | 10.1007/s00134-019-05783-y |
Cover
| Abstract | 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. |
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| AbstractList | 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.
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.
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.
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. PurposeAcute 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.MethodsWe 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.ResultsWe 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.ConclusionsECLS 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. 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. 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. 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. 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. 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. 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.PURPOSEAcute 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.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.METHODSWe 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.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.RESULTSWe 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.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.CONCLUSIONSECLS 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. 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. |
| Audience | Academic |
| Author | Albrahim, Talal Yuan, Yuhong Alshammari, Khalil Steadman, Randolph Baw, Bandar Al-judaibi, Bandar Subramanian, Ram M. Nanchal, Rahul Alshamsi, Fayez Dionne, Joanna Ismail, Mona Belley-Cote, Emilie Huang, David T. Albudoor, Budoor Alhazzani, Waleed Al Quraini, Mustafa Galusca, Dragos |
| Author_xml | – sequence: 1 givenname: Fayez surname: Alshamsi fullname: Alshamsi, Fayez organization: Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University – sequence: 2 givenname: Khalil surname: Alshammari fullname: Alshammari, Khalil organization: Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU) – sequence: 3 givenname: Emilie surname: Belley-Cote fullname: Belley-Cote, Emilie organization: Division of Critical Care, Department of Medicine, McMaster University, Department of Health Research Methods, Evidence and Impact, McMaster University – sequence: 4 givenname: Joanna surname: Dionne fullname: Dionne, Joanna organization: Division of Critical Care, Department of Medicine, McMaster University, Department of Health Research Methods, Evidence and Impact, McMaster University – sequence: 5 givenname: Talal surname: Albrahim fullname: Albrahim, Talal organization: Department of Anesthesiology and Critical Care Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University – sequence: 6 givenname: Budoor surname: Albudoor fullname: Albudoor, Budoor organization: Department of Critical Care Medicine, Shaikh Khalifa Medical City – sequence: 7 givenname: Mona surname: Ismail fullname: Ismail, Mona organization: Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University – sequence: 8 givenname: Bandar surname: Al-judaibi fullname: Al-judaibi, Bandar organization: Transplant Hepatology, University of Rochester Medical Center – sequence: 9 givenname: Bandar surname: Baw fullname: Baw, Bandar organization: Department of Health Research Methods, Evidence and Impact, McMaster University, Department of Medicine, McMaster University – sequence: 10 givenname: Ram M. surname: Subramanian fullname: Subramanian, Ram M. organization: Department of Medicine, Emory University School of Medicine, Department of Surgery, Emory University School of Medicine – sequence: 11 givenname: Randolph surname: Steadman fullname: Steadman, Randolph organization: Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles – sequence: 12 givenname: Dragos surname: Galusca fullname: Galusca, Dragos organization: Department of Anesthesiology, Henry Ford Hospital – sequence: 13 givenname: David T. surname: Huang fullname: Huang, David T. organization: Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization (MACRO), University of Pittsburgh Medical Center – sequence: 14 givenname: Rahul surname: Nanchal fullname: Nanchal, Rahul organization: Department of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin – sequence: 15 givenname: Mustafa surname: Al Quraini fullname: Al Quraini, Mustafa organization: Department of Pulmonary and Critical Care Medicine, King Fahad Medical City – sequence: 16 givenname: Yuhong surname: Yuan fullname: Yuan, Yuhong organization: Department of Medicine, McMaster University – sequence: 17 givenname: Waleed orcidid: 0000-0001-8076-9626 surname: Alhazzani fullname: Alhazzani, Waleed email: alhazzaw@mcmaster.ca organization: Division of Critical Care, Department of Medicine, McMaster University, Department of Health Research Methods, Evidence and Impact, McMaster University |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/31588983$$D View this record in MEDLINE/PubMed |
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| Keywords | Hemoperfusion Acute liver failure Exchange transfusion Extracorporeal liver support Acute on chronic liver failure Albumin dialysis |
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| PublicationTitle | Intensive care medicine |
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Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver... Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support... Purpose Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver... PurposeAcute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver... |
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| SubjectTerms | 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 |
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| Title | Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials |
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