Intensive Care Medicine (2019)
Alshamsi and co-authors performed a systematic review and meta-analysis of randomized controlled trials (RCT) to examine the efficacy and safety of extracorporeal liver support (ECLS) in patients with liver failure . ECLS can be divided into artificial (cell-free systems) and bioartificial liver support devices that incorporate hepatocytes in an artificial device. The authors identified 25 RCTs including 1796 patients, and used the GRADE approach to assess the certainty of evidence. Thirteen RCTs assessed patients with acute liver failure (ALF) and 13 RCTs investigated patients with acute-on-chronic liver failure (ACLF). Nineteen trials used artificial ECLS and five trials used bio-artificial ECLS. The authors observed a significant association of ECLS and reduction in mortality (RR 0.84, 95% CI 0.74–0.96, moderate certainty) and significant improvement in hepatic encephalopathy (RR 0.71, 95% CI 0.60–0.84, low certainty) in patients with ALF and ACLF. Subgroup analysis did not observe a difference of outcome using ECLS in patients with ALF and ACLF. Furthermore, kind of device, risk of bias and funding source did not reveal significant subgroup differences. Additional sensitivity analysis excluding four studies published in abstract form revealed similar results. The number needed to treat was 22 in patients with ALF and 16 in patients with ACLF. In summary, this systematic review and meta-analysis provides evidence that ECLS may reduce mortality in patients with ALF and ACLF. This effect was more prominent with artificial than with bio-artificial devices.