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

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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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Authors and Affiliations

  1. Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates

    Fayez Alshamsi

  2. Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia

    Khalil Alshammari

  3. Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada

    Emilie Belley-Cote, Joanna Dionne & Waleed Alhazzani

  4. Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada

    Emilie Belley-Cote, Joanna Dionne, Bandar Baw & Waleed Alhazzani

  5. Department of Anesthesiology and Critical Care Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia

    Talal Albrahim

  6. Department of Critical Care Medicine, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates

    Budoor Albudoor

  7. Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia

    Mona Ismail

  8. Transplant Hepatology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, USA, 14642

    Bandar Al-judaibi

  9. Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA

    Ram M. Subramanian

  10. Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA

    Ram M. Subramanian

  11. Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA

    Randolph Steadman

  12. Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA

    Dragos Galusca

  13. Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization (MACRO), University of Pittsburgh Medical Center, Pittsburgh, PA, USA

    David T. Huang

  14. Department of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA

    Rahul Nanchal

  15. Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia

    Mustafa Al Quraini

  16. Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada

    Bandar Baw & Yuhong Yuan

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  1. Fayez Alshamsi
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Alshamsi, F., Alshammari, K., Belley-Cote, E. et al. Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials. Intensive Care Med 46, 1–16 (2020). https://doi.org/10.1007/s00134-019-05783-y

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