Extracorporeal therapies for post-liver transplant recipient: The road less traveled

Table 2 Advantages and disadvantages of extracorporeal therapies in post-liver transplant care

Modality	Advantages	Disadvantages
Polymyxin B hemoperfusion	Reduced endotoxemia and potentially improved hemodynamic stability and organ function. Demonstrated positive effects on septic shock caused by gram-negative infections. Can stabilize inflammatory and hemodynamic responses in transplant recipients. Some studies suggest improved survival in specific patient populations	Limited evidence in large, well-designed trials. No consistent reduction in mortality across all trials. Uncertainty around optimal timing for initiation of therapy. High cost and logistical challenges of administering multiple sessions. Not effective for all cases of sepsis, especially when endotoxin levels are low
Cytokine adsorption (Cytosorb®)	Removed a broad spectrum of proinflammatory cytokines, potentially preventing or mitigating cytokine storms and graft rejection. Demonstrated high clearance rates of cytokines (> 90%-95%) in vitro. Can be combined with other therapeutic approaches such as continuous renal replacement therapy. May improve hemodynamics and blood lactate levels in some patients	Clinical evidence is limited and inconsistent, with no definitive survival benefit. Primarily used in case reports or small case series, so generalizability is uncertain. Does not target endotoxins, limiting its effectiveness in endotoxin-driven sepsis. Expensive and may require extended treatment (e.g., 6 h per day). No specific cutoff value of interleukin-6 to initiate cytokine adsorption
oXiris® hemofilter (cytokine + endotoxin removal)	Multitasking device capable of removing endotoxins and cytokines and providing renal support. It showed promise in managing septic shock and liver dysfunction post-transplant. Can provide anticoagulation during treatment, reducing the need for additional medications	Clinical outcomes are not consistently improved in large trials. Data from case reports and small studies did not establish clear benefits in post-transplant care. More research is needed to confirm its clinical efficacy and safety in the liver transplant population
Molecular adsorbent recirculation system	Effectively removed toxins and promoted liver function in cases of liver failure. Showed benefits in early allograft dysfunction and primary allograft nonfunction. Decreased serum bilirubin levels, bile acids, serum creatinine, and ammonia levels	Expensive and resource intensive. Long treatment sessions are required (several hours). Evidence for significant survival benefit remains limited. Not universally available, limiting its application in all settings
Therapeutic plasma exchange	Can remove circulating immune complexes, toxins, and cytokines, potentially improving graft survival and reducing inflammation. Established role in managing autoimmune liver diseases, which could benefit patients after transplant. Some studies suggest improvement in post-transplant liver function	Does not directly address the underlying cause of inflammation; only removes circulating mediators. Limited evidence for efficacy in the specific post-transplant setting. Requires multiple sessions, potentially leading to increased costs and complications like transfusion-related acute lung injury, transfusion-associated circulatory overload, etc.
Extracorporeal membrane oxygenation	Provides respiratory and circulatory support in patients with hepatopulmonary syndrome, portopulmonary syndrome, and/or respiratory failure. Can improve oxygenation and hemodynamics in critical patients, reducing the need for mechanical ventilation. Acts as a bridge to recovery	High risk of complications, including bleeding, infection, and organ dysfunction. High resource utilization and intensive monitoring required. Does not address liver dysfunction directly; only provides supportive care