Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions

Table 3 Advantages, disadvantages, side effects, complications and contraindications, with intended population to treat, for each liver support system (adapted with modifications from[99])

Method	Advantages	Disadvantages-side effects- complications-contraindications	Intended population
Plasma exchange	Easy operation, broad-spectrum rapid, and efficient removal of various toxins, supplementation of fresh frozen plasma, shorter treatment time, acceptable patient tolerance	Higher treatment cost, poor clearance of water-soluble toxins, aggravation of hepatic encephalopathy, plasma allergy, risk of infection associated with blood products, water and sodium retention after treatment	Patients with hepatic failure, hyperbilirubinemia, cryoglobulinemia, Guillain-Barré syndrome, thrombotic thrombocytopenic purpura, myasthenia gravis
Continuous renal replacement therapy	Hemodynamic stability in critically ill patients, maintenance of cerebral homeostasis, inexpensive and widely available	Unable to remove albumin-bound molecules	Critically ill patients, patients with refractory hepatorenal syndrome
High-volume hemofiltration	More effective removal of medium-sized and water-soluble molecules and cytokines; enhances the elimination of ammonia	Undesirable loss of molecules and substances with functional or beneficial properties, including albumin, nutrients, and antibiotics	Patients with ALF and ACLF, inborn urea cycle disorders, in children and adults with liver failure and hyperammonemia
High cut-off membranes	Removal of uremic toxins	Loss of albumin	Patients with ALF and ACLF
Direct hemoperfusion (Cytosorb)	Reduces the levels of plasma bilirubin, ammonia, bile acids, and C-reactive protein, high safety profile and ease of use	Higher treatment cost Removal of beneficial substances, such as anti-inflammatory cytokines or medications, and thrombocytopenia	Patients with liver failure, drug-induced cholestasis, and acute alcoholic hepatitis; bridge to transplantation in patients with ALF or ACLF
Double plasma molecular absorption system	Rapid removal of bilirubin, inflammatory mediators without requiring exogenous plasma	Inability to replenish coagulation factors; hypotension is likely to occur during the initial treatment period	Patients with liver failure, hyperbilirubinemia, hepatic encephalopathy, perioperative treatment of liver transplantation
Molecular adsorbent recirculating system	Effective removal of protein-bound and water-soluble toxins, excellent biocompatibility, relatively safe	Markedly expensive and complex, cannot supplement coagulation factors	Patients with acute severe liver injury or liver failure
Fractionated plasma separation and Adsorption-PROMETHEUS	Elimination of both water-soluble and albumin-bound toxins and drugs, good safety profile and good hemodynamic tolerance	Markedly expensive and complex, lack of efficient clearance of ammonia and creatinine	Patients with hepatic encephalopathy, hepatorenal syndrome
Single-pass albumin dialysis	Inexpensive, widely available, simple technique, effectively removes bilirubin, bile acids, and other albumin-bound toxins	Significant loss of albumin, metabolic disarrangements and loss of antibiotics	Patients with ALF, Wilson’s disease, acute hepatitis A, liver failure, hepatic encephalopathy, hepatorenal syndrome
Coupled plasma filtration adsorption	Removes medium and small molecular weight water-soluble toxins and is capable of volume regulation and renal support	Higher equipment requirements, higher treatment cost	Patients with liver failure, renal insufficiency, hyperammonemia, rhabdomyolysis, burns, severe autoimmune diseases, poisoning

LSS: Liver support system; ALF: Acute liver failure; ACLF: Acute-on-chronic liver failure.