Liver dialysis
This article specifically discusses liver dialysis. For information regarding kidney dialysis or dialysis in general, please click here.

# Overview
Liver dialysis is a type of artificial extracorporeal liver support. It is a new promising emerging therapeutic technique used for the detoxification treatment for liver failure and it has shown positive impact on the outcomes of hepatorenal syndrome. Liver dialysis follows the same principles of hemodialysis. The concerning matter during a liver failure is the accumulation of toxins in the blood stream which are not cleared by an injured liver. Based on this hypothesis, the elimination of albumin-bound substances such as bilirubin, bile acids, metabolites of aromatic amino acids, medium-chain fatty acids and cytokines has led to the invention of artificial filtration and adsorption devices. Several new devices are invented for this purpose such as Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD), Prometheus system and DIALIVE. Hemodialysis is used for renal failure which mainly eliminates water soluble toxins, but it can not eliminate the albumin bound toxins that accumulate in liver failure.

# History
- There has been an increase in interest in the research on extra-corporeal liver support within past 5 decades.
- In the mid of 1990s, the liver dialysis was introduced.
- In 2005, the first MARS unit was established in the Toronto General Hospital, Canada.
- In 2017, the new liver dialysis device DIALIVE was introduced.
- On 24 July 2017, the first patient to undergo liver dialysis with DIALIVE was recruited in London.
- The researchers are expecting to obtain the regulatory approval for DIALIVE by 2019 or 2020.

# Indications
Accepted indications for liver dialysis include the following:
- Acute liver failure
- Acute on chronic liver failure
- Acute liver injury following paracetamol overdose
- Acutely decmpensated liver cirrhosis
- Budd Chiari syndrome
- Endotoxemia
- Fulminant hepatic failure
- Fulminant Wilson disease
- Sub fulminant hepatic failure
- Hepatic encephalopathy gade 2 or above
- Hyperbilirubinemia >5mg/dl
- Hepatorenal syndrome
- Hemochromatosis
- Increased intracraneal pressure
- Progressive hyperbilirubinemia
- Progressive intrahepatic cholestasis
- Reye syndrome
- Transarterial Chemoembolization (TACE)

# Contraindications
Contraindications for Liver dialysis include the following:
- Unstable hemodynamics with mean arterial pressure (MAP) <55 mmHg despite the use of vasoconstrictors
- Thrombocytopenia, platelets count < 50,000
- Disseminated intravascular coagulation (DIC)
- INR over 2.3
- Uncontrolled infection
- Uncontrolled hemorrhage
- Intrinsic renal disease
- Candidate for renal replacement therapy
- Polycystic liver disease
- Severe right-heart failure

# Liver Dialysis Devices
Artificial detoxification liver dialysis devices currently under clinical evaluation include:
- Molecular Adsorbent Recirculating System (MARS)
- Single Pass Albumin Dialysis (SPAD)
- Prometheus system
- DIALIVE

## Molecular Adsorbents Recirculation System (MARS)
- The Molecular Adsorbents Recirculation System (MARS) , its development was started at the University of Rostock in Germany and later was developed by Teraklin AG of Germany.
- MARS is the best available extracorporeal liver dialysis device till date.
- The MARS is in use for liver dialysis for approximately ten years.
- The two separate dialysis circuits for MARS include:

## Single Pass Albumin Dialysis (SPAD)
- SPAD is a simple method of albumin dialysis
Mechanism
- It operates using standard renal replacement therapy machines without any additional perfusion pump system.
- The patients blood passses through the circuit with a high flux hollow fiber hemodiafilter which is identical to the one used in the MARS system.
- The auxillary side of the membrane is cleansed with an albumin solution in counter-directional flow, which is junked away after going through filtration.
- Hemodialysis can be also be performed during the first circuit using the same high-flux hollow fibers.

## Comparing MARS, SPAD,  and Veno-venous haemodiafiltratio (CVVHDF)
- In 2004, an in vitro comparison study was published regarding detoxification capacity of MARS, SPAD and continuous veno-venous haemodiafiltration (CVVHDF).

## Prometheus
- The prometheus system is a device invented recently by Fresenius Medical Care of Bad Homburg, Germany.
- It is composed of the unification of albumin adsorption with high-flux hemodialysis after precise filtration of the albumin fraction through a peculiar polysulfon filter called as the Albuflow.
- This  study was conducted among a group of eleven patients who were suffering from hepatorenal syndrome, acute on chronic liver failure, and accompanying renal failure.
- Over four hours sessions for two succesive days demonstrated improved serum levels of ammonia, bile acids, conjugated bilirubin, cholinesterase, creatinine, urea, and blood pH.
- Prometheus has proven to be a safe supportive management for the patients with liver failure.

## DIALIVE
- The new liver dialysis device DIALIVE was introduced in 2017.
- Dialive is a new emerging system that consolidates albumin removal, replacement, and endotoxin removal.
- The researchers are expecting to obtain the regulatory approval for DIALIVE in 2019 or 2020.
- Among the animal models of liver failure it revealed that it is:
Safe and easy to use
Reduce endotoxemia
Improve albumin
Improve immune function
Prolong survival
- Safe and easy to use
- Reduce endotoxemia
- Improve albumin
- Improve immune function
- Prolong survival

# Liver dialysis prognosis
- At present liver dialysis is only thought to be a bridge for liver transplantation or liver regeneration..
- Liver dialysis is a new techinque and the prognosis of patients with liver failure is still guarded.
- The survival rate with liver dialysis is up to thirty days.
- Liver dialysis cannot support a patient for a longer period of time like renal dialysis.

# Complications
The complications of liver dialysis are:
- Hemorrhage
- Secondary infections
- Hypotension

# Related Chapters
- American Society for Artificial Internal Organs and European Society for Artificial Organs
- Artificial extracorporeal liver support
- Bioartificial liver device

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