Extra-Corporeal Systems in Acute Liver Failure: Quickfire videos from the ILTS Acute Liver Failure SIG

Speakers: Ram Subramanian, Emory University Hospital, Atlanta, US. Akila Rajakumar, Dr Rela Institute & Medical Centre, Chennai, India. Fuat Saner, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. Florent Artru, Clinical Research Fellow - King's College Hospital, London, UK

Florent Artru: Hello, I'm Florent Artru from King's College Hospital London. On behalf of the ILTS Acute Liver Failure Special Interest Group Steering Committee, it's my pleasure to introduce this short video focusing on an emerging field in the management of acute liver failure, which is the use of extracorporeal systems. According to a large international survey launched last year, we have observed a wide heterogeneity of use of these devices worldwide ranging from 20% in Latin America to almost 90 to 100% in Australia and New Zealand. And this, despite emerging evidences regarding the potential benefit of ECLS in the field of acute liver failure, three experts from our group have summarized their opinion for and against the use of the ECLS. We hope that this video will encourage you to better explore the field and eventually participate in future research projects eventually participate in future research projects. Do not hesitate to interact on social media with this video and also with our group.

Ram Subramanian: Hello everyone. I'm Ram Subramanian and I'm an intensivist and hepatologist at Emory University in Atlanta. Regarding my views on the use of the ECLS systems in ALF I think there are two specific modalities that, in my opinion, have an increasing role in the application of the sick ALF patient. Number one is high dose CRRT which is very effective in treating the metabolic acidosis and the hyperammonemia in order to prevent intracranial hypertension. Number two is the utility of plasma exchange with FFP which in our experience has been shown to really favorably influence the treatment of severe shock in these patients, which could have implications regarding hepatic stabilization and extrahepatic stabilization.

Ram Subramanian: So when I think about the potential obstacles to the application of ECLS systems in ALF, I think the main issue may be awareness regarding the efficacy of high dose CRRT and plasma exchange with FFP in the setting of ALF. So I think an important measure would be to share with the scientific community in a broader context of how high-dose CRRT and plasma exchange can be helpful in patients with severe ALF. The second point I'd like to make is the consideration and awareness of applying high-dose CRRT and plasma exchange simultaneously. We've actually done this, especially in younger patients who can tolerate two extracorporeal systems, with great efficacy because, in my opinion, those could be synergistic where the CRRT can address the hyper ammonaemia and metabolic acidosis issues while plasma exchange could provide the hemodynamic benefit with respect to improving shock.

Akila Rajakumar: Hello everybody. I'm Akila, from India. When it comes to acute liver failure management from our part of the world, we're no different from the western world in terms of overall survival or survival with liver transplant. But what is different is the etiology. 60 to 90% of our patients with acute liver failure are due to viral hepatitis. Now we have only two important ECLS interventions which have shown survival benefit in acute liver failure. One is high volume plasma exchange from the European centers and the second one is MARS® from US-ALF study group. Now, when you look carefully at the study population from both studies, half of them are due to acetaminophen poisoning. Can the results from those studies be extrapolated to our population? - is a question which we need to address. There are two other important factors: One is a very, very limited deceased donor organ availability in our part of the world. 85% of the transplants that we perform are living donor liver transplants, and economic resources are also limited: cost is a very important factor. Therefore, for any new intervention to be applicable here, we need to have robust scientific evidence. What additional benefits are they going to offer in addition to this well proven and established standard medical therapy? Do they confer any form of additional harm? Mars® can be prohibitively expensive for our country. Very important concerns accepts this: we have problems with antibiotic prescription practices which are not monitored. The health care practices are not uniform, structured, and standardized across the country, as we see in the western world. Approximately 50% of patients who come for transplants are already colonized with CRE bacteria. So that is a problem and it can be a bigger problem in the institute of high volume plasma exchange: because it involves non selective removal of both pro- and anti-inflammatory cytokines. Hence, it can also be removing your antibacterial and antifungal, which can interfere with liver regeneration and also enhances the susceptibility of these patients to sepsis.

Fuat Saner: We just listened to experts in the field of acute liver failure from two different parts of the world. While Ram from the United States favors continuous renal replacement treatment in acute failure to correct acidosis and hyperammonia. He also recommend the use of high-volume plasmapheresis particularly for patients who were hemodymamic unstable. Akila from India highlighted that results from studies which were done in Europe or United States cannot easily be transferred to other countries. The studies of MARS® for acute liver failure and high-volume plasmapheresis were mainly done in France or in a study in Europe. The majority of patients with ALF suffered here from from acetaminophen intoxication while the main diagnosis in India for acute liver failure are viral hepatitis.