Dialysis for acute hepatic failure

Findings by Alert

This is a translation of version 1 published on April 28, 2000. The latest version of this report is not available in English.

To date, dialysis for acute hepatic failure has been tested on only a small number of patients in the world. Various dialysis methods for hepatic failure are intended to be used as a life supporting intervention while waiting for access to a liver suitable for transplantation. Without treatment, the patient would die within a few days. Currently there are three ways to perform liver dialysis. With albumin hemodiafiltration, the patients blood is filtered through a membrane which captures proteins but releases water-soluble substances and protein-bound toxins. In the second method, the patients blood is circulated through an animal liver located outside of the patients body. The third method involves filtering the patients blood through artificial columns containing liver cells from animals.

Currently, no* scientific evidence is available concerning patient benefit from dialysis in acute hepatic failure, neither in the short nor the long term. The potential risk for spreading infection via the use of cells or organs from animals has not been determined. Likewise, there is no scientific evidence regarding cost effectiveness. If this method is adopted in Sweden, the economic impact on the health services is expected to be minor since the target group for treatment is small.

The most promising method is albumin hemodiafiltration. The method is being studied in patients with chronic hepatic failure awaiting liver transplantation.

This assessment by SBU Alert uses a 4-point scale to grade the quality and evidence of the scientific documentation. The grades indicate: (1) good, (2) moderate, (3) poor, or (4) no scientific evidence on the subject.

This summary is based on a report prepared at SBU in collaboration with Prof Michael Olausson, MD PhD, Sahlgrenska University Hospital. It has been reviewed by Øystein H. Bentdal, MD, Rikshospitalet University hospital, Oslo.

Alert is a joint effort by the Swedish Council on Technology Assessment in Health Care (SBU), the Medical Products Agency, the National Board of Health and Welfare, and the Federation of Swedish County Councils.

References

1. Abouna GM, Fisher LM, Porker KA, Andres G. Experience in the treatment of hepatic failure by intermittent liver hemoperfusions. Surg Gyncol Obstet 1973;137:741-52.
2. Auchincloss H. Xenogeneic Transplantation. Transplantation 1998;46: 1-20.
3. Breimer M, Björck E, Svalander CT et al. Extracorporeal ("ex vivo") connection of pig kidneys to humans I: clinical data and studies of platelet destruction. Xenotransplantation 1996;3:328-329.
4. Chari RS, Collins BH, Magee JC, DiMaio JM, et al. Treatment of hepatic failure with ex vivo pig-liver perfusion followed by liver transplantation. New Engl J Med 1994;331:234-37.
5. Eiseman B, Liem DS, Raffucci F. Heterologous liverperfusion in the treatment of hepatic failure. Ann Surg 1965;162:329-45.
6. Hardison WG, Norman JC. Ex vivo pig liver perfusion for acute hepatic failure: bile salt composition of pig bile during during perfusion. Medicine 1967;46:97-102.
7. Makowka L, Cramer DV, Hoffman A, Breda M, Sher L, et al. The use of a pig liver xenograft for temporary support of a patient with fulminant hepatic failure. Transplantation 1995;59:1654-1659.
8. McDonald JC, Rohr MS, Tucker WY. Recent experiences with autotransplantation of the kidney, jejunum, and pancreas. Ann Surg, 1983;197:678.
9. Naruse K, Nagashima I, Sakai Y, Harihara Y, et al. Efficacy of a bioreactor filled with porcine heliocytes immobilized on nonwoven fabric for ex vivo direct hemoperfusion treatment of liver failure in pias. Artificial organs 1998;22:1031-37.
10. Patience C, Takeuchi Y, Weiss RA. Infection of human cells by an endogenous retrovirus of pigs. Nature Medicine 1997;3:282-286.
11. Starzl TE, Fung J, Tzakis A, Todo S, Demetris A-J, et al. Baboon to human liver transplantation. Lancet 1993;341:65-71.
12. Zaidi A, Schmoeckel M, Bratti F, Waterworth P, Tolan M, et al. Life-supporting pig-to-primate renal xenotransplantation using genetically modified donors. Transplantation 1998;65:1584-90.
13. Stange J, Mitzner SR, Risler T, Erley CM, Lauchart W, et al. Molecular Adsorbent Recycling System (MARS): Clinical results of a new membrane-based blood purification system for bioartificial liver support. Artificial Organs 1999;23:319-30.
14. Socialdepartementet. Från en art till en annan - Transplantation från djur till människa. Betänkande av Xenotransplantationskommittén. SOU 1999:20.