LIVER DIALYSIS

Liver failure is the cause of death for over 30,000 patients each year in the United States. When this process occurs in healthy individuals with normal livers, it is termed acute liver failure (ALF). Loss of liver function that complicates chronic liver disease is termed acute-on-chronic liver failure.

Liver transplantation is curative for ALF and acute-on chronic liver failure. Over the years, survival after transplantation has improved with advances in both patient management and surgical techniques, but the procedure is not always available in a timely fashion, prompting new surgical approaches such as split-liver transplantation, procurement from living donors, and auxiliary liver transplantation.

Liver Function
1. Synthetic
2. Metabolic
3. Detoxification (phase I and II pathways)
4. Biliary excretion

Problems:
1. Organ shortage
2. Predicting the outcome of liver failure

Main cellular approaches that are currently being investigated:
1. Isolated cell transplantation
2. Tissue engineering of implantable constructs
3. Transgenic xenotransplantation
4. Extracorporeal bioartificial liver devices

When to use temporary systems:
1. To expedite recovery from acute decompensation
2. Facilitate regeneration in ALF
3. Serve as a bridge to liver transplantation

Nonbiological approaches:
– Limited success, presumably because of the role of the synthetic and metabolic functions of the liver that are inadequately replaced in these systems.
1. Hemodialysis
2. Hemoperfusion over charcoal or resins or immobilized enzymes
3. Plasmapheresis
4. Plasma exchange have all been explored.

Biological approaches:
– Have been difficult to implement in the clinical setting
1. Liver transplantation
2. Whole organ perfusion
3. Perfusion of liver slices
4. Cross hemodialysis

Artificial detoxification devices currently under clinical evaluation include the Molecular Adsorbent Recirculating System (MARS), Single Pass Albumin Dialysis (SPAD) and the Prometheus system. 

In addition, cell-based therapies are gaining attention as promising treatments for liver failure. Currently, several extracorporeal bioartificial liver devices are undergoing clinical evaluation. Xenogenic primary cells are available in large quantities, but immunologic and infectious concerns may necessitate the use of human cells or human-derived cells.

resources:
1. JARED W. ALLEN,TAREK HASSANEIN, SANGEETA N. BHATIA1. Advances in Bioartificial Liver Devices http://web.mit.edu/lmrt/publications/2001/Allen2001_Hepat.pdf

2. http://en.wikipedia.org/wiki/Liver_dialysis

Ardavan Mashhadian D.O.
Nephrologist
1127 Wilshire Blvd Suite 510
Los Angeles CA 90017
(213) 537-0328