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Review
. 2021 Jan 18;11(1):10.
doi: 10.1186/s13613-020-00795-0.

Uncertainty in the impact of liver support systems in acute-on-chronic liver failure: a systematic review and network meta-analysis

Klementina Ocskay  1 , Anna Kanjo  1   2 , Noémi Gede  1   3 , Zsolt Szakács  1 , Gabriella Pár  4 , Bálint Erőss  1 , Jan Stange  5 , Steffen Mitzner  5 , Péter Hegyi  1   6   7 , Zsolt Molnár  8   9
Affiliations
Review

Uncertainty in the impact of liver support systems in acute-on-chronic liver failure: a systematic review and network meta-analysis

Klementina Ocskay et al. Ann Intensive Care. .

Abstract

Background: The role of artificial and bioartificial liver support systems in acute-on-chronic liver failure (ACLF) is still controversial. We aimed to perform the first network meta-analysis comparing and ranking different liver support systems and standard medical therapy (SMT) in patients with ACLF.

Methods: The study protocol was registered with PROSPERO (CRD42020155850). A systematic search was conducted in five databases. We conducted a Bayesian network meta-analysis of randomized controlled trials assessing the effect of artificial or bioartificial liver support systems on survival in patients with ACLF. Ranking was performed by calculating the surface under cumulative ranking (SUCRA) curve values. The RoB2 tool and a modified GRADE approach were used for the assessment of the risk of bias and quality of evidence (QE).

Results: In the quantitative synthesis 16 trials were included, using MARS®, Prometheus®, ELAD®, plasma exchange (PE) and BioLogic-DT®. Overall (OS) and transplant-free (TFS) survival were assessed at 1 and 3 months. PE significantly improved 3-month OS compared to SMT (RR 0.74, CrI: 0.6-0.94) and ranked first on the cumulative ranking curves for both OS outcomes (SUCRA: 86% at 3 months; 77% at 1 month) and 3-month TFS (SUCRA: 87%) and second after ELAD for 1-month TFS (SUCRA: 76%). Other comparisons did not reach statistical significance. QE was moderate for PE concerning 1-month OS and both TFS outcomes. Other results were of very low certainty.

Conclusion: PE seems to be the best currently available liver support therapy in ACLF regarding 3-month OS. Based on the low QE, randomized trials are needed to confirm our findings for already existing options and to introduce new devices.

Keywords: BioLogic-DT; ELAD; Liver support therapy; MARS; Network meta-analysis; Overall survival; Plasma exchange; Prometheus; SUCRA; Transplant-free survival.

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Conflict of interest statement

ZM is one of the Medical directors at CytoSorbents Europe.

Figures

Fig. 1
Fig. 1
Flowchart of study selection according to the PRISMA Statement
Fig. 2
Fig. 2
b Studies included in the analysis for 3-month overall survival (OS). c Geometry of the network: the nodes represent the number of studies and the thickness of the lines corresponds to the number of direct comparisons. a League table: The league table contains the risk ratios (RR) and credible intervals (CrI) for every possible comparison of the interventions. Events were defined as death during the follow-up period (84–91 days). Significant results are highlighted in bold. d Cumulative ranking curves: On the x axis the cumulative probability of the treatment being in the first n rank is shown, while the y axis shows the ranks. e Surface under the cumulative ranking curves: The surface under the cumulative ranking curve (SUCRA) is a numeric presentation of the overall ranking and presents a single number associated with each treatment. SUCRA values range from 0 to 100%. The higher the SUCRA value, and the closer to 100%, the higher the likelihood that a therapy is in the top rank or one of the top ranks. The height of each bar corresponds to the SUCRA value of the respective treatment
Fig. 3
Fig. 3
Rankograms for 3-month overall survival: Rankograms show the probability (x axis) of the respective treatment achieving certain ranks (y axis). a Plasma exchange, b molecular adsorbent and recirculating system, c Prometheus, d extracorporeal liver assist device, e BioLogic-DT, f Standard medical therapy
See this image and copyright information in PMC

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