Efficacy and safety of liver support devices in acute and hyperacute liver failure: a systematic review and network meta-analysis

Abstract

Acute liver failure (ALF) is a potentially life-threatening condition. Liver support therapies can be applied as a bridging-to-transplantation or bridging-to-recovery; however, results of clinical trials are controversial. Our aim was to compare liver support systems in acute and hyperacute liver failure with network meta-analysis. After systematic search, randomized controlled trials (RCT) comparing liver support therapies in adults with acute or hyperacute liver failure were included. In-hospital mortality was the primary outcome, the secondary outcomes were hepatic encephalopathy and mortality-by-aetiology. A Bayesian-method was used to perform network meta-analysis and calculate surface under the cumulative ranking curve (SUCRA) values to rank interventions. Eleven RCTs were included. BioLogic-DT and molecular adsorbent recirculating system (MARS) resulted in the lowest mortality (SUCRAs: 76% and 73%, respectively). In non-paracetamol-poisoned patients, BioLogic-DT, charcoal hemoperfusion and MARS may be equally efficient regarding mortality (SUCRAs: 53%, 52% and 52%, respectively). Considering hepatic encephalopathy, extracorporeal liver assist device (ELAD) may be the most effective option (SUCRA: 78%). However, in pairwise meta-analysis, there were no statistically significant differences between the interventions in the outcomes. In conclusion, MARS therapy seems to be the best available option in reducing mortality. Further research is needed on currently available and new therapeutic modalities. (CRD42020160133).

Figure 1

Study selection process. PRISMA flowchart containing results of systematic search and article selection. ACLF, acute-on-chronic liver failure.

Figure 2

The network geometry of the eligible comparisons of in-hospital mortality. The thickness of the edges is proportional to the number of the head-to-head trials, and the size of the nodes is proportional to the number of studies in which the intervention was applied. SMT, standard medical therapy; HVPE, high-volume plasma exchange; ET, exchange transfusion; Charcoal-HP, charcoal-hemoperfusion.

Figure 3

Surface under the cumulative ranking curves (SUCRA%) values of in-hospital mortality. Interventions were ranked by their posterior probability via calculating the surface under cumulative ranking (SUCRA) curve values. The higher the SUCRA value, the higher the probability for the interventions to be the best option. HVPE, high-volume plasma exchange; SMT, standard medical therapy; Ch-HP, Charcoal hemoperfusion; ET, exchange transfusion.