Non-biological Extracorporeal Liver Support Treatments: Experiences and Perspectives in the Management of Acute Liver Failure

Acute liver failure (ALF) and acute on chronic liver failure (ACLF) represent severely compromised clinical conditions, characterised by high mortality and often candidates for liver transplantation. Recently, non-biological extracorporeal treatments (ECLSD) have gained an increasing role as temporary support through the removal of water-soluble and albumin-bound toxins. This paper provides an overview of the main available devices, including SPAD (single pass Albumin Dialysis), MARS (Molecular Adsorbent Recirculation System), Prometheus (Fractionated Plasma Separation and Adsorption), Cytosorb, CPFA (Coupled Plasma Filtration Adsorption) and DPMAS (Dual Plasma Molecular Adsorption System), illustrating their technical characteristics, efficacy and limitations. Cytosorb, although originally designed for the treatment of systemic inflammatory conditions, has shown surprising efficacy in reducing bilirubin and bile acids, surpassing the results of MARS in some retrospective studies. Special attention is given to our centre’s experience with the RAED (Recirculated Albumin Extended Dialysis) and RHENOB (Reemplazo Hepático No Biológico) techniques, based on recirculated albumin circuits, with or without regeneration by DPMAS. In a series of seven patients with ALF or ACLF treated with RHENOB, a significant reduction in bilirubin (25-50%) was observed after only a few sessions, without haemodynamic adverse events. One patient subsequently received a successful liver transplant, completing the biochemical stabilisation course. The RAED and RHENOB techniques appear to be innovative, effective, cost-effective approaches that can be applied even in centres without advanced technology. However, controlled prospective studies are needed to consolidate their use in clinical practice.