Liver failure is a severe life-threatening condition that can present acutely or chronically. Unlike kidney failure, there is no long-term replacement treatment apart from liver transplantation. Liver transplantation is expensive, requires a donor, and involves a major operation. The search for an effective liver dialysis machine similar to the successful kidney dialysis machines has been ongoing for a few decades. However, this is still a field in its infancy. At The Asian Centre for Liver Diseases & Transplantation (ACLDT) located at Gleneagles Hospital, Singapore, we have been at the forefront looking for a viable liver dialysis machine for close to a decade.

There are broadly two categories of liver dialysis machines: one that contains liver cells (biological) and one without any living cells (non-biological). The non-biological version is simpler and cheaper, but it merely provides detoxifying functions without any contribution of the normal liver synthetic function. Liver cells, however, are difficult to grow in culture for long periods of time. The source of liver cells is therefore a major stumbling block in generating enough biological systems. Discarded livers have been used as a source, and pig livers have also been used. The only long-term cultured liver cell comes from a hepatoblastoma cell line, and this has been incorporated into the Extracorporeal Liver Assist Device (ELAD). This is a system that is undergoing clinical trials in USA and has been in use at ACLDT since 2009.

Non-biological devices typically have some sort of charcoal-based system that adsorbs the toxins. This may be coupled with a plasma separator and there may also be an albumin dialysate. The system usually has some way of trying to renew the cartridges to prolong its lifespan. Molecular adsorbing re-circulating system (MARS™) is the most commonly used device and comes as an intermittent device or continuous device. This has been utilized extensively at ACLDT for several years. Another new device that uses a plasma separator is called IMPACT from the USA. This is a simpler device and we have pioneered a lot of clinical treatments with this newer device since 2009.

Currently at ACLDT, we have three different liver dialysis devices. This is unique for any liver centre in the world. The dialysis is performed in our dedicated Liver ICU (LICU) that is led by Dr Lee Kang Hoe. We utilize these devices as a bridge to liver transplantation as our Centre can only offer living donor liver transplantation (LDLT). This necessitates a minimum of one week to organize an appropriate liver transplant for a patient with acute liver failure. In that time, liver dialysis is utilized in the appropriate cases to support the patient through his/her liver failure until transplantation can be performed. Patients have been treated even up to one month while waiting for suitable live donors. Having three different devices allows us to customize the treatment according to the patient’s condition and other co-morbid diseases. With our highly-experienced liver transplant team led by Dato’ Dr K C Tan, a renowned liver transplant surgeon, this strategy allows ACLDT to provide the most advanced support available for patients with liver failure. It cements ACLDT’s continued role as a leading liver centre in the world that is based in Singapore.

References:

• Outcome from Molecular Adsorbent Recycling System (MARS™ Liver Dialysis Following Drug-Induced Liver Failure. Liver International 2005: 25: 973-977.
• Predicting the Amount of Conjugated Bilirubin Removal With Extracorporeal Albumin Dialysis MARS Utilizing the Pred-dialysis Conjugated Bilirubin:Albumin Ratio. Liver Transplantation 2002; 8:591-3.
• Molecular Adsorbent Recirculating System for Acute and Acute-on-Chronic Liver Failure: A Meta-analysis. Liver Transpl 2004; 10:1099-1106.
• Liver failure: basis of benefit of therapy with the molecular adsorbents recirculating system. The International Journal of Biochemistry & Cell Biology 35 (2003) 1306-1311.
• MARS liver dialysis in children with acute liver failure. Ann Acad Med Singapore. 2004 Sep; 33(5 Suppl):S73-4.
• MARS: a futile tool in centres without active liver transplant support. Wai CT, Lim SG, Aung MO, Lee YM, Sutedja DS, Dan YY, Aw MM, Quak SH, Lee MK, Da Costa M, Prahbakaran K, Lee KH. Liver Int. 2007 Feb; 27(1):69-75.
• Liver support devices. Phua J, Lee KH. Curr Opin Crit Care. 2008 Apr; 14(2):208-15.
• Pre-transplant optimization by Molecular Adsorbent Recirculating System in patients with severely decompensated chronic liver disease. Wagholikar GD, Lee KH, Pandey D, Leong SO, Singh R, Tan KC. Indian J Gastroenterol. 2007 May-Jun; 26(3):110-2.

The different liver dialysis devices used at ACLDT: (L-R) ELAD*, MARS™ and IMPACT    * Currently undergoing clinical trial in the USA