What are the benefits and harms of liver support systems for adults with acute liver failure?

Key messages

• Due to limited evidence, the effect of liver support systems used alongside standard care compared with standard care alone in people with acute liver failure (rapid loss of liver function) is unclear, and definite conclusions cannot be reached.

• We do not know if the use of liver support systems (therapeutic devices) may decrease or increase death from any cause within 28 days or by the end of the study, the number of serious unwanted effects, the need for liver transplantation, hepatic encephalopathy (brain dysfunction due to liver failure), or the number of multi-organ failures at maximal follow-up, because the evidence is very uncertain.

• No studies reported well-being.

What is acute liver failure?

Acute liver failure is a life-threatening condition. People with acute liver failure have severe liver injury, reduced ability of the liver to produce proteins (e.g. for blood clotting, fluid balance, and production of glucose), and hepatic encephalopathy (altered mental status). Acute liver failure is often caused by viral infections, overdoses of drugs or alcohol.

How can acute liver failure be treated?

Treatment of acute liver failure depends on its causes. In addition to standard medical care, doctors use liver support systems to clean patients' blood of drugs and other harmful substances until the liver works as usual or until a new liver is available for transplantation. There are two types of liver support system: artificial (referred to as non-biological devices or cell-free techniques) and bioartificial liver support systems (referred to as biological liver support devices).

What did we want to find out?

As liver support systems are being used despite the conflicting results of studies and guideline recommendations, we wanted to find out if any of the liver support systems may decrease death due to any cause within 28 days or by the end of the study, the number of serious unwanted effects, the need for liver transplantation, hepatic encephalopathy, the number of multi-organ failures, and non-serious unwanted effects for adults with acute liver failure.

What did we do?

We searched for clinical studies that randomly assigned adults with acute liver failure to have any type of liver support system alongside standard care or receive standard care alone. We summarised the results of the studies and rated our confidence in the evidence, based on factors such as study methods and sizes.

What did we find?

We identified 11 studies. The studies were conducted before the year 2019 and varied in size, quality, and outcomes. All participants had acute liver failure due to various causes, mainly drug poisoning, viral hepatitis, alcohol, or indeterminate causes. The diagnosis of acute liver failure varied across countries and over time. The studies mostly included adults, although a few children were also included; ages ranged from 10 to 69 years old. People were admitted to intensive care units as they were seriously ill, and almost all participants needed liver transplantation. We measured results at the end of the studies.

It is very uncertain whether liver support systems may have any effect on the risk of dying within 28 days (9 studies with 539 participants), within one year (11 studies with 681 participants), on the number of serious unwanted effects (11 studies with 681 participants), and on the need for liver transplantation (5 studies with 519 participants). No study included health-related well-being as an outcome. The evidence is very uncertain about the effect of liver support systems on hepatic encephalopathy (2 studies with 34 participants). Liver support systems may result in little to no difference in the number of multi-organ failures (6 studies with 501 participants), but the evidence is very uncertain. Only one study reported non-serious unwanted effects. Four studies were fully or partially funded by industry, five had no industry funding, and two did not mention their funding sources.

We found no ongoing studies.

What are the limitations of the evidence?

Two of the 11 included studies were only published in short formats rather than full academic papers. We identified studies published between 1973 and 2019 that used various types of liver support systems. Most were small single-centre studies.

We are not confident in the evidence because all studies had problems with study design and there were not enough people in the studies to be sure of their results. Most liver support systems used in the studies were produced by small manufacturers and were on the market for only a short time. Currently, none of the bioartificial liver support systems are available on the market.

How up to date is this evidence?

Date of last search: 10 July 2025