*Purpose: Acute on chronic liver failure (AOCLF) occurs in nearly 25% of patients with acutely decompensated cirrhosis, with many developing multi-organ failure requiring ventilatory, vasopressor and dialysis support, and in the most severe cases, they become unsuitable for liver transplantation. The 28-day mortality with 3 or more organ system failure is 75-90%. Trials of liver assist devices to improve clinical condition allowing transplantation have been disappointing. Purpose of the study was to improve outcome in AOCLF patients with more than 3 organ failure.

*Methods: A modified hemodialysis machine with added albumin circuit (MAHD) was developed and used at University of Washington in 10 AOCLF patients with more than 3 organ failures. All patients were made inactive on the liver transplant wait list, once their encephalopathy worsened, they developed respiratory failure requiring mechanical ventilation, became hypotensive requiring vasopressors, and/or developed large fluid excess with renal failure needing hemodialysis. In all patients the MELD scores were over 40, bilirubin more than 5 mg/dL, with elevated ammonia levels and there was presence of active bleeding from various sites.

*Results: With the use of the MAHD, all patients were eventually extubated, with significant improvement in encephalopathy to baseline status, discontinuation of vasopressor support, and removal of large volumes of extracellular fluid. Four patients underwent liver transplantation, and one recovered liver function and came off the transplant wait list. Five patients died while waiting for a liver, for a period ranging from 12 – 74 days. The causes of death were bleeding (n=4), sepsis (n=3), and stroke and cardiac arrest (n=1), (some patients had more than one cause of death).

*Conclusions: In this limited study, the 28-day survival of 90% was better than expected, and the ability to reactivate wait list status was achieved in all patients (100%), with successful liver transplantation and one native liver recovery seen in 50% of patients (Figure). MAHD was very effective in fluid removal while traditional HD was ineffective. No complications of this treatment were encountered. Thus, MAHD appears to be successful as a bridge to transplantation in patients with AOCLF. The major limitation of the study is the small number of patients.

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