Continuous Renal Replacement Therapy in Acute Liver Failure: Rationale, Evidence, and Evolving Practice.

Acute liver failure (ALF) is a life-threatening condition hallmarked by an acute onset of liver dysfunction, coagulopathy, and encephalopathy in individuals without pre-existing liver disease. Advances in intensive care, coupled with increased access to liver transplant (LT), have substantially improved outcomes of individuals with ALF. Aggressive goal-directed intensive care focusing on individual organs has become the cornerstone of ALF management. In this context, continuous renal replacement therapy (CRRT) has emerged as a critical component in the management of ALF. While traditionally centered around providing renal support and optimizing renal injury, the use of CRRT in ALF has expanded to include potential benefits in controlling intracranial hypertension, managing volume status and metabolic abnormalities, and reducing hyperammonemia. The use of CRRT for nonrenal ALF-centric indications has gradually gained credence. This review examines the mechanistic aspects and principles of CRRT in ALF, summarizing current clinical evidence and practice patterns. We delve into aspects of basic circuit knowledge, timing of initiation, targets of therapy, challenges of anticoagulation, emerging literature on the combination of plasma exchange with CRRT, and provide insights into pragmatic decision-making with CRRT in ALF. Lastly, the review focuses on endpoints for the use of CRRT in ALF, as well as associated challenges and future directions.