BACKGROUND Glucocorticoids (GC) are a potential therapy for acute liver failure (ALF). However, their clinical efficacy remains controversial, with significant interpatient heterogeneity. AIM To assess the impact of GC therapy on 28-day survival of patients with ALF and identify early treatment-response factors. METHODS In this single-centre retrospective cohort study, 179 patients with ALF from the past 12 years were included: 84 received GC treatment, and 95 served as non-GC controls. The primary outcome was 28-day survival. GC-treated patients were further stratified into responders and nonresponders to analyse the determinants of efficacy. Survival distributions were compared using Kaplan-Meier curves with the log-rank test. Independent predictors of GC response were identified through multivariate logistic regression. Statistical significance was set at P < 0.05. RESULTS The 28-day survival rate was significantly greater in the GC group than in the control group (58.3% vs 30.5%, P < 0.001). An early increase in prothrombin activity (PTA ≥ 4.5% by day 3), along with baseline model for end-stage liver disease (MELD) score < 28.5 and blood ammonia concentration < 135.5 μg/dL, was independently associated with GC response. A model combining these factors predicted GC responsiveness with an accuracy of 95.2%. CONCLUSION GC therapy improves 28-day ALF survival. An early increase in the PTA, combined with baseline MELD score and blood ammonia level, effectively identifies patients who are most likely to benefit.

Genetically engineered porcine livers are being developed as a bridge therapy for acute liver failure, providing detoxification and restoration of hepatic protein synthesis. Severe xenograft-associated severe thrombocytopenia remains a major limitation, and human mechanistic data are scarce. Platelet kinetics were characterized in three human decedents undergoing extracorporeal cross-circulation with transgenic porcine livers. Platelet counts, transfusion requirements, and clearance patterns were assessed to distinguish consumption from marrow suppression or hypersplenism. Antibody- and complement-directed inhibitors were administered to test immune-mediated mechanisms. Mechanistic studies focused on porcine von Willebrand factor (pVWF)-dependent platelet activation, including ex vivo blockade with the anti-VWF nanobody caplacizumab, a vWF-directed antibody fragment that prevents vWF-platelet binding. A fourth decedent received caplacizumab during porcine liver perfusion. In all three initial cases, 80%-90% of circulating and transfused platelets were rapidly cleared, a pattern inconsistent with marrow suppression or hypersplenism. Antibody and complement inhibition failed to ameliorate thrombocytopenia. Recipient plasma induced robust pVWF-mediated platelet activation analogous to human Type IIb von Willebrand disease, which was completely abrogated ex vivo by caplacizumab. In a fourth decedent treated with caplacizumab, aberrant platelet activation was prevented, though full hematologic recovery was limited by pre-existing disseminated intravascular coagulation (DIC). Early thrombocytopenia during porcine liver xenotransplantation appears to be primarily driven by pVWF-mediated platelet activation rather than by classical immune or splenic mechanisms. Targeted VWF blockade with agents such as caplacizumab may mitigate platelet loss and improve the safety profile of extracorporeal porcine liver support in acute liver failure.

Acute liver failure (ALF) represents a life-threatening medical emergency with high mortality, yet limited treatment is available clinically. Here, we report albumin-biomineralized nonstoichiometric copper sulfide nanoparticles serving as first-aid nanomedicine to combat ALF, conceptualized as NanoAID. The NanoAID exhibits an electron-donor nanoantioxidant property to scavenge reactive oxygen species and concurrent anti-inflammatory capacity to reprogram pro-inflammatory M1 macrophages into anti-inflammatory M2-phenotype, thereby mitigating excessive oxidative and inflammatory stress in ALF lesions. More interestingly, we found Cu ions release under an in situ oxidative stress switch and the resulting H2S gas generation by NanoAID degradation, which further enhance the biosynthesis of intrahepatic antioxidant enzyme SOD1 and the repolarization of M1-to-M2 macrophages, respectively, thereby self-reinforcing ALF therapy. Such microenvironment self-adaptive regulation confers NanoAID with effective prophylactic efficacy and significant ALF survival advantages over the FDA-approved N-acetyl cysteine in multiple animal models, extending the first-aid window to 6 h post APAP intoxication. Transcriptomics results reveal the molecular mechanisms of NanoAID by promoting antioxidative and inhibiting inflammatory pathways, underscoring its great potential as a next-generation first-aid nanomedicine for ALF management.

High-volume plasma exchange for acute liver failure: A retrospective study of 45 patients in Vietnam.

The mortality rates are significantly elevated with the rapid progression of acute liver failure in the absence of timely diagnosis and treatment. Liver transplantation is an effective therapeutic approach that can halt disease progression, but transplantation timing is a crucial factor affecting prognosis. Patients with acute liver failure should be promptly transferred to hospitals equipped for liver transplantation while simultaneously preparing for the procedure during the course of treatment to avoid missing the opportunity to save lives when the condition suddenly worsens. Auxiliary liver transplantation preserves the patient's native liver while transplanting a new liver. Therefore, patients are expected to gradually reduce immunosuppressants following the regeneration of the autologous liver, so avoiding the problem of lifelong use of immunosuppressants. This is also a unique advantage, offering benefits to patients undergoing auxiliary liver transplantation therapy for acute liver failure, while simultaneously presenting challenges for clinicians in terms of technical skill and comprehensive management.

Acetaminophen-induced acute liver failure is a serious medical emergency with a high risk of complications and mortality, particularly when treatment is not administered early and promptly. N-acetylcysteine (NAC) is typically the primary treatment, but patients who are at a risk of progressing to multi-organ failure or present late may benefit from therapeutic plasma exchange (TPE). We present a case of a 32-year-old male patient who presented with acute liver failure caused by late present of acetaminophen toxicity, but made significant clinical progress through the use of high-volume plasma exchange, thus by passing the need for liver transplantation. This report examines the underlying causes, diagnostic methods, treatment options, and supporting evidence derived from relevant case studies.

Abstract Drug‐induced acute liver failure (ALF) is characterized by rapid hepatocyte necrosis caused by oxidative stress and Kupffer cell (KC)‐mediated inflammation, with limited therapeutic options due to narrow treatment windows. To target this challenge, a biomimetic nanomedicine (RBLN) is developed for balanced drug delivery to both hepatocytes and KCs. Layered double hydroxide nanoparticles (clinically used as Talcid) are loaded with the antioxidant naringin and then coated with red blood cell membranes in fresh (fRBLN) or senescent (sRBLN) states, leveraging the preferential clearance of senescent red blood cells by KCs. This cell membrane coating enabled fRBLN to evade KC clearance and target hepatocytes, while sRBLN is selectively internalized by KCs. Intravenous administration of a 1:1 combination of fRBLN and sRBLN efficiently delivered naringin to both hepatocytes and KCs in a balanced manner, reduced hepatocyte oxidative stress, and mitigated KC‐driven inflammation by polarizing KCs from the M1 to M2 phenotype. Such a pre‐treatment significantly alleviated drug‐induced liver damage and nearly restored the liver functions in the mouse model. This strategy introduces a novel paradigm for balanced liver cell‐targeted drug delivery with promising potential for ALF therapy.

Sa1466: ESSENTIAL: EFFICACY AND SAFETY OF NON-TRANSPLANT THERAPIES FOR ACUTE LIVER FAILURE SYNDROMES DUE TO INFECTIVE AETIOLOGIES – A REAL-WORLD EXPERIENCE

Acute liver failure (ALF) is a life-threatening condition caused by rapid hepatocyte death and impaired liver regeneration. Here we show that extracellular vesicles engineered to express Signal Regulatory Protein Alpha (SIRP-EVs), produced via a scalable 3D bioreactor process with high yield and purity, exhibit significant therapeutic potential by targeting damaged cells and promoting tissue repair. SIRP-EVs block CD47, a crucial inhibitory signal on necroptotic cells, to enhance macrophage-mediated clearance of dying hepatocytes. They also deliver regenerative cargo from mesenchymal stem cells, reprogramming macrophages to support liver regeneration. In male animal models, SIRP-EVs significantly reduce liver injury markers and improve survival, demonstrating their dual-function therapeutic efficacy. By integrating the resolution of necroptosis with regenerative macrophage reprogramming, SIRP-EVs represent a promising platform for restoring liver function. These findings support the development of EV-based in vivo macrophage reprogramming therapies for ALF and other inflammation-driven diseases, paving the way for the clinical application of engineered EV therapeutics.

Objective(s):Acute liver failure (ALF) is a life-threatening condition marked by rapid hepatocellular damage. This study investigates the therapeutic efficacy of human umbilical cord-derived mesenchymal stem cells (hUCMSCs) in a rat model of ALF.Materials and Methods: ALF was induced using D-galactosamine and lipopolysaccharide in rats. hUCMSCs were administered intravenously at different time points and dosages. Liver function, inflammatory cytokine levels, histopathology, neutrophil infiltration, and survival rates were evaluated. Additionally, biodistribution was tracked using 89Zr-labeled hUCMSCs, and fresh versus cryopreserved cells were compared.Results: Administration of hUCMSCs, especially at the prog-2h time point, significantly improved survival and liver histology. Treatment reduced ALT and AST levels and modulated pro- and anti-inflammatory cytokines. Neutrophil infiltration was alleviated by both fresh and cryo-preserved hUCMSCs. Biodistribution data revealed hepatic enrichment of hUCMSCs peaking at 24 hr post-injection.Conclusion: hUCMSCs exhibit strong immunomodulatory and hepatoprotective properties in ALF, offering promise for clinical translation. Timing and dosage significantly influence therapeutic efficacy, and cryopreserved cells maintain functionality comparable to that of fresh cells.

NLRP3 inflammasomes are considered to be key factors in the pathogenesis of Acute Liver Failure (ALF). Some Traditional Chinese Medicines (TCMs) have shown protective and therapeutic effects against ALF by inhibiting NLRP3 inflammasomes. However, the inhibitory effects of most TCMs on ALF remain to be further elucidated. This study aimed to screen potential herbs that can treat ALF based on the inhibition of NLRP3 inflammasomes. Initially, we constructed the target set for 502 herbs. Subsequently, based on the target set and the gene set related to the NLRP3 inflammasome, using the ssGSEA algorithm, we evaluated herb scores and NLRP3 scores in the ALF expression matrix and performed a preliminary herb screening based on score correlations. Through bioinformatics approaches, we identified the key targets for candidate herbs and determined core herbs based on the herb-compound-target network. Furthermore, molecular docking and molecular biology methods validated the screening results of the herbs. A total of 18 crucial targets associated with the inhibition of the NLRP3 inflammasome were identified, which included ALDH2, HMOX1, and VEGFA. Subsequently, based on these key targets, a set of 10 primary herbs was chosen, notably Qinghao, Duzhong, and Gouteng. Moreover, the results were verified through molecular docking and molecular dynamic simulation. Ten key herbs have been identified as potential inhibitors of the NLRP3 inflammasome, offering insights into ALF therapy for drug development.

Inflammation is critical in the development of acute liver failure (ALF). Peroxisome proliferator-activated receptor delta (PPARδ) regulates anti-inflammatory responses and is protective in several diseases such as obesity and cancer. However, the beneficial effects and underlying mechanisms of PPARδ agonist GW501516 in ALF remain unclear. This study investigated the molecular mechanisms underlying the anti-inflammatory effects of GW501516 in macrophages and assessed its protective potential against lipopolysaccharide (LPS)/galactosamine (GalN)-induced ALF. In vivo administration of GW501516 significantly reduced LPS/GalN-induced hepatotoxicity, as evidenced by lower mortality, decreased liver damage, and attenuated secretion of IL-1β, IL-6, and TNF-α. GW501516 treatment also decreased LPS-induced nitric oxide synthase 2 (NOS2) expression and nitric oxide (NO) production in RAW264.7 cells, an effect reversed by PPARδ siRNA. Additionally, GW501516 inhibited LPS-induced phosphorylation of p38 and c-Jun N-terminal kinase (JNK), suggesting that inactivation of these MAPKs contributes to its effects. The secretion of IL-6, TNF-α, and NF-κB DNA-binding activity were also suppressed by GW501516, while the nuclear translocation of the NF-κB p65 subunit was unaffected. In conclusion, our findings suggest that GW501516 exerts protective effects in ALF by inhibiting the production of inflammatory mediators. Therefore, GW501516 may act as a potential agent for developing anti-inflammatory therapies for ALF.

3D printing incorporating gold nanozymes with mesenchymal stem cell-derived hepatic spheroids for acute liver failure treatment

Acute liver failure (ALF), associated with a clinical fatality rate exceeding 80%, is characterized by severe liver damage resulting from various factors in the absence of pre-existing liver disease. The role of microbiota in the progression of diverse liver diseases, including ALF, has been increasingly recognized, with the interactions between the microbiota and the host significantly influencing both disease onset and progression. Despite growing interest in the microbiological aspects of ALF, comprehensive reviews remain limited. This review critically examines the mechanisms and efficacy of microbiota-based treatments for ALF, focusing on their role in prevention, treatment, and prognosis over the past decade.

Framework nucleic Acid-MicroRNA mediated hepatic differentiation and functional hepatic spheroid development for treating acute liver failure

Acute liver failure (ALF) is a life-threatening disease associated with the rapid development of inflammatory storms, level elevation of reactive oxygen species (ROS), and hepatocyte necrosis, which results in high short-term mortality. Except for liver transplantation, no effective strategies are available for ALF therapy due to the rapid disease progression and narrow window of therapeutic time. Therefore, there is an urgent demand to explore the fast and effective modalities for ALF treatment. Herein, a multifunctional tetrahedral DNA nanoplatform (TDN) is constructed by incorporating tumor necrosis factor-α siRNA (siTNF-α) through DNA hybridization and antioxidant manganese porphyrin (MnP4) via π-π stacking interaction with G-quadruplex (G4) for surprisingly rapid and significant ALF therapy. TDN-siTNF-α/-G4-MnP4 silences TNF-α of macrophages by siTNF-α and polarizes them to the anti-inflammatory M2 phenotype, providing appropriate microenvironments for hepatocyte viability. Additionally, TDN-siTNF-α/-G4-MnP4 scavenges intracellular ROS by MnP4, protecting hepatocytes from oxidative-stress-associated cell death. Furthermore, TDN itself promotes hepatocyte proliferation by modulating the cell cycle. TDN-siTNF-α/-G4-MnP4 shows almost complete liver accumulation after intravenous injection and exhibits excellent therapeutic efficacy of ALF within 2h. The multifunctional DNA nanoformulation provides an effective strategy for rapid ALF therapy, expanding its application for innovative treatments of liver diseases.

Healthy livers contain 80% of body resident macrophages known as Kupffer cells. In diseased livers, the number of Kupffer cells usually drops but is compensated by infiltration of monocyte-derived macrophages, some of which can differentiate into Kupffer-like cells. Early studies suggest that Kupffer cells play important roles in both promoting liver injury and liver regeneration. Yet, the distinction between the functionalities of resident and infiltrating macrophages is not always made. By using more specific macrophage markers and targeted cell depletion and single-cell RNA sequencing, recent studies revealed several subsets of monocyte-derived macrophages that play important functions in inducing liver damage and inflammation as well as in liver repair and regeneration. In this review, we discuss the different roles that hepatic macrophages play in promoting necrotic liver lesion resolution and dead cell clearance, as well as the targeting of these cells as potential tools for the development of novel therapies for acute liver failure and acute-on-chronic liver failure.

The acute inflammatory milieu in patients with acute liver failure (ALF) results in 'toxic' blood in these patients. In vitro experiments have shown that the plasma obtained from ALF patients is toxic to rabbit hepatocytes and inhibits regeneration of rat hepatocytes. Treatments such as plasma exchange and continuous renal replacement therapy to cleanse the blood have improved survival in ALF patients. In the liver microcirculation, the exchange of fluid across fenestrae in liver sinusoidal endothelial cells (LSECs) is vital for proper functioning of hepatocytes. Clogging of the liver filter bed by inflammatory debris and cells ('traffic jam hypothesis') impeding blood flow in sinusoids may in turn reduce the exchange of fluid across LSEC fenestrae and cause dysfunction and necrosis of hepatocytes in ALF patients. In mouse model of paracetamol overdose, disturbances in microcirculation in the liver preceded the development of injury and necrosis of hepatocytes. This may represent a reversible pathophysiological mechanism in ALF which may be improved by the anti-inflammatory effect of plasma exchange. Wider access to urgent plasma exchange is a major advantage compared to urgent liver transplantation to treat ALF patients worldwide, especially so in resource constrained settings. Continuous hemo-filtration or dialysis is used toreduce ammonia levels and treat cerebral edema in ALF patients. In this review, we discuss the different modalities to cleanse the blood in ALF patients, with an emphasis on plasma exchange, from a hepatology perspective.

Objectives: Acute liver failure (ALF) is associated with high morbidity and mortality. Timely liver transplantation (LT) is the only universally accepted therapy for ALF that is non-responsive to medical therapy. Data regarding the use of living donor LT (LDLT) for this indication in the US is scarce. Materials and Methods: United Network of Organ Sharing/Organ Procurement and Transplantation Network (UNOS/OPTN) data from January 2002 to December 2020 were reviewed. Adult and pediatric recipients listed as status 1 were included. Demographics, clinical and laboratory data, and post-LT survival rates were compared for LDLT vs. DDLT recipients. Results: There were 180 LDLT (3.6%) and 4779 DDLT (96.4%) recipients with a diagnosis of ALF. The majority of recipients in the LDLT group were pediatric (n = 164, 91%) compared to the DDLT group (n = 1455, 30%), p < 0.001. In the pediatric-only group, post-LT survival was comparable between LDLT and DDLT recipients (p = 0.15). Five-year post-LT survival was higher for pediatric recipients compared to adults in the LDLT group (84.2% vs. 62.5%, respectively, p < 0.001) and the DDLT group (82.8% vs. 78.7%, respectively, p < 0.001). Adults had a higher hazard of death compared to pediatric recipients in the LDLT group (HR = 3.560, 95% CI 1.612-7.844, p = 0.002) and the DDLT group (HR = 1.472, 95% CI 1.290-1.679, p < 0.001). In multivariate analysis results, the type of LT and age group were not associated with higher post-LT mortality. Conclusions: In the US, LDLT constitutes 3.6% of LTs for ALF. In the pediatric-only group, post-LT survival was comparable between LDLT and DDLT recipients. Overall, there were superior post-LT outcomes for pediatric recipients compared to adults for LDLT and DDLT.

Dihydroquercetin improves experimental acute liver failure by targeting ferroptosis and mitochondria-mediated apoptosis through the SIRT1/p53 axis