Acute Liver Failure: Should CRRT Start Before the Kidneys Fail?: Alimentary Pharmacology & Therapeutics | September 2026

What Did the Study Find?

This pilot RCT evaluated pre-emptive CRRT in patients with acute liver failure (ALF) and cerebral edema receiving therapeutic plasma exchange.

Starting CRRT within 12 hours reduced 7-day mortality from 17.8% to 2.2%.

Early CRRT produced greater ammonia reduction and improved hemodynamics.

However, the key 28-day survival outcome was similar in the intention-to-treat analysis.

Per-protocol analysis favored early CRRT, but interpretation is limited by substantial crossover and protocol violations in the delayed-treatment arm.

The trial was open-label and pilot-sized, so definitive survival benefit remains unproven.

Why Does It Matter?

In ALF, hyperammonemia contributes to cerebral edema and intracranial hypertension. CRRT may therefore have a role before conventional renal indications develop, targeting ammonia rather than kidney failure alone.

GastroAGI Takeaway

Think of CRRT in severe ALF as an ammonia-control strategy—not merely renal replacement therapy. Early CRRT produced a striking reduction in early mortality and improved ammonia clearance, but the neutral 28-day ITT result prevents a definitive survival claim. For now, pre-emptive CRRT is best considered in experienced liver-ICU/transplant centres, while awaiting a larger definitive trial.