***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract For patients with acute-on-chronic liver failure ( ACLF ) , artificial liver support system ( ALSS ) may help prolong lifespan and function as a bridge to liver transplantation ( LT ) , but data on its long-term benefit are lacking . We conducted this prospect i ve , controlled study to determine the efficacy of ALSS and the predictors of mortality in patients with hepatitis B virus (HBV)-associated ACLF.From January 2003 to December 2007 , a total of 234 patients with HBV-associated ACLF not eligible for LT were enrolled in our study . They were allocated to receive either plasma exchange centered ALSS plus st and ard medical therapy ( SMT ) ( ALSS group , n = 104 ) or SMT alone ( control group , n = 130 ) . All the patients were followed-up for at least 5 years , or until death . At 90 days , the survival rate of ALSS group was higher than that of the control group ( 62/104 [ 60 % ] vs 61/130 [ 47 % ] , respectively ; P < 0.05 ) . Median survival was 879 days in the ALSS group ( 43 % survival at 5 years ) and 649 days in the control group ( 31 % survival at 5 years , log-rank P < 0.05 ) . ALSS was found to be associated with favorable outcome of these patients by both univariate and multivariate analysis . Multivariate Cox regression analysis also revealed that lower serum sodium levels , higher grade s of encephalopathy , presence of cirrhosis , hepatorenal syndrome , and higher model for end-stage liver disease scores were independent predictors for both 90-day and 5-year mortality due to ACLF.Our findings suggest that ALSS is safe and may improve the short- and long-term prognosis of patients with HBV-associated ACLF Flaws in the design , conduct , analysis , and reporting of r and omised trials can cause the effect of an intervention to be underestimated or overestimated . The Cochrane Collaboration ’s tool for assessing risk of bias aims to make the process clearer and more Patients with liver cirrhosis and a superimposed acute injury with progressive hyperbilirubinemia have a high mortality . A prospect i ve , controlled study was performed to test whether hyperbilirubinemia , 30‐day survival , and encephalopathy would be improved by extracorporeal albumin dialysis ( ECAD ) .  Twenty‐four patients were studied ; 23 patients had cirrhosis ; 1 had a prolonged cholestatic drug reaction and was excluded from per protocol ( PP ) analysis . Patients had a plasma bilirubin greater than 20 mg/dL and had not responded to prior st and ard medical therapy ( SMT ) . Patients were r and omized to receive SMT with ECAD or without ( control ) . ECAD was performed with an extracorporeal device that dialyzes blood in a hollow fiber dialyzer ( MW cutoff < 60 kd ) against 15 % albumin . Albumin‐bound molecules transfer to dialysate albumin that is regenerated continuously by passage through a charcoal and anion exchange column and a conventional dialyzer . ECAD was associated with improved 30‐day survival ( PP , 11 of 12 ECAD , 6 of 11 controls ; log rank P < .05 ) . Plasma bile acids and bilirubin decreased on average by 43 % and 29 % , respectively , in the ECAD group after 1 week of treatment , but not in the control group . Renal dysfunction and hepatic encephalopathy improved in the ECAD group , but worsened significantly in the control group . ECAD was safe , with adverse events being rare and identical in both groups . In conclusion , ECAD appears to be effective and safe for the short‐term treatment of patients with cirrhosis and superimposed acute injury associated with progressive hyperbilirubinemia and may be useful for increasing survival in such patients awaiting liver transplantation The Molecular Adsorbent Recirculating System ( MARS ) has been proven to prolong survival in  patients with hepatorenal syndrome .  MARS is a modified dialysis that uses an albumin containing dialysate , which is recirculated and perfused online through charcoal and anion exchanger columns . It allows the selective removal of albumin bound substances . Despite advances in medical therapy and technology , the prognosis of patients with cardiogenic shock remains poor . Mortality rates are as high as 80 % , often because of persistent multiple organ failure . To determine whether patients with hypoxic liver failure after cardiogenic shock after cardiac surgery might benefit from MARS , we performed a prospect i ve , r and omized , controlled , single center study . The primary objective was to prove that MARS improves survival . This article is a report on the interim analysis of the first 27 patients included between August 2000 and December 2001 ; 14 patients were in the MARS group , and 13 patients were in the non-MARS group . All had bilirubin levels greater than 8 mg/ml . Both groups had a similar risk profile . The MARS group received MARS for 3 consecutive days — if bilirubin was still greater than 6 mg/dl afterward , MARS was continued . The non-MARS group received conventional therapy . We had seven survivors in the MARS group ( 50 % ) compared with four ( 32 % ; p = ns ) in the non-MARS group . We conclude that despite the limited number of patients included in this analysis , MARS can be recommended for patients with acute , hypoxic liver failure because it might prolong survival . Further studies in similar patient cohorts are needed to verify our results BACKGROUND Albumin dialysis with the Molecular Adsorbent Recirculating System ( MARS ) ( Gambro , Lund , Sweden ) , a noncell artificial liver support device , may be beneficial in acute liver failure ( ALF ) . OBJECTIVE To determine whether MARS improves survival in ALF . DESIGN R and omized , controlled trial . ( Clinical Trials.gov : NCT00224705 ) . SETTING 16 French liver transplantation centers . PATIENTS 102 patients with ALF . INTERVENTION Conventional treatment ( n = 49 ) or MARS with conventional treatment ( n = 53 ) , stratified according to whether paracetamol caused ALF . MEASUREMENTS 6-month survival and secondary end points , including adverse events . RESULTS 102 patients ( mean age , 40.4 years [ SD , 13 ] ) were in the modified intention-to-treat ( mITT ) population . The per- protocol analysis ( 49 conventional , 39 MARS ) included patients with at least 1 session of MARS of 5 hours or more . Six-month survival was 75.5 % ( 95 % CI , 60.8 % to 86.2 % ) with conventional treatment and 84.9 % ( CI , 71.9 % to 92.8 % ) with MARS ( P = 0.28 ) in the mITT population and 75.5 % ( CI , 60.8 % to 86.2 % ) with conventional treatment and 82.9 % ( CI , 65.9 % to 91.9 % ) with MARS ( P = 0.50 ) in the per- protocol population . In patients with paracetamol-related ALF , the 6-month survival rate was 68.4 % ( CI , 43.5 % to 86.4 % ) with conventional treatment and 85.0 % ( CI , 61.1 % to 96.0 % ) with MARS ( P = 0.46 ) in the mITT population . Sixty-six of 102 patients had transplantation ( 41.0 % among paracetamol-induced ALF ; 79.4 % among non-paracetamol-induced ALF ) ( P < 0.001 ) . Adverse events did not significantly differ between groups . LIMITATION The short delay from r and omization to liver transplantation ( median , 16.2 hours ) precludes definitive efficacy or safety evaluations . CONCLUSION This r and omized trial of MARS in patients with ALF was unable to provide definitive efficacy or safety conclusions because many patients had transplantation before administration of the intervention . Acute liver failure not caused by paracetamol was associated with greater 6-month patient survival . PRIMARY FUNDING SOURCE Assistance Publique-Hôpitaux de Paris Background For patients with an acute exacerbation of chronic liver failure ( ACLF ) , the molecular adsorbent recirculating system ( MARS ) can result in a prolongation of life , but data on costs and cost-effectiveness are lacking . Methods A health economic evaluation of a prospect i ve controlled cohort trial in patients with ACLF not eligible for liver transplantation with 3 years follow-up and consecutive modelling of long-term costs , outcomes and cost-effectiveness was conducted . Costs were calculated from the perspective of the German health-care system . Results One hundred and forty-nine patients with ACLF were included of which 67 ( 44.9 % ) were treated with MARS and 82 ( 55.1 % ) assigned to the control group . Mean survival was 692 days in MARS-treated patients ( 33 % survival after 3 years ) and 453 days in control patients ( 15 % after 3 years , logrank P = 0.022 ) . MARS patients gained 0.66 [ 95 % confidence interval ( CI ) : −0.12 to 1.46 ] life years ( LYs ) , determined by the bootstrap method . The mean cost difference was 19.835 & U20AC ; ( 95 % CI : 13.308–25.429 ) with 35639 & U20AC ; for MARS-treated patients and 15804 & U20AC ; for controls . Incremental costs per LY gained were 29.985 & U20AC ; ( 95 % CI : 9.441–321.761 ) and 43.040 & U20AC ; ( 95 % CI : 13.551–461.856 ) per quality -adjusted LY gained . Conclusion There is an acceptable cost-effectiveness of MARS , compared with other medical technologies presently reimbursed . R and omized controlled trials with sufficient sample size are necessary before a final recommendation for MARS can be given The objective of this pilot controlled study was to evaluate the extracorporeal liver assist device ( ELAD ) in patients with acute liver failure who were judged to still have a significant chance of survival ( approximately 50 % ) and in those who had already fulfilled criteria for transplantation . Twenty-four patients were divided into two groups , 17 with a potentially recoverable lesion ( group I ) and 7 listed for transplantation ( group II ) , and then r and omly allocated to ELAD haemoperfusion or control . The median period of ELAD haemoperfusion was 72 hours ( range 3 - 168 h ) . Biocompatibility of the device was good , with no acceleration in platelet consumption , and haemodynamic stability was maintained . Two patients were withdrawn from the study because of worsening of preexisting disseminated intravascular coagulation in one case and a hypersensitivity reaction in the other . Deterioration with respect to encephalopathy grade was more frequent in the control patients , 7 of 12 ( 58 % ) , than in the ELAD-treated patients , 3 of 12 ( 25 % ) . In group I where survival for the ELAD cases was 7 of 9 ( 78 % ) , there was a higher than expected survival in the controls , 6 of 8 ( 75 % ) . For group II cases , survival was 1 of 3 ( 33 % ) for the ELAD-treated patients , and 1 of 4 ( 25 % ) for the controls . Both of the survivors underwent transplantation . Assessment of additive function for the device revealed an improvement in galactose elimination capacity after 6 hours of haemoperfusion . Based on the results of this pilot-controlled trial , better indices of prognosis will be required , in addition to those used to select for transplantation , if patients at an earlier stage of clinical deterioration are to be included in future studies Patients with acute-on-chronic liver failure ( ACLF ) are known to have a very high mortality rate as the majority of these patients succumb to multiorgan failure . Liver transplant remains the only option for these patients ; however , there are problems with its availability , cost and also the complications and side effects associated with immunosuppression . Unlike advanced decompensated liver disease , there is a potential for hepatic regeneration and recovery in patients with ACLF . A liver support system , cell or non-cell based , logically is likely to provide temporary functional support until the donor liver becomes available or the failing liver survives the onslaught of the acute insult and spontaneously regenerates . Underst and ing the pathogenesis of liver failure and regeneration is essential to define the needs for a support system . Removal of hepatotoxic metabolites and inhibitors of hepatic regeneration by liver dialysis , a non-cell-based hepatic support , could help to provide a suitable microenvironment and support the failing liver . The current systems , i.e. , MARS and Prometheus , have failed to show survival benefits in patients with ACLF based on which newer devices with improved functionality are currently under development . However , larger r and omized trials are needed to prove whether these devices can enable restoration of the complex dysregulated immune system and impact organ failure and mortality in these patients To investigate the role of extracorporeal detoxification in cirrhotic patients with advanced hepatic encephalopathy not responding to medical 
    Output:
    
Conclusions ECLS may reduce mortality and improve HE in patients with ALF and ACLF .
The effect on other outcomes is uncertain .