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Attempts to replace liver function with extracorporeal procedures date back to the 1950s. The absence of evidence of effectiveness with regard to mortality and the successful introduction of liver transplantation caused these procedures to be applied very rarely. With the development of new technologies and the shortage of organs for transplantation, several groups introduced liver support systems once more into clinical practice. The idea is to inhibit further liver damage and to reduce or eliminate the negative effects of insufficient liver function on various organs and organ systems. The ultimate purpose is to improve morbidity and mortality in patients with acute and acute-on-chronic liver failure and to reduce the need for liver transplantation.We have reviewed the literature addressing different forms of extracorporeal therapies in patients with acute and acute-on-chronic liver failure.In trials carried out so far, the use of extracorporeal therapy was shown to eliminate the various toxins and to improve organ function. However, there have yet been no controlled trials on mortality. While the available systems of detoxification are technically highly advanced, hybrid systems using liver cells have not yet succeeded in resolving all the problems.Over the past 30 years, a variety of supportive therapies for patients with acute liver failure have been proposed, including charcoal haemoperfusion, haemodialysis, plasmapheresis, ex vivo liver perfusion and cross circulation, but none have proved efficacious when studied in carefully controlled trials. In recent years the removal of albuminbound substances has gained increasing interest especially in acute-on-chronic liver failure. Preliminary results using this new detoxification system are encouraging.