Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are life-threatening conditions with high short-term mortality. Single Pass Albumin Dialysis (SPAD) is an extracorporeal liver support therapy designed to remove albumin-bound toxins such as bilirubin and bile acids. Its efficacy has been inconsistent, and the role of albumin gradient—the difference between dialysate and serum albumin concentrations—remains unclear.

We conducted a retrospective cohort study of adult patients with ALF or ACLF who underwent SPAD at a tertiary medical center between January 2023 and December 2025. Demographic, clinical, and laboratory data were collected pre- and post-SPAD, including bilirubin fractions, ammonia, hemoglobin, and platelet counts. Spearman correlation was used to assess associations between albumin gradient and biochemical changes. Wilcoxon signed-rank tests evaluated pre- and post-SPAD differences. Survival outcomes at 7 and 28 days were reported as proportions.

Thirty-six patients were included (58% male; 69% with decompensated cirrhosis, Child-Pugh C). The albumin gradient did not significantly correlate with changes in bilirubin, hemoglobin, platelet, or ammonia (all p > 0.05). However, SPAD achieved significant reductions in total bilirubin (median 18.65 to 17.37 mg/dL, p < 0.001), conjugated bilirubin (median 13.0 to 11.96 mg/dL, p < 0.001), and unconjugated bilirubin (median 6.0 to 5.3 mg/dL, p = 0.003). Hemoglobin, platelet, and ammonia showed no significant differences. Seven-day survival was 69%, declining to 42% at 28 days, with 16% mortality and 42% missing follow-up data.

SPAD effectively reduces bilirubin fractions in patients with ALF and ACLF, confirming its role in bilirubin clearance. Albumin gradient, however, was not predictive of toxin clearance or hematologic changes, suggesting that other procedural and patient-specific factors are more critical determinants of efficacy. Survival benefit was limited, consistent with priorreports that extracorporeal liver support provides transient stabilization rather than long-term improvement. These findings highlight SPAD’s feasibility as a bridging therapy in resource-limited settings and underscore the need for prospective trials to optimize protocols and clarify survival outcomes.