Dialysis method

Abstract

The invention relates to the treatment of an individual suffering from liver disease. It relates to methods for the treatment of such an individual and to in vitro methods of cleaning blood extracorporeally.

Description

DIALYSIS METHODField of the inventionThe invention relates to the treatment of an individual suffering from liver disease. It relates to methods for safely treating such an individual and to in vitro methods of cleaning blood extracorporeally.Background to the inventionAcute-on-chronic liver failure (ACLF) occurs in patients with cirrhosis who present at hospital with acute liver decompensation and liver-related complications. It is characterized clinically by multiorgan failure and high risk of short-term mortality and, pathophysiologically by the presence of systemic inflammation. Mechanistically, systemic inflammation observed in ACLF is thought to be driven to a significant extent by severe albumin dysfunction and accumulation of damage- and pathogen-associated molecular patterns (DAMPs and PAMPs).The European Association for the Study of Liver diseases - Chronic Liver Failure (EASL-CLIF) Consortium criteria for the diagnosis of ACLF and prognosis of these patients have been well-validated.The CLIF-Consortium (CLIF-C) ACLF score, which is a composite score derived from CLIF-C organ failure (CLIF-OF) score, patient age and white cell count has been validated as a more accurate score than the conventionally used scoring systems in defining the prognosis of ACLF patients with respect to risk for mortality.Depending upon the severity of ACLF grade, resolution of ACLF occurs in about 20-55% of patients with the current standard of care (SOC). Once recovered, the survival rates approach those without ACLF. The short-term goal of therapy, therefore, is to increase the proportion of patients that resolve ACLF and reduce the time to achieve resolution.Several extracorporeal liver assist devices have been tested to date but none of them have shown an improvement in the survival of ACLF patients. Apart from liver transplantation, no treatment has been shown to reduce mortality of these patients and its treatment therefore is an important unmet need. Currently, the management of ACLF involves treatment of the specific complications and multiorgan supportive care.DIALIVE is an extracorporeal liver dialysis device that has been built to specifically address the pathophysiological sequelae responsible for the development of ACLF. DIALIVE incorporates a renal dialysis machine (e.g., Prismaflex, Baxter) and uses a dual filtration system connected in series. The first filter is comprised of a membrane that allows ultrafiltration of albumin and cytokines (Septex, Baxter, USA) and the second filter adsorbs PAMPs such as endotoxins and DAMPs such as genomic DNA (Oxiris, Baxter, USA). The removed albumin is replaced in similar quantities with bottled, 20% albumin. The rationale underlying DIALIVE are the following. First, the circulating albumin in ACLF is not only dysfunctional but can itself induce an inflammatory response. Second, systemic inflammation is the result of accumulation of DAMPs and PAMPs which leads to organ dysfunction and increased risk of infections. Therefore, DIALIVE aims to safely remove dysfunctional albumin and replace it with functional albumin and remove DAMPs and PAMPs from circulation. In large animal models of liver failure DIALIVE was shown to be safe, gave evidence of device performance and reduced short term mortality. WO 2008 / 050148 and WO 2021 / 198674 describe uses of the DIALIVE device.However, there is a need to ensure that the DIALIVE method is safe and effective in human patients with liver failure, such as patients with ACLF.Summary of the inventionThe present inventors have investigated use of the DIALIVE extracorporeal liver dialysis device in the treatment of patients with liver failure, such as patients with ACLF in a controlled randomized study. Through the conduct of this study the inventors discovered critical improvements in the methods of using the DIALIVE machine, from what was tested in the animal studies, that are needed to achieve substantial improvements in the safety and efficacy of DIALIVE. Changes to the methods that significantly enhance the safety include, but are not limited to, in-treatment interventions that prevent hypotensive, coagulation and bleeding events. Other changes to the method that enhance safety include pre-treatment interventions that prevent hypotensive, coagulation and bleeding events and continuous monitoring of blood pressure and markers of tissue hypoperfusion. Furthermore, it is beneficial that these methods are implemented under the continuous oversight of a healthcare professional familiar with extracorporeal interventions,monitoring and troubleshooting in a high dependency environment such as an Intensive Care or High Dependency Unit (ICU / HDU).As such the present invention relates to:A method of treating an individual with liver disease, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is about >1.0 g / L.In a further embodiment, the present invention relates to:A method of treating an individual with liver disease, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets / mm3or lower and the fibrinogen level is about 1.0 g / L or lower.In a further embodiment, the present invention relates to:An ex vivo method of treating blood extracorporeally by removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease, the method comprising:(a) contacting the blood with a solid support which binds albumin and thereby removing albumin from the blood;(b) contacting the blood with a solid support which selectively binds endotoxin and thereby removing endotoxin from the blood;(c) simultaneously adding to the blood albumin that does not derive from the same individual as the blood; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the blood has a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L.In a further embodiment, the present invention relates to:Albumin that does not derive from the blood of an individual to be treated for use in a method of liver disease, said method comprising the steps of:(a) removing albumin from the blood of the individual;(b) reducing the level of endotoxin in the blood of the individual; and(c) introducing said albumin that does not derive from the individual to be treated into the blood of the individual; wherein step (a) is carried out by dialysis using means comprising a membrane having a pore size of greater than 45kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is about >1.0 g / L.Brief description of the drawingsFigure 1. Biomarkers of the device performance in patients treated with DIALIVE or Standard of Care (SOC).A. These eight panels describe changes in albumin concentration and the functional domains that were measured in the DIALIVE and SOC groups at Days 0, 5 and 10. The data show that there was no significant difference in the albumin concentration either within the group nor between the groups. There was a significant increase in human mercapt albumin (HMA) and a reduction in the human non-mercapt albumins (HNA 1 and 2) both at Days-5 and- 10 in the DIALIVE arm compared with the SOC arm resulting in a significant increase in albumin redox status reflected by an increase in the HMA / HNA ratio at Days-5 and- 10 respectively. There was a significant increase in the binding efficiency of albumin at Day- 10 in the DIALIVE group compared with the SOC group, but detoxification efficiency did not change significantly. Ischemia modified albumin ratio (IMAR) was significantly reduced in the DIALIVE group compared with the SOC group at both Days-5 and 10.B and C. These 3 panels describe changes in markers of endotoxin activity. The results for endotoxin activity assay (EAA) described here represents data from patients with coefficient of variation < 15%. Pre-specified target value was 40% and acceptable value was 20% (panel B). The second endotoxin measure used was the limulus amebocyte lysate assay. There was also a statistically significant advantage for DIALIVE at Day- 10 (panel C).The analyses were performed using data from all patients from the modified safety population included in both the groups. Mixed Models for Repeated Measurements (MMRM) analysis was performed to evaluate the statistically significant differences between groups (SOC and DIALIVE) at the main time-points including absolute values (Day-5 and Day- 10). Reported p-values, effect sizes and 95% confidence intervals of time effect comparison obtained from MMRM for the absolute values adjusted by treatment, time (Baseline, Day-5 and Day- 10) and interaction between time and treatment. *Describes statistically significant difference with the groups and between groups at specified time points [*p<0.05; **p<0.01; ***p<0.001].Figure 2. Clinical effect of DIALIVE or Standard of Care (SOC) on severity of acute on chronic liver failure and its resolution.A. These 6-panels describe the effect of DIALIVE or SOC on individual organ functions There were significant improvements in the liver, kidney, coagulation, and brain subscores in both groups but the changes in each of these subscores was significantly greater in the DIALIVE group at Day- 10.B. Significantly greater improvement in the CLIF-OF and CLIF-C ACLF scores were observed in DIALIVE group at Day-10. Although ACLF grades were not statistically different between groups, there were greater proportion of patients that resolved ACLF at Day-10 (42.9% vs 26.7%; p=0.450) in the DIALIVE group, which was not statistically significant.C. The time to resolution of ACLF was also significantly faster (log rank p=0.036). The analyses were performed using data from all patients from the modified safety population included in both the groups. Mixed Models for Repeated Measurements (MMRM) analysis was performed to evaluate the statistically significant differences between groups (SOC and DIALIVE) at the main time-points (Day-5 and Day-10). Reported p-values, effect sizes and 95% confidence intervals of time effect and within treatment comparison obtained from MMRM for the absolute values adjusted by treatment, time and interaction between time and treatment. Overall treatment effect was calculated absolute differences adjusted by treatment and interaction between both. Individual organ scores and ACLF grade were evaluated using Cumulative Link Mixed Models (CLMM) with Laplace approximation adjusted by treatment, time and interaction between time and treatment. Kaplan-Meier curve was constructed to determine differences between groups in the resolution of ACLF and logrank test was used for survival comparison. * Describes statistically significant difference with the groups and between groups at specified time points [*p<0.05; **p<0.01; ***p<0.001], # Describes overall treatment effect [#p<0.05; ##p<0.01 ] .Figure 3. Selected biomarkers assessing the impact of DIALIVE or Standard of Care (SOC) on the pathophysiological factors associated with acute on chronic liver failure.A. These 4-panels show changes in markers of the key cytokines and chemokines associated with ACLF. DIALIVE significantly lowered IL-8 at both Day-5 and Day- 10 compared with SOC resulting in a significant overall treatment effect. For TNF-a, IL-6 and IL- 18 there were trends to lower levels, but no statistical significance was observed.B. These 3-panels describe markers of cell death. For the M30 component of cytokeratin-18, a marker of apoptosis, there was a significant treatment effect overall and a significant reduction at Day-10 compared to SOC group. For the M65 component of cytokeratin-18, there was a significant treatment effect overall and a significant advantage for DIALIVE at Day- 10. For receptor-interacting serine / threonine-protein kinase 3 (RIPK3) there was a significant advantage for DIALIVE at Day-5.C. The first two panel show the effect of incubation of the patient’s plasma with reporter cell lines that would become activated by toll-like 4 receptor (TLR4) or inflammasome ligands. There was a significant treatment effect overall with significant reduction for DIALIVE group at both Day-5 and Day- 10 when the patient’s plasma was incubated with TLR4 reporter cell line. Similarly, there was an overall significant treatment effect when the patient’s plasma was incubated with the ILlb / IL18 inflammasome cell line. There were significant advantages for DIALIVE at both Day-5 and Day- 10.D. The third and fourth panels show biomarkers of endothelial dysfunction. For asymmetric dimethylarginine (ADMA) there was a significant treatment effect overall with a significant reduction in the DIALIVE group at Day-10. For Factor VIII, there was a significant treatment effect overall in favour of DIALIVE with a significant reduction observed at Day 5.The analyses were performed using data from all patients from the modified safety population included in both the groups. Mixed Models for Repeated Measurements (MMRM) analysis was performed to evaluate the statistically significant differences between groups (SOC and DIALIVE) at the main time-points (Day-5 and Day-10). Reported p-values, effect sizes and 95% confidence intervals of time effect comparisons obtained from MMRM for the absolute values adjusted by treatment, time and interaction between time and treatment. Overall treatment effect was calculated using absolute differences adjusted by treatment and interaction between both. * Describes statistically significant difference with the groups and between groups at specified time points [*p<0.05; **p<0.01; ***p<0.001], # Describes overall treatment effect [#p<0.05; ##p<p.01].Figure 4. Relationship of the device performance and pathophysiology-relatedbiomarkers to resolution of ACLFA. This describes trends of changes from baseline in all the biomarkers measured in the patients treated with DIALIVE and standard of care (SOC) at Days-5 and 10. Statistically significant changes in human mercaptalbumin (HMA), human non- mercapt albumin-2 and IL-8 at both Day-5 and 10 respectively were observed. Furthermore, statistically significant changes at only Day-5 were observed in IL-18, IL1B, IL1B / IL-18 inflammasome cell line response, RIPK3 and platelets. Statistically significant changes at Day-10 alone were observed in HNA-1, HMA / HNA ratio and M30 component of cytokeratin-18. More variable results of the biomarkers were observed in the patients treated with SOC. Red indicates higher values at Day-5 or Day- 10 compared to baseline, blue otherwise.B. This describes trends of changes from baseline and Day- 10 in all the biomarkers measured and their relationship with resolution of ACLF (responder vs non-responder) in the patients treated with DIALIVE or SOC at Day- 10. Resolution of ACLF in the DIALIVE group was associated with trends to improvements in most of the biomarkers measured with significant changes in coagulation factor VIII, IL-18, M30 component of cytokeratin-18 and RIPK3. In the SOC group, there was an apparently paradoxical relationship with CCL5 / Rantes and M65 component of cytokeratin-18 being associated with resolution of ACLF. A reduction in INR was associated with resolution of ACLF. Color scale in each parameter has been calculated subtracting mean value for responders minus mean value in non-responders and then divide by mean in nonresponders. Red indicates higher values in responder group, blue otherwise.C. This describes trends of changes from baseline and Day- 10 in all the biomarkers measured and their relationship with resolution of ACLF (responder vs non-responder) in the patients treated with either DIALIVE or SOC at Day-10. The data show that a reduction in coagulation factor VIII, IL-7, IL- 18, RIPK3 and INR and an increase in CCL5 / Rantes were associated with resolution of ACLF. Color scale in each parameter has been calculated subtracting mean value in responders minus mean value in non- responder and then divide by mean in non-responders. Red indicates higher values in responder group, blue otherwise.Figure 5. Operational characteristics and set-up of DIALIVESchematic of one embodiment of device set up.Abbreviations:Acute-on-chronic liver failure (ACLF); Acute Kidney Injury (AKI); adverse events (AEs); Alcohol Abuse and Alcoholism (NIAAA); asymmetric dimethylarginine (ADMA); Chronic Liver Failure Consortium (CLIF-C); CLIF-C organ failure (CLIF-OF); Data Safety Monitoring Board (DSMB); Disseminated intravascular coagulation (DIC); Endotoxin activity assay (EAA); European Association for the Study of Liver diseases - Chronic Liver Failure (EASL-CLIF); Human mercaptalbumin (HMA); human non- mercapt albumin (HNA); Intensive Care Unit (ICU); International Normalized Ratio (INR); limulus amebocyte lysate (LAL); lipoprotein binding protein (LBP); mean arterial pressure (MAP); model for end-stage liver disease (MELD); National Institute on Alcohol Abuse and Alcoholism (NIAAA); organ failure (OF); serious adverse events (SAEs); standard of care (SOC); UTI: Urinary tract infection; Toll-like 4 receptor (TLR4).Detailed description of the inventionThroughout this specification, the word “comprise”, or variations such as “comprised” or “comprising”, will be understood to imply the inclusion of a stated element, integer or step, or group of elements, integers or steps, but not the exclusion of any other element, integer or step, or group of elements, integers or steps. The terms “patient” and “individual” are used interchangeably in the disclosure herein.The reference to any prior art in this specification is not, and should not be taken as, an acknowledgement or any form of suggestion that that prior art forms part of the general knowledge in Australia or elsewhere.Currently, the range of treatments available for patients with liver disease, particularly those patients with liver failure, is limited. None of the other extracorporeal liver support systems such as the molecular adsorbents recirculating system, Prometheus or extracorporeal liver assist device have shown any survival benefit. For many patients the only option is transplant, yet there is no effective treatment available to extend the lifetime of this group of patients. There is thus a need to find treatment regimes which can be used to improve the condition of individuals suffering from liver disease.Albumin is the major plasma protein that is produced in the liver. Albumin undertakes a variety of functions including fatty acid transport, metal chelation, drug binding and anti-oxidant activity. In liver disease its concentration is diminished either due to decreased synthesis or resulting from higher degradation rates. The present inventors have additionally shown that in patients having liver disease, a proportion of the albumin in the blood circulation is structurally abnormal. The inventors have also found that the amount of ischaemia modified albumin (IMA) is increased in patients with liver disease compared with healthy control subjects. The functional ability of a proportion of the albumin from the patient with liver failure is permanently destroyed.In one aspect, therefore, the invention relates to the removal of albumin from the blood of an individual having liver disease.Removal of albumin in this context refers to the removal of structurally normal albumin, and also to the removal of any structurally or functionally modified forms of albumin present in the blood of the individual. That is, preferably, the means for removing albumin used in accordance with the present invention will be capable of removing not only normal, naturally occurring albumin, but also albumin which may have an abnormal structure or albumin which has been modified. Removal of any damaged or abnormal albumin may also be therapeutically useful because damaged albumin has poor functionality and may be associated with damaging side reactions. For example, the means for removing albumin may also remove albumin having reduced molecular flexibility, reduced fatty acid binding affinity, reduced transport quality, reduced transport efficiency and / or reduced detoxification ability compared with normal, unmodified albumin. The means for removing albumin may also remove particular modified forms of albumin, such as ischaemia modified albumin (IMA). Such structural and functional modifications may be detected using conventional techniques, for example as described in Example 1. In particular, albumin functionality may be assessed using a spin label and electron paramagnetic resonance spectroscopy. The presence of IMA may be detected by examining the ability of the albumin to bind metal atoms.Removal of albumin may also detoxify the blood by removing any associated albumin-bound toxins. That is, the means for removing albumin may also consequently remove toxins in the blood that are bound to the albumin.Preferably, the means for removing albumin from the blood removes albumin selectively. That is, albumin is removed in preference to other substances in the blood, such as other proteins. Preferably the amount of albumin removed from the blood is significantly greater than that of other blood components removed. For example, more than 99% by weight of the component removed in this aspect may be albumin. More than 98%, more than 95%, more than 90%, more than 80%, more than 70%, more than 60% or more than 50% of the component removed in this aspect may be albumin. Removal of albumin here includes the removal of the various modified forms of albumin described herein.The means for removing albumin may be any means capable of selectively removing albumin from blood.In one aspect, albumin is selectively removed using a ligand that binds the albumin. The ligand may be any molecule that binds albumin. For example, a number of reactive dyes are known to bind albumin. The ligand may be an antibody or other affinity ligand that specifically binds albumin. Typically, a ligand that specifically binds albumin is a ligand capable of selectively removing albumin from blood as explained above. For example, the ligand may be capable of binding albumin more strongly than other components of blood. For example, the ligand may be an antibody that specifically binds human albumin. The ligand may be an antibody that binds an epitope that is specific to albumin. The ligand may be a combination of molecules which each bind albumin, such as a combination of molecules which bind different parts of the albumin molecule. The ligand may be a polyclonal antibody or mixture of antibodies which bind to multiple epitopes on the albumin protein. Such a combination approach may be useful in the removal of modified forms of albumin as different antibodies may target different parts of the albumin molecule.Antibodies may be raised against specific epitopes of the albumin molecule. For example, antibodies may be raised specifically against those regions, which are expected to be structurally similar in unmodified and particular modified forms of albumin. For the purposes of this invention, the term “antibody”, unless specified to the contrary, includes fragments which bind albumin. Such fragments include Fv, F(ab’) and F(ab’)2 fragments, as well as single chain antibodies. Furthermore, the antibodies and fragment thereof may be chimeric antibodies, CDR-grafted antibodies or humanised antibodies.Antibodies for use in the present invention can be produced by any suitable method. Means for preparing and characterising antibodies are well known in the art, see for example Harlow and Lane (1988) “Antibodies: A Laboratory Manual”, Cold Spring Harbor Laboratory Press, Cold Spring Harbor, NY. For example, an antibody may be produced by raising antibody in a host animal against the whole polypeptide or a fragment thereof, for example an antigenic epitope thereof, herein after the “immunogen”.A method for producing a polyclonal antibody comprises immunising a suitable host animal, for example an experimental animal, with the immunogen and isolating immunoglobulins from the animal’s serum. The animal may therefore be inoculated with the immunogen, blood subsequently removed from the animal and the IgG fraction purified.A method for producing a monoclonal antibody comprises immortalising cells which produce the desired antibody. Hybridoma cells may be produced by fusing spleen cells from an inoculated experimental animal with tumour cells (Kohler and Milstein (1975) Nature 256, 495-497).An immortalized cell producing the desired antibody may be selected by a conventional procedure. The hybridomas may be grown in culture or injected intraperitoneally for formation of ascites fluid or into the blood stream of an allogenic host or immunocompromised host. Human antibody may be prepared by in vitro immunisation of human lymphocytes, followed by transformation of the lymphocytes with Epstein-Barr virus.For the production of both monoclonal and polyclonal antibodies, the experimental animal is suitably a goat, rabbit, rat or mouse. If desired, the immunogen may be administered as a conjugate in which the immunogen is coupled, for example via a side chain of one of the amino acid residues, to a suitable carrier. The carrier molecule is typically a physiologically acceptable carrier. The antibody obtained may be isolated and, if desired, purified.An antibody, or other ligand, “specifically binds” to a protein when it binds with preferential or high affinity to the protein for which it is specific but does substantially bind not bind or binds with only low affinity to other proteins. That is, an antibody specifically binds albumin if it binds to albumin more strongly than it binds to other blood components, such as other proteins in the blood. As explained above, the specificity ofbinding may be such that it binds structurally or functionally altered forms of albumin as well as unmodified albumin. Preferably it binds structurally or functionally altered forms of albumin with the same or substantially the same binding affinity as unmodified albumin. Preferably, it binds both modified and unmodified forms of albumin with a greater affinity than other blood components, such as other proteins in the blood. A variety of protocols for competitive binding or immunoradiometric assays to determine the specific binding capability of an antibody are well known in the art (see for example Maddox et al, J. Exp. Med. 158, 1211-1226, 1993). Such immunoassays typically involve the formation of complexes between the specific protein and its antibody and the measurement of complex formation.Where a ligand is used to achieve removal of albumin, the ligand may be provided attached to a solid support. The ligand may be immobilised on such a solid support. A suitable solid support may be in the form of a column through which the blood may be passed. A suitable solid support may be, for example, a porous material such as a membrane, particle bed or filter which is sufficiently porous to allow blood cells to pass through it. A suitable solid support may alternatively be a solid substrate across the surface of which blood may be passed. Preferably the solid support has a large surface area to maximise the area of contact between the blood of the individual and the ligand attached to the support. The solid support may be in the form of beads, which can be filled into a container into which the blood can be inserted, or through which the blood can be passed. The beads will preferably have a size sufficient to allow sufficient porosity when packed into a column or filter bed. Various bead materials are known in the art.Accordingly, the means for removing albumin according to the present invention may comprise or consist of such a solid support on which is attached or immobilised a ligand capable of binding albumin. The means for removing albumin may comprise or consist of a container through which blood is passed. The container may thus comprise an inlet and an outlet. The inlet and outlet are positioned so that blood passing through the container comes into contact with a solid support as described herein. Preferably the means for removing albumin is designed or selected to maximise the area of contact between the blood and the solid support. A variety of such designs are known in the art. For example, the means for removing albumin may be a column or filter bed packed with beads, wherein a ligand for albumin is immobilised on the beads.In another aspect, removal of albumin may be achieved via dialysis. Such an approach may also lead to the removal of other blood components that are dialysed together with the albumin. Typically, albumin should be the predominant component removed. This dialysis step can use any albumin dialysis system. A variety of such systems are known in the art. One such system is the molecular absorbance recirculating system (MARS). An alternate is a generic single pass albumin dialysis (SPAD) system. These systems use a 50kDa pore membrane to dialyse albumin in blood. This system is designed particularly to remove albumin-bound toxins from the blood of patients. As an alternative to this system, a larger pore membrane can be utilised so that albumin from the patient’s blood is actively exchanged with fresh albumin via dialysis. This permits the removal of toxins and abnormal forms of albumin in the same step. This also allows the introduction into the blood of new albumin, not from the individual, as discussed further below.Studies in which the MARS system is modified to include a larger pore membrane indicate that there is a substantial improvement in protein-bound toxin removal compared to the standard 50kDa pore device. For example, a membrane having a pore size of greater than 50 kDa, greater than 60 kDa, greater than 70 kDa, greater than 80 kDa, greater than 90 kDa or greater than 100 kDa may be used. The membrane may have a pore size of less than 60 kDa, less than 75 kDa, less than 100 kDa or less than 150 kDa. The membrane may have a pore size of greater than 45 kDa and less than 100 kDa. The membrane may have a pore size of greater than 50 kDa and less than 100 kDa.Other blood components may be removed together with albumin depending on the particular means used to remove the albumin. In one embodiment, other components which are removed with the albumin may be returned to the blood of the individual. The components to be returned may be purified from the albumin mixture that has been removed from the blood, or may be replaced by fresh equivalent components not deriving from the individual.Various methods of removing albumin from the blood are known in the art. For example, US Patent No. 4,093,612 discloses reactive dye compositions that can be used to remove albumin from a fluid. In accordance with the present invention, such compositions may be used for the removal of albumin from the blood of the individual. This may therefore be a selective albumin trapping system based on compounds which specificallybind albumin. These may be, for example reactive dyes as described in US Patent No. 4,093,612 such as cibacron-blue, or may be other molecules capable of binding albumin, such as albumin-specific antibodies.In accordance with the present invention therefore, albumin is removed from the blood of an individual with liver disease. In the present invention this albumin is replaced simultaneously with new albumin which does not derive from the individual.The new albumin is preferably structurally and functionally normal. That is, the new albumin may comprise no, or substantially no, structurally or functionally modified forms of albumin. Where albumin removed from the blood of an individual comprises one or more modified forms of albumin, the albumin returned to the blood of that individual preferably comprises less modified albumin than has been removed. For example, the albumin returned to the blood of the individual may comprise less than 50%, less than 30%, less than 20%, less than 10%, less than 5% or less than 1% of the amount of modified albumin removed from that individual. Preferably, the albumin returned to the individual will comprise no modified albumin or no modified albumin of one or more of the types that were removed from the individual, such as no ischaemia modified albumin (IMA).The new albumin may derive from another individual, such as an individual that does not have liver disease, an individual that does not have liver failure or an individual that has normal liver function. The new albumin will typically have a higher proportion of structurally and functionally normal albumin than the albumin removed from the individual. The new albumin can be pharmaceutical grade albumin.This new albumin is introduced into the blood of the individual to ensure that the individual has a suitable level of circulating albumin. This can be a direct replacement for the albumin removed, for example, the same or an equivalent amount of albumin to that that is removed can be returned to the blood. In this system, the individual’s albumin is effectively exchanged with new albumin. Alternatively, by varying the amount of albumin introduced at this stage, the overall albumin concentration in the blood can be increased or decreased if necessary. The amount of albumin that is introduced to the blood may thus be greater than or less than the amount that is removed. For example, liver disease can lead to a decrease in the level of circulating albumin. This can result in a low functional capacity. In accordance with the present invention the amount of new albumin introduced to theblood of the patient may be greater than the amount of albumin removed. This may supplement the level of albumin in the circulation of the individual. For example, an amount of new albumin may be introduced which raises the overall albumin level in the blood to a level the same as, or similar to, that seen in an individual not having liver disease.The new albumin is introduced to the blood of the individual simultaneously with the removal of the individual’s albumin. For example, an exchange of albumin may be achieved by dialysis. Simultaneous albumin removal and albumin return may also comprise sequentially or separate steps. For example, where the invention is carried out ex vivo, the blood of the individual may be passed through means for removing albumin and then subsequently have fresh albumin added to it. This may be achieved by different parts of the same apparatus.The inventors have previously shown that endotoxin is a component in the blood of individuals with liver disease which may be associated with the prognosis of those patients, for example their susceptibility to infection or organ failure, their risk of mortality and their potential responsiveness to some therapies such as immunosuppression.The inventors have found that these prognosis factors are linked to activation of neutrophils in the blood of an individual having liver disease, and that such activation may be related to the presence of a transmissible factor in the plasma of those individuals. Thus, plasma from an individual having a high degree of neutrophil activation is capable of increasing the level of activation of normal neutrophils.The inventors have further found that a similar effect may be achieved by contacting normal neutrophils with endotoxin, and that removal of endotoxin from the blood of patients having a high degree of neutrophil activation can reduce the activation levels of neutrophils in that blood. Removal of endotoxin is therefore believed to be useful in the treatment of patients having liver disease whose neutrophils are in an activated state. By restoring normal neutrophil function, the ability of those individuals to combat infection may be improved.Accordingly, the present invention also relates to the removal of endotoxin from the blood of the patients. Removal of albumin addresses one issue of detoxification, removal of endotoxin relates to a further issue of reduced immune response. Bycombining these two approaches in a single apparatus or method, a particularly effective treatment of liver disease is achieved.Preferably, the means for removing endotoxin from the blood removes endotoxin selectively. That is, endotoxin is removed in preference to other substances in the blood. Preferably the amount of endotoxin removed from the blood is significantly greater than that of other blood components removed. For example, more than 99% by weight of the component removed in this aspect may be endotoxin. More than 98%, more than 95%, more than 90%, more than 80%, more than 70%, more than 60% or more than 50% of the component removed in this aspect may be endotoxin.The means for removing endotoxin may be any means capable of selectively removing endotoxin from blood.In one aspect, endotoxin may be selectively removed using a ligand that binds the endotoxin. The ligand may be any molecule that binds endotoxin. For example, antiendotoxin antibodies, LPS binding proteins, Polymyxin B, polyethyleneimine, an arginine ligand and various peptides are known to bind endotoxin. The ligand may be an antibody or other affinity ligand that specifically bind endotoxin. For example, the ligand may be an antibody that specifically binds endotoxin. Typically, a ligand that specifically binds endotoxin is a ligand capable of selectively removing endotoxin from blood as explained above. For example, the ligand is capable of binding endotoxin more strongly than other components of blood. The ligand may be an antibody that binds an epitope that is specific to endotoxin. The ligand may be a combination of molecules which each bind endotoxin, such as a combination of molecules which bind different parts of the endotoxin molecule or different endotoxins. The ligand may be a polyclonal antibody or mixture of antibodies which bind to multiple epitopes on the endotoxin molecule or different endotoxins.Antibodies may be raised against specific epitopes of the endotoxin molecule. Suitable antibody types may be any antibody type, as described above in relation to albumin, such as an antibody fragment.Antibodies that bind endotoxin may be prepared by any means, for example as described above in relation to albumin-binding antibodies. The antibody obtained may be isolated and, if desired, purified.An antibody, or other ligand, “specifically binds” to a protein when it binds with preferential or high affinity to the protein for which it is specific but does substantiallybind not bind or binds with only low affinity to other proteins. That is, it binds to endotoxin more strongly than it binds to other blood components, such as other proteins in the blood. The specificity of binding may be such that it binds different forms of endotoxin. Preferably, it binds a variety of forms of endotoxin with a greater affinity than other blood components.Where a ligand is used to achieve removal of endotoxin, the ligand may be provided attached to a solid support. The ligand may be immobilised on such a solid support. Suitable solid supports are as discussed above in relation to albumin-binding ligands.Accordingly, the means for removing endotoxin according to the present invention may comprise or consist of such a solid support on which is attached or immobilised a ligand capable of binding endotoxin. The means for removing endotoxin may comprise or consist of a container through which blood is passed. The container may thus comprise an inlet and an outlet. The inlet and outlet are positioned so that blood passing through the container comes into contact with a solid support as described herein. Preferably the means is designed or selected to maximise the area of contact between the blood and the solid support. A variety of such designs are known in the art. For example, the means may be a column or filter bed packed with beads, wherein a ligand for albumin is immobilised on the beads.In another aspect, rather than physically removing the endotoxin from the blood, an agent may be administered to the individual to reduce endotoxin levels. For example, the endotoxin in the blood may be functionally neutralised rather than removed. Various methods for neutralising endotoxin are known in the art. This may comprise administering an agent to the individual, which agent is capable of selectively removing or neutralising the activity of the endotoxin. This may rely on the host immune system to aid removal of endotoxin. For example, a suitable agent may bind endotoxin and allow the immune system of the individual to clear the endotoxin-agent complexes from the blood. Various agents for decreasing circulating endotoxin levels are known, for example anti-endotoxin antibodies, albumin and LPS-binding proteins, LPS neutralising CD-14 antibodies.Other blood components may be removed together with endotoxin depending on the particular means used to remove the endotoxin. For example, some methods for removing endotoxin may also remove other toxins from the blood. This may be beneficialto the patient. Some methods for removing endotoxin may also remove other blood components which it is desired to maintain in the blood. In this case, blood components which are removed with the endotoxin may be returned to the blood of the individual. The components to be returned may be purified from the endotoxin mixture removed, or may be replaced by fresh equivalent components that do not derive from the individual.Various approaches for removing endotoxin from a sample have been described in the art. For example, EP-A-0 129 786 describes the use of Polymyxin B covalently immobilized on polystyrene fibres for the removal of endotoxins from blood. Falkenhagen et al (Artificial Organs (1996) 20:420) described the removal of endotoxin from plasma using polyethyleneimine coated beads. WO 01 / 23413 describes oligopeptides having a high degree of dispersity which are used to selectively remove endotoxin from blood or plasma. US 5,476,715 describes materials for the removal of endotoxin from a sample, which comprise a porous carrier made from polymers of acrylic acid and methacrylic acid with a particular particle size and spacing. Staubach et al (Transfusion and Apheresis Science (2003) 29: 93-98) describes a device for endotoxin adsorption which is based on immobilized albumin. There are thus a number of available methods which could be used to remove endotoxin from a sample. Any of these methods may be used or adapted for use in accordance with the present invention. The skilled reader would be able to select a suitable method and conditions for its use.The apparatus or method of the invention will preferably be effective in achieving a significant reduction in circulating blood endotoxin levels. For example, the apparatus or method may lead to a reduction by at least 25%, at least 50%, at least 70%, at least 80%, at least 90%, at least 95%, at least 99% or more in the level of endotoxin in the blood of the individual.The two aspects of the present invention are also linked. Albumin is capable of binding endotoxin in the blood. Thus, the removal of albumin may also lead to the removal of some endotoxin which is bound to albumin. Furthermore, by increasing the level of normal albumin in the individual, again, albumin in the blood can bind to circulating endotoxin and the levels of free endotoxin in the blood may be decreased. However, the amount of endotoxin reduction achieved in this way is relatively small, so the present invention preferably utilises separate means for (a) removing albumin and (b) reducing endotoxin levels. This effect of albumin removal and / or replacement maysupplement other means for reducing endotoxin and may help to “mop up” endotoxin remaining in the blood of the individual.Based on these findings, the inventors have developed a new method for use in the treatment of individuals having liver disease. These comprise a combination of components which act to remove both albumin and endotoxin from the blood of an individual having liver disease.Particularly, the inventors have developed an apparatus for use in the treatment of an individual having liver disease, the apparatus comprising means for removing albumin from the blood of the individual, removing albumin from the blood of the individual, and means for selectively removing endotoxin from the blood of the individual. Preferably these are two separate means, each directed to achieving one of these effects. The apparatus also comprises means for supplying new albumin, that does not derive from the individual, to the blood of the individual. The apparatus may also comprise means for supplying new fully functional albumin, that does not derive from the individual, to the blood of the individual.Use of such an apparatus thus results in the removal of albumin from the blood of the individual, a reduction in the level of endotoxin in the blood of the individual and the simultaneous introduction of new albumin to the blood of the individual. This is therapeutically useful in a variety of ways. Removal of endogenous albumin from the blood of an individual may result in the removal of unwanted toxins bound to the albumin and may also result in the removal of abnormal modified forms of albumin from the blood. Such modified forms often have reduced functional ability. The introduction of new albumin can be used to replace the albumin that has been removed with fresh albumin. Preferably the fresh albumin does not comprise toxins bound to the albumin molecules and preferably the fresh albumin is in unmodified form. The addition of fresh albumin to the blood can also be used to supplement endogenous albumin levels where these are reduced as a result of liver disease. Finally, the removal of endotoxin from the blood of an individual having liver disease can help to reduce the level of activation of neutrophils in the blood of the individual. This reduction in neutrophil activation can lead to decreased risk of infection, organ failure and mortality, and can improve the responsiveness of the individual to immunosuppressive therapy and steroid or antibiotic treatment.The methods of the invention thus provide a targeted approach to the treatment of liver disease, addressing multiple factors linked to such disease and benefiting the individual in multiple ways.In one aspect, therefore, the invention relates to an apparatus for use in the treatment of an individual with liver disease. The apparatus may comprise a number of components, which may be used in combination or separately. An apparatus of the invention will comprise or consist essentially of means for removing albumin from the blood of an individual, means for selectively removing endotoxin from the blood of the individual and means for the simultaneous supply of albumin that does not derive from the individual to the blood of the individual.Any means described herein may be used for the removal of albumin or endotoxin. In one aspect, a single component of the apparatus may be used for the removal of both albumin and endotoxin. Typically, such a component of the apparatus will comprise both means for removing albumin and means for removing endotoxin. For example, where albumin and endotoxin are both to be removed by binding to specific ligands, then one or more ligands specific for albumin and one or more ligands specific for endotoxin may be used together in the same component of the apparatus. For example, the apparatus may comprise a single container, such as a column or filter bed, which comprises solid support(s) onto which the two ligands are immobilised. The ligands may be immobilised onto different supports or onto the same support. The albumin and endotoxin may thus be removed simultaneously from the blood of the individual.Alternatively, the apparatus may include separate means for removal of albumin and endotoxin. The apparatus may include more than one means capable of removing albumin and / or more than one means capable of removing albumin.The apparatus also comprises means for supplying new albumin, i.e. albumin that does not derive from the individual, to the blood. The apparatus may be for use ex vivo. For example, the apparatus may be designed such that blood from the individual passes through it so as to achieve albumin removal and endotoxin removal before returning to the body of the individual.An example apparatus is illustrated in Figure 5. It will be clear from the discussion herein and the apparatus exemplified in Figure 5 that a number of different components may be used in a variety of combinations in order to achieve the desired effects.The components of the illustrated apparatus in Figure 5 are as follows:1. Means for trapping albumin. The albumin trap selectively removes albumin from the blood of the patient.2. Means for carrying out albumin dialysis to remove toxins. For example, the use of a large pore membrane (greater than 45 kDa) to allow albumin exchange permits improved toxin removal by allowing patient albumin to interact with the “cleaning” filters. This also permits the removal of patient albumin as it is exchanged across the filter with the albumin dialysate.3. Filters to clean albumin.4. Endotoxin removal component.5. New albumin infusion.The invention also relates to a method of treating liver disease by using the apparatus of the invention. For example, blood from the individual may be contacted with an apparatus of the invention such that albumin and endotoxin are removed from the blood and albumin that does not derive from the individual may optionally be supplied to the blood. This method may be carried out ex vivo and the blood may be subsequently returned to the individual.The invention relates to a method of treating an individual having liver disease. The method comprises or consists essentially of the following steps: (a) removing albumin from the blood of the individual; (b) reducing the level of endotoxin in the blood of the individual, and (c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual. This may be achieved by any method or means as described herein. This method may be carried out ex vivo. Steps (a) and (c) may be achieved using dialysis. Step (a) may be achieved using a ligand capable of specifically binding albumin. Step (b) may be achieved by directly removing endotoxin from the blood. Step (b) may be achieved using a ligand that specifically binds endotoxin. Step (b) may be achieved by administering to the individual a therapeutically effective amount of an agent capable of reducing the level of endotoxin in the blood. Any combination of step (a), step (b) and step (c) methods described herein may be used.Furthermore, the method of treating a subject having liver failure as described herein comprises further steps. In the method of the invention, the method comprisingtreatment of said individual’s blood comprises measurement of levels of various chemicals and / or biomarkers in the blood.In the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets / mm3. Preferably, the platelet count is more than about 30,000 platelets / mm3. The method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g / L. Preferably, the fibrinogen level more than about 1.0 g / L. Preferably, in the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L maximises the safety of the method and reduces the risk of hypotension. In a preferred embodiment of the invention, platelet count and fibrinogen levels are monitored during the method. In a preferred embodiment of the invention, the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets / mm3or lower and the fibrinogen level is l.Og / L or lower.In a preferred embodiment of the invention the method comprises measurement of blood gas analysis. Blood gas analysis comprises of measurements of Oxygen (O2) and Carbon dioxide (CO2) levels in the blood. These are important markers of respiratory function such as oxygenation level and adequate removal of CO2 from the body. These are essential elements of monitoring a sick patient such as patients with liver failure, they provide early signs of deterioration of respiratory function e.g. fluid accumulation in the lungs, new pneumonias may lead to inadequate oxygenation and change in CO2 may occur with worsening brain function (hepatic encephalopathy) or patient not able to breathe enough to eliminate CO2 adequately. In addition to O2 and CO2 levels, blood gas analysis reveals any major changes in acid levels in the body such as H+ions and other acids, of which lactic acid is particularly important in liver failure patients. Lactate and lactic acid accumulation occur because of excessive anaerobic metabolism of glucose as occurs with mitochondrial dysfunction seen in sepsis or with or insufficient oxygen at cell level of which circulatory dysfunction from sustained hypotension is an important cause.Furthermore, lactate and lactic acidosis is worse in the presence of liver failure since liver is primarily responsible for metabolising lactate into bicarbonate (HCO3), the most important buffer in the body. Low HCO3 and elevated H+may also reflect acid accumulation from other sources such as in kidney failure. In a preferred embodiment of the invention the method comprises measurement of blood gas analysis, including measurement of lactate. Therefore, blood gas analysis is an important component of monitoring patients while being treated by the method of the invention. It provides regular information about respiratory, circulatory, renal and homeostatic functions, each of which is important in defining the survival of a patient with ACLF.In a preferred embodiment of the invention the method comprises measurement of full blood count (FBC). Full blood count (FBC) provides following important information: a. Haemoglobin (Hb) level - Regular Hb monitoring allows early detection of anaemia and need for blood transfusion - this is particularly relevant with extracorporeal therapy as dilutional anaemia can occur because of the priming of the filter. It is even more important with DIALIVE being a dual filter system and has a much higher priming volume because of two filters. To counteract this, the starting Hb level of at least 9g / dL (90g / L) is targeted. Hb monitoring is also important for early identification of potential haemolysis, though uncommon, associated with extracorporeal therapy and, in unexplained anaemia require a full haemolysis screen (Hb, reticulocyte count, blood film analysis, lactic dehydrogenase (LDH), serum haptoglobin, split bilirubin; unconjugated and conjugated, urinary and effluent fluid free Hb) b. White cell count (WCC) - ACLF is associated with infection, both as a major trigger precipitating acute decompensation and development of new infections. WCC is an important marker of systemic inflammation and infection. c. Platelet count - consumption of platelets is an important feature of extracorporeal intervention, can lead to severe reduction in platelet counts promoting bleeding complications. Monitoring platelet count closely and aiming for a platelet count of above 30,000 / mm3 with platelet transfusion where required, especially in patients with high bleeding risk mitigates this risk.In a preferred embodiment of the invention the method comprises measurement of FBC including Haemoglobin (Hb) level, White cell count (WCC) and Platelet count.In a preferred embodiment of the invention the method comprises measurement of urea and electrolytes (U / E). In a preferred embodiment of the invention the method comprises monitoring of U / E to continuously assess acute kidney injury.In a preferred embodiment of the invention the method comprises conducting a Liver function test (LFT). LFTs act to assess the trajectory of liver function during treatment. Examples of LFTs include measurement of total serum bilirubin. In a preferred embodiment of the invention the method comprises measurement of total serum bilirubin. Total serum bilirubin is most important LFT in defining liver-specific organ failure and its impact on the ACLF grade and severity. A measure of >12mg / dL total serum bilirubin constitutes liver organ failure.Coagulation profile includes the following: a. Prothrombin time (PT) or International Normalised Ratio (INR) which are a direct function of the clotting factors produced by the liver and is usually deranged, in varying degree, in ACLF, an INR above 2.5 constitutes coagulation organ failure. b. Activated Partial Thromboplastin Time (APTT) which is a function of endothelial activation (for example following an infection) or heparin therapy, an anticoagulant agent used for most patients to prevent filter thrombosis / clotting, and APTT therefore is an important monitoring tool to assess optimal anti coagulation of the system and APTT ratio maintained at 1.5-2. c. Fibrinogen, a coagulation factor synthesized by the liver may be low in liver failure to start with. Further reduction in levels can occur from potential consumption by extracorporeal treatment, or more commonly by severe infection, precipitating consumptive coagulopathy DIC (Disseminated Intravascular Coagulation) with exaggerated risk of both bleeding as well as thrombosis. Where DIC is suspected a full DIC screen must be sought which includes blood film analysis, platelet count, fibrinogen levels, D-dimer or fibrin degradation products (FDP).In an embodiment of the invention, fibrinogen levels are detected in a blood sample taken from the patient, and a fibrinogen level of >1.0 g / L is to be considered before commencement of treatment. In an embodiment of the invention, fibrinogen levels are detected in a blood sample taken from the patient, and a fibrinogen level of >1.0 g / L is to be considered as best practice before commencement of treatment. In an embodiment of the invention, fibrinogen levels are detected in a blood sample taken from the patient withactive search and treatment of any untreated or partially treated infection commenced. In an embodiment of the invention a platelet count is carried out on a blood sample taken from the patient, and a platelet count of > 30,000 platelets / mm3is considered as best practice before commencement of treatment.* It is to be noted that a platelet count (> 30,000 platelets / mm3) and a fibrinogen level >1 g / L are standard pre-requisite for safely inserting a dialysis catheter required for DIALIVE and achieved by transfusion of platelets and cryoprecipitate respectively.** For all blood and blood-products infused prior to treatment commencement an equivalent volume should be removed during the treatment to prevent volume overload, unless the patient was deemed volume depleted at the outset.In a preferred embodiment of the invention the method comprises measurement of blood gas analysis, including measurement of lactate, measurement of full blood count (FBC), measurement of, urea and electrolytes (U / E), conducting a Liver function test (LFT), and measurement of coagulation levels. In a preferred embodiment of the invention the method comprises 2-hourly arterial blood gas analysis (ABG including lactate) and 4 hourly bloods (FBC, U / E, LFT, coagulation) at 0, 4 and 8-12 hours (end of treatment). Any unexpected change to be investigated and treated accordingly. Any evidence of consumptive coagulopathy (platelets and fibrinogen falling significantly during treatment) should be investigated fully with DIC (Disseminated Intravascular Coagulation) screening.In a preferred embodiment of the invention the method comprises monitoring for the presence of anaemia. It is beneficial that unexplained anaemia during treatment is investigated for haemolysis.In a preferred embodiment of the invention, the step of removing albumin from the blood of the individual, comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and an initial blood flow rate through the means of approximately 30 - 60 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 200 - 250 ml / min.In a preferred embodiment of the invention, the initial flow rate through the means is approximately 30 ml / min, approximately 35 ml / min, approximately 40 ml / min, approximately 45 ml / min, approximately 50 ml / min, approximately 55 ml / min, or approximately 60 ml / min. In an especially preferred embodiment, an initial blood flowrate through the means is approximately 50 ml / min. In a preferred embodiment of the invention, the flow rate is increased during dialysis to no more than approximately 200 ml / min, no more than approximately 210 ml / min, no more than approximately 220 ml / min, no more than approximately 220 ml / min., no more than approximately 230 ml / min, no more than approximately 240 ml / min or no more than approximately 250 ml / min. In an especially preferred embodiment, the flow rate is increased during dialysis to no more than approximately 250 ml / min. In an especially preferred embodiment, the initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min.In a preferred embodiment of the invention, blood flow rate through the system to be increased gradually from 50ml / min to 250ml / min and convective clearance rate (effluent production) increased slowly from IL / hour to pre-defined target of 50ml / kg / hr (approximately 3.5L / hr for a 75kg person), haemodynamic stability permitting.In a preferred embodiment of the invention, the step of removing albumin from the blood of the individual, comprises use of means for dialysis of albumin, said means comprising a high cut-off membrane in the first filter, e.g. Septex, having a pore size of greater than 45 kDa and less than 100 kDa, and an initial blood flow rate through the means to start gently at 50ml / min and increasing gradually to 250ml / min, provided the patient tolerates high blood flow rates in terms of haemodynamic stability. Higher flow rates will ensure effective removal of substances through the membrane, the efficiency of which depends on various factors including the blood flow rates, but also the rate of production of the effluent (waste) fluid, sieving co-efficient of the membrane (which reduces over time because of decreasing pore size due to clogging by waste elements, requiring a change of filter for every 12-hour treatment. The second filter in the DIALIVE system (e.g. oXiris), an endotoxin binding filter can last for 48 hours without much reduction in its adsorptive capacity.In a further embodiment of the invention the method of treatment also comprises anti coagulation whilst the individual’s blood is treated. In a further embodiment of the invention the method of treatment also comprises anti coagulation of the means of dialysis whilst the individual’s blood is treated. Anti coagulation of the means of dialysis whilst the individual’s blood is treated to ensure filter patency thus avoiding the need to change filters because of thrombosis and unnecessary interruption in treatment.In a preferred embodiment the anti coagulation is with unfractionated heparin. In a preferred embodiment the anti coagulation is achieved with unfractionated heparin. In a preferred embodiment the anti coagulation is achieved with infused unfractionated heparin. In a preferred embodiment the anti coagulation is achieved with infused unfractionated heparin (for example 500-1000 units / hour targeting an APTT of 1.5-2). Preferably, regional anti coagulation rather than systemic administration of heparin is provided to avoid unnecessarily increased bleeding risk associated with the latter. Where patients have deranged clotting to begin with, particularly low platelets (<20,000 platelets / mm3for example), unfractionated heparin is either completely avoided or the dose reduced and anti coagulation supplemented with alternatives such as the commonly used prostacycline analogue. In a preferred embodiment the anti coagulation is achieved with prostacycline analogues. In a preferred embodiment the anti coagulation is achieved with unfractionated heparin and / or prostacycline analogues. Examples of prostacycline analogues include Treprostinil, Iloprost, Epoprostenol and Beraprost. Suitable doses for said treatment are known in the art. These preserve platelet function compared with heparin.In a further embodiment of the invention the method of treatment also comprises continuous measurement of mean arterial pressure (MAP) whilst the individual’s blood is treated. Continuous measurement is defined herein as continuous invasive blood pressure monitoring, via for example, an arterial line. Continuous measurement as described herein may be defined as, for example measurement of MAP for 10 seconds every 10 minutes.In a preferred embodiment of the invention, MAP should be maintained at 90% or higher of pre-treatment MAP or above 65 mmHg, whichever is higher. In a preferred embodiment of the method of the invention, blood pressure monitoring is in place during treatment and rates adjusted to ensure a MAP of 65mmHg and above. Preferably, this should be invasive blood pressure monitoring. In the event of hypotension these rates should be reduced to prevent a reduction in blood pressure. Other causes of hypotension should be searched for; for example, dehydration, septic shock etc. and treated accordingly. If required, vasopressors such as low-dose norepinephrine (0.1-0.2microgram / kg / min) should be considered early.In a further embodiment of the invention the method of treatment also comprises the use of replacement fluid (pre-dilution solution) started at a rate of 1000 ml / hr andincreased gradually to up to 3500 ml / hr (50mls / kg / hr for a 75 kg person) subject to hemodynamic stability. The concomitant dialysis component should run at 1500 ml / hr (25 ml / kg / hr for a 75 kg person).In a further embodiment of the invention the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin). In a further embodiment of the invention the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin) when blood passes through the means for removing albumin. In a further embodiment of the invention the method of treatment also comprises convective clearance of effluent (such as waste fluid containing PAPMs and DAMPs and albumin) when blood passes through the means for removing albumin, such as the first filter e.g. a Septex filter. Rate of effluent production determines how much of these solutes are removed. In a preferred embodiment, rate of removal has been increased from 35ml / kg / hr (approximately 2.5 L / hr for a 75 kg person) to 50ml / kg / hr (3.5 L / hr) for more effective convective clearance. In a preferred embodiment, rate of removal has been increased from 35ml / kg / hr (approximately 2.5 L / hr for a 75 kg person) to 50ml / kg / hr (3.5 L / hr) for more effective convective clearance starting slow and at low volume of IL / hr and increasing slowly to a pre-defined target of 50ml / kg / hr, haemodynamic stability permitting. The waste volume can be then replaced in similar quantities as a continuous infusion by standard replacement fluid where blood enters the Septex filter (called pre-dilution replacement).In a preferred embodiment, an additional counter-current dialysis component is also incorporated running through the Septex filter to improve clearance of very small molecules and for better acid base homeostasis. The rate for this was increased from IL / hr in the previous iteration to 1.5L / hr ((25 ml / kg / hr for a 75 kg person).In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 3-10g / hr. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 5g / hr.In a further embodiment of the invention the method of treatment also comprises the simultaneous replacement of removed albumin with exogenous bottled 20% Humanalbumin solution exchange of albumin at a rate of approximately 5g / hr before the purified blood had been returned back to the patient. The amount of albumin lost during DIALIVE treatment was assessed from animal studies, further in-vitro studies and from data collected from the first few treated patients in the trial.The invention also relates to method of treating blood extracorporeally by removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease. Said method may be an in vitro method. This method may be achieved by any suitable means as described herein and comprises the additional step of adding to the blood albumin that does not derive from the individual. Blood which has been treated in this way may be returned to the individual for therapeutic purposes, or may be used for another purpose. For example, blood may be treated in this way prior to transfusion into a different individual.Furthermore, the method of treating blood extracorporeally by selectively removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease as described herein comprises further steps. In the method of the invention, the method comprising treating said individual’s blood may also comprise measurement of levels of various chemicals and / or biomarkers in the blood.In the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets / mm3. Preferably, the platelet count is more than about 30,000 platelets / mm3. The method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g / L. Preferably, the fibrinogen level more than about 1.0 g / L. Preferably, in the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L maximises the safety of the method and reduces the risk of hypotension. In a preferred embodiment of the invention, platelet count and fibrinogen levels are monitored during the method. In a preferred embodiment of the invention, the method is stopped if the platelet count in theblood of the individual is about 30,000 platelets / mm3or lower and the fibrinogen level is l.Og / L or lower.In a preferred embodiment of the invention the method comprises measurement of blood gas analysis as defined herein. In a preferred embodiment of the invention the method comprises measurement of blood gas analysis, including measurement of lactate. In a preferred embodiment of the invention the method comprises measurement of full blood count (FBC). In a preferred embodiment of the invention the method comprises measurement of FBC including Haemoglobin (Hb) level, White cell count (WCC) and Platelet count. In a preferred embodiment of the invention the method comprises measurement of urea and electrolytes (U / E). In a preferred embodiment of the invention the method comprises monitoring of U / E to continuously assess acute kidney injury. In a preferred embodiment of the invention the method comprises conducting a Liver function test (LFT). Examples of LFTs include measurement of total serum bilirubin. In a preferred embodiment of the invention the method comprises measurement of total serum bilirubin. Total serum bilirubin is most important LFT in defining liver-specific organ failure and its impact on the ACLF grade and severity. A measure of >12mg / dL total serum bilirubin constitutes liver organ failure.In a preferred embodiment of the invention the method comprises measurement of blood gas analysis, including measurement of lactate, measurement of full blood count (FBC), measurement of, urea and electrolytes (U / E), conducting a Liver function test (LFT), and measurement of coagulation levels. In a preferred embodiment of the invention the method comprises 2-hourly arterial blood gas analysis (ABG including lactate) and 4 hourly bloods (FBC, UZE, LFT, coagulation) at 0, 4 and 8-12 hours (end of the method). Any evidence of consumptive coagulopathy (platelets and fibrinogen falling significantly during the method) should be investigated fully with DIC (Disseminated Intravascular Coagulation) screening.In a preferred embodiment of the invention the method comprises monitoring the blood for the presence of anaemia. It is beneficial that unexplained anaemia during the method is investigated for haemolysis.In a preferred embodiment of the invention, the step of selectively removing albumin from the blood of the individual, comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than100 kDa, and an initial blood flow rate through the means of approximately 30 - 60 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 200 - 250 ml / min. In a preferred embodiment of the invention, the initial flow rate through the means is approximately 30 ml / min, approximately 35 ml / min, approximately 40 ml / min, approximately 45 ml / min, approximately 50 ml / min, approximately 55 ml / min, or approximately 60 ml / min. In an especially preferred embodiment, the initial blood flow rate through the means is approximately 50 ml / min. In a preferred embodiment of the invention, the flow rate is increased during dialysis to no more than approximately 200 ml / min, no more than approximately 210 ml / min, no more than approximately 220 ml / min, no more than approximately 220 ml / min, no more than approximately 230 ml / min, no more than approximately 240 ml / min or no more than approximately 250 ml / min. In an especially preferred embodiment, the flow rate is increased during dialysis to no more than approximately 250 ml / min. In an especially preferred embodiment, the initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min.In a further embodiment of the invention the method also comprises the use of replacement fluid (pre-dilution solution) started at a rate of 1000 ml / hr and increased gradually to up to 3500 ml / hr (50mls / kg / hr for a 75 kg person) subject to hemodynamic stability. The concomitant dialysis component should run at 1500 ml / hr (25 ml / kg / hr for a 75 kg person).In a further embodiment of the invention the method also comprises the simultaneous exchange of albumin should at a rate of approximately 3-10g / hr. In a further embodiment of the invention the method of treatment also comprises the simultaneous exchange of albumin at a rate of approximately 5g / hr.The invention also relates to albumin that does not derive from the blood of an individual to be treated for use in a method of liver disease, said method comprising the steps of:(a) removing albumin from the blood of the individual;(b) reducing the level of endotoxin in the blood of the individual; and(c) introducing said albumin that does not derive from the individual to be treated into the blood of the individual;wherein step (a) is carried out by dialysis using means comprising a membrane having a pore size of greater than 45kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is >1.0 g / L.This method may be achieved by any suitable means as described herein. In the method of the invention, the method comprising treating said individual may also comprise measurement of levels of various chemicals and / or biomarkers in the blood of said individual as described herein.In the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count more than about 25,000, 26,000, 27,000, 28,000, or 29,000, or 30,000 platelets / mm3. Preferably, the platelet count is more than about 30,000 platelets / mm3. The method is carried out on individuals who have a fibrinogen level of more than about 0.9, 0.95, or 1.0 g / L. Preferably, the fibrinogen level more than about 1.0 g / L. Preferably, in the method of the invention, the platelet count and fibrinogen level in the blood of the individual to be treated is determined. The method is carried out on individuals who have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L. Ensuring that the individuals to be treated have a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L maximises the safety of the method and reduces the risk of hypotension. In a preferred embodiment of the invention, platelet count and fibrinogen levels are monitored during the method. In a preferred embodiment of the invention, the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets / mm3or lower and the fibrinogen level is l.Og / L or lower.In a further embodiment of the invention, monitoring of the patient is conducted before the method of the invention is conducted. In a further embodiment of the invention the risk of blood pressure drop during treatment is mitigated through pre-treatment with fluids before starting treatment. The need for pre-treatment and volume of fluid required to achieve this will vary from patient to patient and is to be assessed by a clinician. In certain embodiments of the invention, an algorithm is used to guide the clinician on the need and criteria for the pre-treatment.Patients with liver failure are often dehydrated from reduced oral intake and renal and bowel losses from diuretic and laxative use which are common treatments for decompensated chronic liver disease. Furthermore, acute decompensation and ACLF, because of intense systemic inflammation and endothelial dysfunction, causes capillary leak and increased capillary permeability with body fluids re-distributed away from the circulation to tissues, causing further depletion of the circulatory volume and making patients susceptible to haemodynamic instability during an extracorporeal intervention.In a further embodiment of the invention a method of treating an individual with liver disease is provided, said method comprising infusing the individual’s blood with 5% Human Albumin Solution (HAS); and then subsequently treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual;(d) measurement of blood gas analysis, including measurement of lactate;(e) measurement of full blood count (FBC);(f) measurement of urea and electrolytes (UZE);(g) conducting a Liver function test (LFT); and(h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:(i) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and(ii) an initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min, and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is >1.0 g / L.In a preferred embodiment of the invention the fluid for pre-treatment is 5% Human Albumin Solution (HAS), infused as boluses of 250 ml, to a maximum of IL.The individual to be treated according to the invention is an individual having liver disease. Liver failure is the final stage of liver disease. Liver failure is divided into types depending on the rapidity of onset. Acute liver failure develops rapidly, but chronic liver failure may take months or years to develop. By definition, liver failure occurs when the liver is so diseased, and functioning so poorly, that encephalopathy is evident. Any progressive liver disease can result in liver failure; examples include: acetaminotophen toxicity, cirrhosis, viral hepatitis, and metastatic cancer of the liver. Other signs of liver disease such as jaundice, ascites, fetor hepaticus, and failure of coagulation indicate that the liver is having trouble performing its normal physiological duties, but it is not termed liver failure until the mental status changes appear.The prognosis for patients with liver disease is difficult to estimate because the condition has many causes.Accordingly, the individual to be treated may be an individual whose liver is decompensated or which shows hepatic encephalopathy. The individual’s liver may be in the compensated state. The individual may have chronic liver disease. The individual may have liver cirrhosis, for example with or without alcoholic hepatitis. The individual may have acute liver failure. The individual may have hepatic encephalopathy.The onset of both acute and chronic liver disease may be due to a xenobiotic cause. For example, the individual may have been exposed to a chemical, drug or some other agent which causes liver damage. The individual may have a reaction to an over-the- counter, prescriptive or “recreational” drug which causes liver damage. The individual may have been taking RezulinTM (troglitazone; Parke-Davis), SerzoneTM (nefazodone; Bristol-Myers Squibb) or other drugs thought to cause liver damage. The individual may be one who has had an overdose of a particular drug or exceeded the recommended dosage of a drug capable of causing liver damage. For example, the individual may have taken an overdose of paracetamol. The individual may have been exposed to chemicals which can cause liver damage such as, for example, at their place of work. For example, the individual may have been exposed to such chemicals in an industrial or agricultural context. The individual may have consumed plants which contain compounds which cancause liver damage, in particular this may be the case where the individual is an animal, such as a herbivore. For example, the individual may have consumed a plant containing pyrrolizidine alkaloid such as ragwort. The individual may have been exposed to environmental toxins thought to cause liver disease.Drug-related liver toxicity comprises more than 50% of all cases with acute liver disease (acute liver failure). Acetaminophen-(also known as paracetamol and N-acetyl-p- aminophenol) toxicity is the most common cause of acute liver failure in the United States and Great Britain. Long-term moderate to heavy alcohol users who take acetaminophen in therapeutic or modestly excessive doses are at risk of severe hepatic injury and possibly acute liver failure. Alcohol use potentiates the toxic effects of acetaminophen. Idiosyncratic drug toxicity also contributes to acute liver failure. Idiosyncratic drug toxicity is thought to be a hypersensitivity response wherein the individual responds to a drug in a pharmacologically abnormal way. This abnormal response can lead to acute liver failure.The acute liver failure or chronic liver disease may be caused by infection with a pathogenic organism. For example, the liver disease may be due to viral infection. In particular, the individual may be infected, or have been infected, with a virus which causes hepatitis. The individual may have chronic viral hepatitis. The virus may, for example, be hepatitis B, C or D virus. In some cases, and in particular where the individual has viral hepatitis, the individual may also be infected with HIV-I or II. The individual may have AIDS. It is possible that the individual may have been, or be, infected with other organisms which cause liver disease and in particular those which are present in the liver during some stage of their life cycle. For example, the individual may have, or have had, liver fluke.The individual may have an inherited disease which causes, or increases the risk of, chronic liver disease. For example, the individual may have one or more of hepatic hemochromatosis, Wilson’s disease or a- 1 -antitrypsin deficiency. The individual may have an inherited disorder which causes some kind of structural or functional abnormality in the liver which increases the likelihood of liver fibrosis. The individual may be genetically predisposed to develop an autoimmune disorder which damages the liver and hence which can contribute to liver fibrosis.The chronic liver disease may be alcohol-induced. A man or woman to be treated may be, or have been, an alcoholic. He or she may be, or have been, consuming onaverage 50 or more units of alcohol per week, 60 or more units of alcohol per week, 75 or more units of alcohol per week and even 100 or more units of alcohol per week. The man or woman may be, or have been, consuming on average up to 100 units of alcohol per week, up to 150 units of alcohol per week and even up to 200 units of alcohol per week. The measurement of one unit of alcohol differs from country to country. Here, one unit equals 8 grams of ethanol in accordance with the United Kingdom standard.The man or woman may have been consuming such levels of alcohol for 5 or more years, 10 or more years, 15 or more years or 20 or more years. The individual may have been consuming such levels of alcohol for up to 10 years, up to 20 years, up to 30 years and even up to 40 years. In cases of alcohol-induced liver cirrhosis the individual may be aged, for example, 25 years or over, 35 years or over, 45 years or over and even over 60 years.The individual may be male or female. Women may be more susceptible to the adverse effects of alcohol than men. Women can develop alcoholic chronic liver disease in a shorter time frame and from smaller amounts of alcohol than men. There seems to be no single factor to account for increased susceptibility to alcoholic liver damage in females, but the effect of hormones on the metabolism of alcohol may play an important role.Thus, the individual may be suffering from alcoholic hepatitis. Alcoholic hepatitis may range from a mild hepatitis, with abnormal laboratory tests being the only indication of disease, to severe liver dysfunction with complications such as jaundice (yellow skin caused by bilirubin retention), hepatic encephalopathy, ascites, bleeding esophageal varices, abnormal blood clotting and coma.In a preferred embodiment of the invention, the individual may be suffering from acute-on-chronic liver failure (ACLF).The individual may have one or more of a number of other conditions known to result in liver damage such as, for example, primary biliary cirrhosis, autoimmune chronic active hepatitis, and / or schistosomiasis (parasitic infection). The individual may have or have had a bile duct blockage. In some cases, the underlying cause of liver disease may not be known. For example, the individual may have been diagnosed as having cryptogenic cirrhosis. Accordingly, the individual may be suspected of having any of the conditions listed herein.Methods for diagnosing liver disease such as acute liver failure and hepatic encephalopathy are well known in the art and in particular to clinicians and veterinarians in the field. Preferably, the individual will have been diagnosed as having a liver disease and hepatic encephalopathy, for example by a medical or veterinarian professional. The individual may display one or more symptoms associated with liver disease such as one or more of jaundice, ascites, skin changes, fluid retention, nail changes, easy bruising, nose bleeds, oesophageal varices, and in male individuals may have enlargement of breasts. The individual may display exhaustion, fatigue, loss of appetite, nausea, weakness and / or weight loss. The individual may also display one or more symptoms associated with hepatic encephalopathy such as one or more of confusion, disorientation, dementia, stupor, coma, cerebral edema, multiorgan failure (respiratory failure, cardiovascular failure or kidney failure), muscle stiffness / rigidity, seizures or speech impairment. The individual to be treated may or may not be taking other drugs to treat liver disease. The individual to be treated may be at risk of developing hepatic encephalopathy.The liver disease may have been, or be, confirmed by physical examination including techniques such as ultrasound. Liver biopsies may have been taken to look for build-up of fibrosis, necrotic cells, cellular degeneration and / or inflammation and other characteristic features of liver disease. Liver function may have been assessed in the individual to determine whether this is compromised in the individual. The nature and underlying cause of the liver disease may be characterized. Any history of exposure to causative agents of liver disease may be determined.The individual to be treated may be at risk for hepatic encephalopathic episodes, for example patients who are awaiting liver transplants, surgical and / or portal hypertension patients. A person at risk for hepatic encephalopathic episodes is a person who has not suffered any hepatic encephalopathic episodes or has not suffered any hepatic encephalopathic episode for an extended period of time (about 12 weeks or longer), but has a disorder or medical condition which creates a risk of hepatic encephalopathic episodes. A hepatic encephalopathic episode is a clinical condition characterised by the presence of cerebral dysfunction in patients with liver disease or dysfunction. There is a wide spectrum of mental disturbances in hepatic encephalopathy which range from minimal where the main effects are a reduction in the quality of life, to overt which leads to coma and ultimately death.The individual on which the method of the invention is practiced may be a liver transplant patient, an individual suffering from reperfusion injury, for example in a graft after liver transplantation or a patient at risk of developing or who has developed multiorgan failure.Where the level of endotoxin is reduced using an agent to be administered to the individual, the agent may be administered in a variety of dosage forms. Thus, an agent may be administered orally, for example as tablets, troches, lozenges, aqueous or oily suspensions, dispersible powders or granules. The agent may also be administered parenterally, either subcutaneously, intravenously, intramuscularly, intranasally, intrasternally, transdermally or by infusion techniques. The agent may also be administered in the form of a suppository. A physician will be able to determine the required route of administration for each particular patient.The formulation of an agent will depend upon factors such as the nature of the exact agent, whether a pharmaceutical or veterinary use is intended, etc. An agent which is to be used to treat liver disease may be formulated for simultaneous, separate or sequential use.An agent is typically formulated for administration in the present invention with a pharmaceutically acceptable carrier or diluent. The pharmaceutical carrier or diluent may be, for example, an isotonic solution. For example, solid oral forms may contain, together with the active compound, diluents, e.g. lactose, dextrose, saccharose, cellulose, com starch or potato starch; lubricants, e.g. silica, talc, stearic acid, magnesium or calcium stearate, and / or polyethylene glycols; binding agents; e.g. starches, gum arabic, gelatin, methylcellulose, carboxymethylcellulose or polyvinyl pyrrolidone; disaggregating agents, e.g. starch, alginic acid, alginates or sodium starch glycolate; effervescing mixtures; dyestuffs; sweeteners; wetting agents, such as lecithin, polysorbates, laurylsulphates; and, in general, non-toxic and pharmacologically inactive substances used in pharmaceutical formulations. Such pharmaceutical preparations may be manufactured in known manner, for example, by means of mixing, granulating, tabletting, sugar-coating, or film-coating processes.Liquid dispersions for oral administration may be syrups, emulsions or suspensions. The syrups may contain as carriers, for example, saccharose or saccharose with glycerine and / or mannitol and / or sorbitol.Suspensions and emulsions may contain as carrier, for example a natural gum, agar, sodium alginate, pectin, methylcellulose, carboxymethylcellulose, or polyvinyl alcohol. The suspensions or solutions for intramuscular injections may contain, together with the active compound, a pharmaceutically acceptable carrier, e.g. sterile water, olive oil, ethyl oleate, glycols, e.g. propylene glycol, and if desired, a suitable amount of lidocaine hydrochloride.Solutions for intravenous administration or infusion may contain as carrier, for example, sterile water or preferably they may be in the form of sterile, aqueous, isotonic saline solutions.The dose of an agent may be determined according to various parameters, especially according to the substance used; the age, weight and condition of the patient to be treated; the route of administration; and the required regimen.Again, a physician will be able to determine the required route of administration and dosage for any particular patient. A typical daily dose is from about 0.1 to 50 mg per kg of body weight, according to the activity of the specific inhibitor, the age, weight and conditions of the individual to be treated, the type and severity of the degeneration and the frequency and route of administration. Preferably, daily dosage levels are from 5 mg to 2 g-All publications and patent applications mentioned in this specification are indicative of the level of those skilled in the art to which this invention pertains.All publications and patent applications are herein incorporated by reference to the same extent as if each individual publication or patent application was specifically and individually to be incorporated by reference.Although the foregoing invention has been described in some detail by way of illustration and example for purposes of understanding, it will be clear to those skilled in the art that certain changes and modifications may be practiced within the scope of the appended claims.Further embodiments1. In an embodiment of the invention a method of treating an individual with liver disease is provided, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual;(d) measurement of blood gas analysis, including measurement of lactate;(e) measurement of full blood count (FBC);(f) measurement of urea and electrolytes (UZE);(g) conducting a Liver function test (LFT); and(h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:(1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and(2) an initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min.2. The method of embodiment 1, wherein steps (a) and (b) comprise different means for removing albumin and reducing the level of endotoxin.3. The method of embodiment 1 or embodiment 2, wherein the method comprises:(i) removing cytokines from the blood of the individual.4. The method of any one of the preceding embodiments, wherein the method comprises:(j) removing toxins bound to albumin from the blood of the individual.5. The method of any one of the preceding embodiments, wherein said step (a) comprises the use of a solid support capable of selectively binding albumin.6. The method of any one of the preceding embodiments, wherein said step (b) comprises the use of a solid support capable of selectively binding endotoxin.7. The method of any one of the preceding embodiments, wherein the albumin of part (c) is pharmaceutical grade albumin.8. The method of any one of the preceding embodiments, wherein after treating said individual’s blood the blood within the means for dialysis is returned to the patient.9. The method of any one of the preceding embodiments, wherein fibrinogen level are detected in a blood sample taken from the individual before the method as described in any one of the preceding claims is carried out.10. The method of embodiment 9, wherein the method as described in any one of embodiments 1 to 8 is only carried out if the fibrinogen level detected in the blood sample are about >1.0 g / L.11. The method of any one of the preceding embodiments, wherein a platelet count is carried out on a blood sample taken from the individual before the method as described in any one of the embodiments 1 to 8 is carried out.12. The method of embodiment 11, wherein the method as described in any one of embodiments 1 to 8 is only carried out if a platelet count of about > 30,000 platelets / mm3is detected in the blood sample.13. The method of any one of the preceding embodiments, which is carried out ex vivo.14. The method of any one of the preceding embodiments, wherein other components removed with the albumin are returned to the blood of the individual.15. The method of any one of the preceding embodiments, wherein the method of treatment also comprises the following whilst the individual’s blood is treated:(k) anti coagulation of the means of for dialysis with unfractionated heparin and / or prostacycline analogues; and / or(l) continuous measurement of mean arterial pressure (MAP) of the individual.16. In an embodiment of the invention an ex vivo method of treating blood extracorporeally by removing albumin and endotoxin from the blood is provided, wherein the blood is from an individual having liver disease, the method comprising:(a) contacting the blood with a solid support which binds albumin and thereby removing albumin from the blood;(b) contacting the blood with a solid support which selectively binds endotoxin and thereby removing endotoxin from the blood;(c) simultaneously adding to the blood albumin that does not derive from the same individual as the blood;(d) measurement of blood gas analysis, including measurement of lactate;(e) measurement of full blood count (FBC);(f) measurement of urea and electrolytes (UZE);(g) conducting a Liver function test (LFT); and(h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:(1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and(2) an initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min.17. The method according to embodiment 16, wherein:(i) steps (a) and (b) of the method comprise different means for removing albumin and removing endotoxin; and / or(ii) the solid support of (a) comprises an antibody that specifically binds albumin.18. In an embodiment of the invention a method of treating an individual with liver disease is provided said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual;(d) measurement of blood gas analysis, including measurement of lactate;(e) measurement of full blood count (FBC);(f) measurement of urea and electrolytes (UZE);(g) conducting a Liver function test (LFT); and(h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:(i) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and(ii) an initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min.19. In an embodiment of the invention a method of treating an individual with liver disease is provided, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual;(d) measurement of blood gas analysis, including measurement of lactate;(e) measurement of full blood count (FBC);(f) measurement of urea and electrolytes (UZE);(g) conducting a Liver function test (LFT); and(h) measurement of coagulation levels; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising:(1) a membrane having a pore size of greater than 45 kDa and less than 100 kDa, and(2) an initial blood flow rate through the means of approximately 50 ml / min, wherein the flow rate is increased during dialysis to no more than approximately 250 ml / min; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is about >1.0 g / L.In an embodiment of the invention, before starting treatment there is:1. Continuous monitoring of patient’ s blood pressure while on DIALIVE treatment, aiming at all times to maintain the mean arterial blood pressure (MAP) above 90%of the patient’s MAP measured prior to the commencement of treatment or above 65mmHg, whichever of the two is higher. Blood pressure monitoring can be performed using either as an invasive monitoring (preferred) using an arterial catheter inserted in a peripheral artery (radial or brachial artery) for beat-to-beat (pressure with every heartbeat) BP monitoring. When invasive blood pressure monitoring is not possible or feasible, either because not available (in a non HDU / ICU environment) or deemed not very safe (bleeding and infection risk associated with invasive lines) or not actually necessary (for patients who are relatively very stable haemodynamically), standard non-invasive BP monitoring can be considered. The latter uses a standard BP cuff measuring BP every 10 minutes at a minimum or more frequently if clinical condition demands. Invasive methods offer the additional advantage of obtaining frequent blood samples from the indwelling line without the need for multiple venepunctures. Mitigation of risk of blood pressure drop through pre-treatment with fluids before starting a session of DIALIVE treatment. Patients with liver failure are often dehydrated from reduced oral intake and renal and bowel losses from diuretic and laxative use which are common treatments for decompensated chronic liver disease. Furthermore, acute decompensation and ACLF, because of intense systemic inflammation and endothelial dysfunction, causes capillary leak and increased capillary permeability with body fluids re-distributed away from the circulation to tissues, causing further depletion of the circulatory volume and making patients susceptible to haemodynamic instability during an extracorporeal intervention. The preferred fluid for pre-treatment is 5% Human Albumin Solution (HAS), infused as boluses of 250 ml to a maximum of IL. The need for pretreatment and volume of fluid required to achieve this will vary from patient to patient and needs to be assessed by a senior clinician. Confirmation that there is a haemoglobin level of at least 9g / L (90g / dL) using blood transfusion if necessary to mitigate for dilutional anaemia which may be more significant with DIALIVE system because of priming two filters rather that one. This will prevent the risk of hypotension and desaturation. Target for a platelet count and fibrinogen level above 30,000 platelets / mm3and above 1.0 g / L respectively prior to treatment initiation by platelet transfusions. Thiswill be required anyway to safely insert arterial line and the dialysis catheter required for the treatment.In an embodiment of the invention, during treatment:1. Blood flow rate through the system to be increased gradually from 50ml / min to 250ml / min and convective clearance rate (effluent production) increased slowly from IL / hour to pre-defined target of 50ml / kg / hr (approximately 3.5L / hr for a 75kg person), haemodynamic stability permitting. Blood pressure monitoring should be in place during this and rates adjusted to ensure a MAP of 65mmHg and above. Preferably, this should be invasive blood pressure monitoring. In the event of hypotension these rates should be reduced to prevent a reduction in blood pressure. Other causes of hypotension should be searched for; example dehydration, septic shock etc. and treated accordingly. If required, vasopressors such as low-dose norepinephrine (0.1-0.2microgram / kg / min) should be considered early.2. Estimated amount of removed albumin (approximately 5g / hr of DIALIVE treatment) to be replaced as an infusion of bottled Human Albumin Solution, injected into the purified blood just before it being returned to the patient.3. 2-hourly arterial blood gas analysis (ABG including lactate), 4 hourly bloods (FBC, UZE, LFT, coagulation) at 0, 4 and 8-12 hours (end of treatment) should be performed. Any unexpected change to be investigated and treated accordingly.4. Unexplained anaemia during treatment should be investigated for haemolysis.5. Any evidence of consumptive coagulopathy (platelets and fibrinogen falling significantly during treatment) should be investigated fully with DIC (Disseminated Intravascular Coagulation) screening.In an embodiment of the invention, after treatment:1. Following completion of each treatment blood within the circuit should be returned to the patient unless the filter was clotted.2. All bloods tests should be repeated and any unexpected abnormality investigated and addressed appropriately.Performance / efficacy improvements1. Treatment dose escalation to achieve both better convective and diffusive clearance, former achieved by increasing effluent production rate from 17ml / kg / hr to up to lOOml / kg / hr (haemodynamic stability permitting) and the latter by increasing the dialysis component which runs countercurrent to the blood flow in Septex filter from 0.5L / hr to 3L / hr.2. Anti coagulation should be performed to optimize circuit life with minimal interruptions to treatment without increasing any bleeding risk through the use of unfractionated heparin and / or epoprostenol, a prostacycline analogue throughout the treatment.The following Examples illustrate the invention:ExamplesA multi-center, randomized clinical trial of DIALIVE versus standard of care (SOC) was designed to test its safety and verify the hypothesis that DIALIVE will significantly improve the prognostic scores of patients with alcoholic cirrhosis and ACLF by impacting on the pathophysiological mechanisms and resolving organ failure.Material and MethodsPatient eligibilityThe study (NCT03065699) was approved by the relevant Institutional Review Boards of the participating sites and was conducted according to the protocol, the ISO 14155, the ethical principles originating from the Declaration of Helsinki, and consistent with ICH Guidelines. Patients were required to supply written informed consent prior to participating. The study protocol(s) are presented as Appendix 1. During the study, two major and a few minor amendments were made to the protocol. The first major amendment included incorporation of recommendations of the Data Safety Monitoring Board (DSMB) to make DIALIVE therapy safer with detailed treatments to be carried out within intensive care unit (ICU) environment with frequent monitoring, immediaterecognition and treatment of hypotensive episodes, volume pre-loading in clinically hypovolemic patients and albumin replacement simultaneously to removal (Appendix 2). In both groups, ICU admission was mandated in case of requirement of circulatory, renal or respiratory organ support or, the need of airway protection for severe hepatic encephalopathy (HE). The second major amendment was expansion of inclusion criteria to allow patients with ACLF grade 3 (maximum 3 OF; grade 3a) to be enrolled and, serum bilirubin above 20mg / dl and serum creatinine above 1.5 mg / dl to be ACLF- defining diagnoses.This was a multi-center, European, randomized, controlled, open-label study to generate data from the evaluation of safety and performance of a novel liver dialysis device, the DIALIVE in patients with ACLF versus SOC. Cirrhosis was defined by clinical, biochemical, or histological evidence.Patients had to be 18 years or over with ACLF Grades 1-3 a. Inclusion and exclusion criteria are described in the protocol. They were assigned to five (5) Cohorts. Each cohort consisted of six (6) patients (3 DIALIVE: 3 SOC). Dropouts in any of the cohorts were replaced by new patients to ensure accrual of 6 evaluable patients per cohort. Data from each cohort were reviewed for safety by the DSMB before proceeding to the next cohort.Study design and treatmentPatients were recruited from in-patient wards. Randomization was performed electronically with an Interactive Wireless Randomization System (IWRS). Patients were randomized and then followed for a maximum treatment window period of todays (DIALIVE arm), which is the time used for evaluation of device performance, clinical efficacy, and exploratory end points. A minimum of 3 DIALIVE sessions of 8- 12 hours each were needed for the patient to be evaluable for efficacy assessment.Set up time for each DIALIVE session was about 45 min. Operational characteristics and set-up of DIALIVE are summarized in Figure 5.All patients were followed for 28-days, and those from Cohorts 4 (2 patients) and 5 (6 patients) were followed for 90-days. The main time points for data and sample collection were at baseline, Day-5, and Day- 10.Removal of Patients from Therapy or AssessmentThe participant (or their legal representative) was allowed to voluntarily withdraw from the study at any time for any reason. The investigator also had the right to withdraw a patient at any time due to failure to follow clinical investigation plan, administrative, safety or other reason.Endpoints and assessmentsPrimary EndpointThe goal was to evaluate the percentage of patients who experienced at least one serious adverse event (SAE) between study Day-1 (first day of treatment) and Day- 10; especially the incidence rate of SAEs between the study groups occurring in this period as well as to determine the percentage of patients who discontinued DIALIVE due to a serious adverse device event (SADE) between Day-1 and Day-10 (applicable to DIALIVE only).Secondary EndpointsTo evaluate the performance of DIALIVE device as measured by change in plasma endotoxin level (endotoxin activity and concentration), albumin function, 28-day mortality; change in individual organ function, in CLIF-OFs, ACLF Grade and CLIF-C ACLF score; ICU and hospital stay.Exploratory EndpointsTo study exploratory biological and clinical effects of the DIALIVE compared with SOC, evaluating organ function and pathophysiological markers of inflammation.Data Analysis and StatisticsThe data analysis was performed by an independent group (ID IB APS) under the direction of the Data Management Centre (EFCLIF), for regulatory purposes by an independent group (PL, CA) and re-checked by another independent statistician (JC, Incliva, Spain). No specific hypothesis was to be statistically assessed in this study. As this was a first-in-man study, it was not poweredto detect any pre-planned safety or efficacy differences. All statistical testing was therefore post-hoc and exploratory.The Safety population (Safety set) was defined as the subset of randomized patients who received at least one session of treatment (in the DIALIVE arm). The Modified Safety population (Modified Safety set) only included the evaluable patients to estimate the efficacy endpoints including the biomarkers. Values are reported as using mean and standard deviation if the variable is quantitative and with frequencies and percentages otherwise.Mixed Models for Repeated Measurements (MMRM) analysis was performed to evaluate the statistically significant differences between and within groups (SOC and DIALIVE) at the main time-points (Day-5 and Day- 10) in the Modified Safety population for the biomarkers and efficacy endpoints. Reported p-values, effect sizes and 95% confidence intervals (95% CI) of time effect and within treatment comparison obtained from MMRM for the absolute values adjusted by treatment, time and interaction between time and treatment. Overall treatment effect was calculated using absolute differences to baseline adjusted by time, treatment and interaction between both. Individual organ scores were evaluated using Cumulative Link Mixed Models (CLMM) with Laplace approximation adjusted by treatment, time and interaction between time and treatment. The effect of resolution of ACLF was studied using a two-way Analysis of Variance (ANOVA) for absolute values adjusted by resolution, time and interaction between both. All p value calculations are two sided and no p-value adjustment was performed except for ANOVA model where Tukey method was used to control familywise error rate. Kaplan -Mei er curves were constructed to compare time to resolution between groups and differences were assessed using log-rank statistic. SAS 9.4 was used for all MMRM, and R 4.0.1 was used for CLMM and ANOVA.RESULTSStudy Conduct and Patient CharacteristicsA total of 32-patients with ACLF were included, DIALIVE (n=17) versus SOC (n=15),in 8-European hospitals in 6-countries, between July 2017 and January 2020. Mean age was 49 years and approximately 75% patients were male. All had clinical, radiological, or histological evidence of underlying alcoholic cirrhosis. The precipitating event in all patients was alcoholic hepatitis (NIAAA criteria) with superimposed infection in 4 cases in each group. Six patients in each group were corticosteroids non-responders; the rest had contraindications to steroids or steroids not considered according to local practice. Bacterial infection was controlled at the time of randomization. Two patients were replaced according to the study protocol due to early deaths. Therefore, a safety population was defined and referred to as DIALIVE-safety (32 patients) for all safety analyses and a modified safety population (DIALIVE-modified safety) (n=30) was used for efficacy assessments.DIALIVE treatment and device deficiencyDIALIVE therapy was administered for a median of 3-sessions (range 1-5), each session lasting 8-12 hours, in the first 3 -days (range 1-6). Two patients were treated for 1-day, 11 for 3-days, 1 for 4-days and 3 for 5-days. User errors occurred in 3- patients and filter clotting occurred in 5-patients. The latter resolved with filter replacement.SafetyOver the specified study period, 2-patients in the DIALIVE group died after the first session and did not complete 3 -treatments. The first death was due to hypotension consequent on possible sepsis and the second due to a combination of sepsis, hypotension and disseminated intravascular coagulation. These early deaths were analyzed by the DSMB after the 2nd patient death, which occurred in the 2nd study cohort.For the first 7 patients included in the study, no specific criteria for the management of the patients were stipulated apart from an agreement to maintain a high level of clinical oversight and close adherence to the published guidelines (Nadim et al, 2016). After the first 7 patients were included in the study, a significant heterogeneity was observed in the management of patients at individual sites, which were thought by the DSMB topotentially put patients at risk. In discussions with the DSMB, guidelines were instituted by the inventors for the management of subsequent patients including during the dialysis session.The analysis of the inventors provided important insights on how to enhance the safety and prevent the hypotension and contributed to increased safety risks. Consequently, new guidelines were implemented in the protocol that enhanced the safety of the system as demonstrated by the subsequent study results. It was unexpected that the guidelines would provide such an enhancement of safety and, as a result improved results in the study.The main improvement to the DIALIVE process was the identification of specific risk factors in the patient population to be treated. The inventors found that a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L in the blood of the patients were correlated with decreased safety risks and reduced risk of hypotension.Thus, ensuring that patients had a platelet count of > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L before beginning treatment, and monitoring the levels during treatment, lead to an increase in safety and efficacy of the DIALIVE process.An example of other best practice guidelines include:• Anti coagulation with unfractionated heparin and / or prostacycline analogues (the dose as per local protocols).• Blood flow rates on DIALIVE device should be started at 50 ml / min and increased gradually over 1-2 hours to up to a maximum of 250 ml / min.• Replacement fluid (pre-dilution solution) should be started at a rate of 1000 ml / hr and increased gradually to up to 3500 ml / hr (50mls / kg / hr for a 75 kg person), subject to hemodynamic stability. Concomitant dialysis component should run at 1500 ml / hr (25 ml / kg / hr for a 75 kg person).• Albumin should be exchanged simultaneously with DIALIVE treatment. Infusion of bottled albumin (through the Hepalbin filter or without) at a rate of 5 g / hr (to replace albumin removed by the device). This equates to an infusion of 20% human albumin solution at a rate of 25ml / hr.• Mean arterial pressure (MAP) should be continuously monitored. MAP should be maintained at 90% or higher of pre-treatment MAP or above 65 mmHg, whichever is higher.• 2-hourly blood gas analysis (including lactate), and 4 hourly other bloods (FBC, UZE, LFT, coagulation) at 0, 4 and 8-12 hours (end of treatment) should be performed.• Following completion of the treatment session blood within the circuit should be returned to the patient unless the filter was clotted.A senior staff member should closely supervise the dialysis procedure during the first few hours of treatment, with a clear internal escalation plan available, and discuss with study Chief Investigator where necessary.Rules for discontinuing DIALIVE therapy during a treatment session, based on safety: a. Persistent shock (mean arterial pressure -MAP- <65mmHg or <90% pre-treatment value, whichever was higher) for >2 hours with features of tissue hypoperfusion, unresponsive to volume resuscitation and / or low dose noradrenaline (0.1 pg / kg / min). Treatment could be restarted once hemodynamic stability was restored. b. Deteriorating respiratory failure as defined by worsening PaO2 / FiO2 to <200 mmHg (27kPa) and oxygen saturation / FiO2 (SaO2 / FiO2) ratio to <214. Treatment was to be recommenced following a 12-hour recovery period. c. Disseminated Intravascular coagulation (DIC). Thrombocytopenia alone (to below exclusion criterion threshold) without evidence of DIC was not a stopping rule. d. Progression to more than 3 -organ failures. e. In the opinion of the PI, the treatment was unsafe to continue.Within 28-days, 2 other patients died in the DIALIVE group and 3 died in the SOC group. All the deaths in the SOC group were thought to be liver-related whereas in the DIALIVE group, one death was consequent upon myocardial infarction and one due to progressive liver failure in a patient with ACLF grade 3 and a CLIF-ACLF score of 66 at the time of randomization. Between 28- and 90-days post-randomization, 1 further SOC and 1 DIALIVE treated patient died.76.5% of DIALIVE patients and 80% of SOC patients reported treatment-emergent adverse events (AEs), without significant differences between both groups(95% CI 0.35-0.29, p=1.000). Regarding SAEs, 64.7% of patients in the DIALIVE group and 53.3% of patients in the SOC group experienced at least one SAE (Table 2b; 95% CI 0.29-0.51, p=0.769). Of these, 41.2% of DIALIVE patients were considered to have had a related SAE. The most common SAEs in the DIALIVE and SOC patients were hypotension (52.9% vs 20%) and thrombocytopenia, anemia, or bleeding (47.1% vs 26.7%) and bacterial infection (53.3% vs 35.3%) respectively. The issue with hypotension was largely resolved following implementation of the DSMB guidance for patient management. However, two further transient episodes of hypotension were reported. The first was associated with concomitant stopping of terlipressin and was corrected promptly with re-introduction. The second was in a patient with concomitant sepsis, which was corrected rapidly with fluids and inotropes. Need for antibiotics, inotropes and renal replacement therapy were similar between the groups.Device PerformanceAlbumin ultrafiltrationOver a treatment period of 8-hours a mean of 41.1 (SD 11.7) g of albumin was lost in the dialysate on the first day of DIALIVE with no significant difference hour per hour during the eight hours of dialysis. Similar amounts of albumin were lost on each day of DIALIVE.Albumin functionNo trends towards any differences in albumin concentrations was observed between groups at Day-5 (p=0.529) or Day-10 (p=0.792). Therefore, any changes observed in albumin function would likely be attributable to the intervention (Extended Data Table 5). The main functional domains of albumin were tested. There was a significant increase in human mercaptalbumin (HMA) (p=0.001 and p<0.001) and a reduction in both human non-mercapt albumin 1 (HNA-1) 1 (p=0.023 and p=0.005) and HNA 2 (p=0.002 and p=0.017) at both Days-5 and- 10 in the DIALIVE group compared with SOC resulting in a significant increase in albumin redox status as reflected by anincrease in the HMA / HNA ratio (0.491 [0.164; 0.817], p=0.004 and 0.554 [0.227; 0.881], p=0.002 at Days-5 and-10 respectively) (Figure 1).Electron parametric resonance spectroscopy was performed to evaluate the functional efficiency of the albumin binding sites. Two composite measures were analyzed: binding and detoxification efficiencies of albumin. There was a significant increase in the binding efficiency of albumin at Day- 10 in the DIALIVE group compared with the SOC (p=0.016), while detoxification efficiency did not reach statistical significance (Figure 1). The function of the metal binding domain was measured as ischemia modified albumin ratio, which was significantly reduced in the DIALIVE group compared with the SOC group at both Days-5 (p<0.001) and 10 (p=0.009) (Figure 1).Severity of endotoxemiaThree endotoxin measures were performed to evaluate effect of DIALIVE on the severity of endotoxemia.1. Endotoxin activity assay (EAA). Reliable measures (coefficient of variation < 15%) were obtained in 21 -patients (DIALIVE: 10; SOC: 11). There were trends towards reduction in the severity of endotoxemia in the DIALIVE group which was most marked at Day-5, but the differences were not statistically significant (-0.293 [-0.697; 0.111], p=0.145). The patient-level pre-defined reduction goals were 40% as the target; a 20% reduction was considered acceptable. Target values were reached in 3 out of 10 patients (30%) in DIALIVE group and 0 out of 11 (0%) in SOC at Day-5 (p=0.090). Acceptable values were reached in 8 out of 10 patients (80%) in DIALIVE and 4 out of 11 patients (36.4%) in SOC (p=0.081) at Day-5. By Day-10, this advantage observed for DIALIVE was not retained.2. Limulus amebocyte lysate assay (LAL). No significant effect was found at Day- 5 (p=0.152), but there was a statistically significant advantage for DIALIVE at Day-10 (p=0.001).3. Lipoprotein binding protein (LBP) did not show any significant differences (Figure 4a).Clinical EfficacyChanges in organ function and related prognostic scoresThere were significant improvements in the liver (p<0.001), kidney (p<0.001), coagulation (p<0.001) and brain (p<0.001) sub scores of CLIF-C OF score in both groups but the changes in each of these sub-scores were significantly greater in the DIALIVE group at Day- 10 (Figure 2). Although the ACLF grades were not statistically different between groups, 6 (42.9%) DIALIVE patients compared to 4 (26.7%) in SOC achieved ACLF resolution at Day-10 (p=0.450). All patients in either group who resolved ACLF were on antibiotics either beforehand or started them at the time of randomization. The time to resolution of ACLF was significantly faster in DIALIVE patients (log rank test, p=0.036) (Figure 2c). Length of stay in ICU was available for 24 of the 32 randomized patients. In these patients, the mean ICU length of stay was 6.6 + / - 3.2 days for DIALIVE and 8.2 + / - 2.6 days for SOC group. There was no treatment effect overall on CLIF-C OF score (p=0.260) or ACLF score (p=0.134) but a significant decrease was observed in the DIALIVE group at Day-10 (differences between groups: (-1.271 [-2.316; -0.226], p=0.018 for CLIF-C OF score and -4.2 [-8.72; -0.176], p=0.042 for ACLF score) (Figure 2). MELD score showed no significant changes (p=0.256).Pathophysiologic Effects.To determine whether the clinical effects of DIALIVE were associated with changes in the known pathophysiological mechanisms underlying ACLF, several biomarkers were measured at similar time points to the clinical assessments.Systemic inflammationFifteen markers of inflammation were measured (Extended Data Table 6). For IL-8, there was overall treatment effect (p=0.008). There was significantly larger reduction in IL-8 levels in the DIALIVE group at both Day-5 (-43.355 [-85.390; -1.320], p=0.044) and Day-10 (-61.231 [-103.266; -19.196], p=0.006). For TNF-a, there was no significant treatment effect (p=0.094) (Figure 3). There were trends to reduction thatwas consistent in the DIALIVE group but more variable in the SOC group. Statistically significant changes from baseline were observed in the DIALIVE group in IL10 (p=0.026 at Days-5 and 10), IL-18 (p=0.021 at Day-5), CXCL1 (p=0.010 at Day-10), CCL5 / RANTES (p=0.015 at Day-10). No statistically significant changes were observed in IL-6, IL-7, CX3CL1, sCD63, and CCL2 / MCP1 in either group (Figure 4a).DAMPsFor the M30 component of cytokeratin-18 there was a significant treatment effect overall (p=0.002), and a significant reduction at Day- 10 in the DIALIVE group (p=0.005). Similarly, for the M65 component there was a significant treatment effect overall (p=0.028) and a significant advantage for DIALIVE at Day-10 (p=0.029). For receptor-interacting serine / threonine-protein kinase 3 (RIPK3) there was no treatment effect overall (p=0.094) but there was a significant advantage for DIALIVE at Day-5 (p=0.030) (Figure 3).Toll-like receptor 4 and Inflammasome ligandsThere was a significant treatment effect overall (p=0.003) with significant reduction in the DIALIVE group at both Day-5 (p=0.005) and Day-10 (p=0.030) when the patient’s plasma was incubated with toll-like 4 receptor (TLR4) reporter cell line. Similarly, there was a significant treatment effect (p<0.001) when the patient’s plasma was incubated with the ILlb / IL18 inflammasome cell line. There were significant advantages for DIALIVE at both Day-5 (p<0.001) and Day-10 (p=0.002) (Figure 3).Endothelial dysfunctionFor asymmetric dimethyl arginine (ADMA) there was a significant treatment effect overall (p=0.001) with a significant reduction in the DIALIVE group at Day- 10 (p=0.002). For Factor VIII, there was a significant treatment effect overall (p=0.009) with significantly greater reduction observed at Day 5 (p=0.002) in the DIALIVE group. Although not statistically significant, there were trends towards reduction in E-Selectin, ICAM-1 and VCAM-1 that appeared more marked in the DIALIVE group (Figure 4a).Ammonia and symmetric dimethylarginineDecreases from baseline were observed for ammonia in the DIALIVE group through Day-5, but this was not statistically significant. Symmetric dimethylarginine is a stereo isomer of ADMA and a sensitive measure of renal function. There was a significant treatment effect overall (p=0.021) with a significant advantage for DIALIVE at Day-5 (p=0.040).Clinical and pathophysiological factors associated with ACLF resolution.Resolution of ACLF in the DIALIVE group was associated with trends to improvements in most of the biomarkers measured with significant changes in coagulation factor VIII (p=0.032), IL- 18 (p=0.002), M30 component of cytokeratin-18 (p=0.018) and RIPK3 (p=0.031). In the SOC group, there was an apparently paradoxical relationship with CCL5 / Rantes (p=0.004) and M65 component of cytokeratin-18 (p=0.029) being associated with resolution of ACLF. A reduction in INR was associated with resolution of ACLF (p=0.022) (Figure 4b).To determine whether there were general factors associated with resolution of ACLF, both groups were combined (Figure 4c). In general, the data suggested that a reduction in the pathophysiologic factors studied is associated with ACLF resolution in all major domains. The data showed that a reduction in coagulation factor VIII (p=0.018), IL-7 (p=0.027), IL-18 (p=0.030), RIPK3 (p=0.034) and INR (p=0.011) and, an increase in CCL5 / Rantes (p=0.003) were associated with resolution of ACLF.DISCUSSIONThe results of this randomized clinical trial of DIALIVE versus SOC in patients with ACLF Grades 1 to 3 provides data indicating the safety of DIALIVE as evidenced by similar proportion of patients experiencing serious and treatment emergent adverse events in the DIALIVE and SOC groups. There were however, two early deaths in the DIALIVE arm.Following the two early deaths, changes in the guidance to patient and device management were provided in consultation with the DSMB after the recruitment of Cohort 2. These changes brought about unexpected improvements in patient safety and therefore contributed to the successful results of the trial.The statistically significant effect of DIALIVE therapy on the severity of endotoxemia and albumin function suggests evidence of device performance. From the efficacy standpoint, the results suggest that treatment with DIALIVE results in a more rapid resolution of ACLF. Furthermore, this was associated with significant impact on the known pathophysiological mechanisms underlying ACLF development, such as markers of systemic inflammation, DAMPs and PAMPs, endothelial function and ligands of the tolllike receptor 4 and inflammasome pathways.This is the first study of an extracorporeal liver assist device in patients with ACLF using well-validated diagnostic and prognostic criteria. All patients included in this study had severe alcoholic hepatitis that were either unresponsive, had contraindications or thought to be inappropriate for corticosteroid therapy according to local guidelines, and 27% also had a concomitant infection. A 28-day cumulative mortality of 21.8% at 28-days is in keeping with current literature.Apart from user errors and clotting of the filters, there were no significant technical issues with the application of DIALIVE. Patients with ACLF are known to have severely deranged coagulation with some patients having a pro-coagulant state. Therefore, filter clotting is common in ACLF even in those having only renal replacement therapy. The anti coagulation regime in future might therefore be best guided by global coagulation assessments such as thromboelastography. A program of robust training for the nursing staff who would run DIALIVE set up will be an important consideration to deliver safe treatment as most of the sessions of DIALIVE in the present study were delivered by a dedicated team.The application of DIALIVE in clinical practice for the first time depicts evidence of a learning curve as evidenced by two deaths in the early phase of the study. These deaths occurred in hemodynamically unstable patients. Following extensive review by the DSMB, important necessary changes were made to patient management including requirement for managing these patients in a high dependency area and albumin replacement to occur concomitant to treatment and not at the end of treatment session. In the modified-safety cohort, two other DIALIVE treated patients died; one of whom had a CLIF-C ACLF score of 66 which is now widely regarded as a sub-group associated with extremely high risk of death and potential futility of ongoing ICUcare. Nevertheless, this patient tolerated the treatment well but died from sepsis due to a previously undiagnosed osteomyelitis. The second death was precipitated by an acute myocardial infarction well after the end of DIALIVE treatment and thought to be unrelated to DIALIVE treatment. All three deaths in the SOC group were thought to be liver related.The treatment emergent and the serious adverse event rate in the two groups were similar. DIALIVE patients had greater incidence of thrombocytopenia, bleeding, and hypotension, which are not uncommon in critically ill patients receiving extracorporeal therapy. Following protocol modification after the inclusion of Cohort 2, the incidence of hypotension was almost fully addressed. A further two milder episodes were corrected with prompt recognition and appropriate action around the time of starting DIALIVE therapy. The most frequent SAE in the SOC patients was infection, which is well-known to complicate the course of ACLF and is a major cause of death. DIALIVE-treated patients had lower rates of new infections and this is likely secondary to attenuation / dampening of endotoxemia, which drives the risk of infection through its deleterious effects on neutrophil function. In pre-clinical studies, DIALIVE has also shown to restored neutrophil function.Albumin is the most abundant plasma protein in humans and has many pleotropic effects. In ACLF, there is both a reduction in the quantity and function of the circulating albumin, which not only adversely impacts on its detoxification ability, but the oxidized forms act as pro-inflammatory species and contribute to systemic inflammation. DIALIVE by virtue of exchanging the dysfunctional albumin with bottled albumin showed significantly improved albumin function. This was despite there being no difference in the concentration of circulating albumin between the DIALIVE and the SOC groups. During the 8-hour period, about 40-50g of albumin was recovered from the effluent, which is roughly what was replaced. DIALIVE treatment resulted in an improvement in the thiol function, reduction in the deleterious (HNA-1) and permanently damaged fraction of albumin (HNA-2), binding and detoxification function and metal binding ability. It is important to note that this improved functionality was apparent even at day- 10 which is well beyond the scheduled treatment limited to 5 days, indicating perhaps that the sustained improvement might be a reflection of themodification of pathogenic factors responsible for albumin dysfunction.Bacterial translocation is a particular feature of cirrhosis and ACLF and, manifests as accumulation of PAMPs. As many of these substances are ligands for the tolllike receptor and inflammasome pathways, they can drive systemic inflammation. There is good evidence linking accumulation of lipopolysaccharides with systemic inflammation and risk of mortality in ACLF.In in vitro studies, removal of endotoxin or its function, prevented neutrophil dysfunction. DIALIVE was therefore, specifically designed to remove endotoxin. Data from this study demonstrated that significantly greater reduction in the severity of endotoxemia using the LAL assay was observed in the DIALIVE treated patients, which was also sustained at Day- 10. It is difficult to draw conclusions from the results of the EAA assay as the data was analyzed in only about two thirds of the patients in both groups due to the high coefficient of variation in the others. Nevertheless, DIALIVE treatment reached the pre-defined acceptable value for >20% reduction from baseline in 80% and 30% patients at 5-days and 10-days compared with 36% and 50% in the SOC group respectively, but this was not statistically significant.The most important observation of potential efficacy of DIALIVE was the significantly greater improvement in the liver, kidney, coagulation, and brain sub-scores of CLIF- OF scores compared with the SOC group at day 10. Collectively, these resulted in a significant reduction in the CLIF-C OF score and the CLIF-C ACLF score, and a significantly lower time to the resolution of ACLF in the DIALIVE group. Additionally, a larger proportion of patients achieved ACLF resolution with DIALIVE treatment (43% vs. 27%). These data are important since ACLF resolution itself is a desirable clinical end point. Previous observations confirm that resolution of ACLF at Days 3-7 does translate into survival benefit at 28-and 90-days. From the clinical standpoint, in addition to potentially improving survival, resolution of ACLF may allow the patients to be discharged from the intensive care unit and bridging to transplantation in those that do not resolve ACLF completely. In this small study, ICU stay between groups were similar.Molecular adsorbents recirculating systems (MARS) and Prometheus are extracorporeal liver assist devices using principles of albumin dialysis, which were tested in large clinical trials and shown not to reduce mortality. Extracorporeal cellular therapy (ELAD) used hepatoblastoma-derived cells in the dialysis circuit to treat patients with severe alcoholic hepatitis but again failed to show a survival benefit. DIALIVE is very different from these devices as it has been designed to directly impact some of the known pathophysiological mechanisms of ACLF and it does so by exchanging dysfunctional albumin and removing inflammatory mediators PAMPs and DAMPS.The results of the biomarker data associated with ACLF provide insights into the mechanisms of the positive clinical effects of DIALIVE. First, the effect of DIALIVE on the severity of systemic inflammation is clear from trends towards reduction in many of the cytokines measured of which the most significant was IL-8. A change in IL-8 has been shown to be associated with resolution of ACLF. Second, the data showed significant and sustained effect of DIALIVE on markers of cell death, which is known to be elevated in ACLF. Both the M30 component of cytokeratin-18, a marker of apoptosis and RIPK1, a marker of necroptosis was significantly reduced in the DIALIVE-treated patients. Third, together with the observed reduction in PAMPs described above, these translated into significantly lower burden of ligands that stimulate the toll-like 4 receptor or the inflammasome pathways. Fourth, there was a significant effect of DIALIVE on markers of endothelial function, which is known to dysfunctional in ACLF.A correlation analysis of the factors associated with ACLF resolution with DIALIVE suggested a multimodal effect on all categories of the pathophysiological variables known to be associated with the pathogenesis of ACLF. When patients from both groups were combined, ACLF resolution was again shown to be associated with modulation of each of the pathways studied rather than predominance of any single pathway. This observation is largely in keeping with previous data, which have shown similar associations with ACLF resolution and suggests that any biomarker (s) for the early prediction of resolution of ACLF will require a panel combining markersrepresenting multiple pathways. The data showing that an increase CCL5 / Rantes, which is a chemokine, was associated with resolution of ACLF in the SOC group and when both groups were combined, seems paradoxical. Previous studies in patients with alcoholic liver disease patients have shown elevated levels but whether this increase is pathological or compensatory is unknown.The multidimensional effect of DIALIVE does not allow identification of a particular pathway but confirms the importance of albumin dysfunction and, PAMPs and DAMPs in the pathogenesis of ACLF as these were the main variables directly targeted by DIALIVE.In conclusion, the data from this study suggests that DIALIVE is likely to be safe with careful patient management and monitoring of the hemodynamically unstable patient population to be treated. DIALIVE achieves its aims of reducing endotoxin and improving albumin function, which impacts positively on organ function allowing a greater proportion of patients to resolve ACLF with greater rapidity.References[1] Arroyo V, Moreau R, Jalan R. Acute-on-Chronic Liver Failure. N Engl J Med 2020;382:2137-2145.[2] Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on- chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013;144: 1426-1437, 1437 el421- 1429.[3] Claria J, Stauber RE, Coenraad MJ, Moreau R, Jalan R, Pavesi M, et al.Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology 2016;64: 1249-1264.[4] Engelmann C, Sheikh M, Sharma S, Kondo T, Loeffler-Wirth H, Zheng YB, et al. Toll-like receptor 4 is a therapeutic target for prevention and treatment of liver failure. J Hepatol 2020;73: 102-112.[5] Soffientini U, Beaton N, Baweja S, Weiss E, Bihari C, Habtesion A, et al. The Lipopolysaccharide-Sensing Caspase(s)-4 / l 1 Are Activated in Cirrhosis and Are Causally Associated With Progression to Multi-Organ Injury. Front Cell Dev Biol 2021;9:668459.[6] Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Gines P, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on- chronic liver failure. J Hepatol 2014;61 : 1038-1047.[7] Gustot T, Fernandez J, Garcia E, Morando F, Caraceni P, Alessandria C, et al. Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis. Hepatology 2015;62:243-252.[8] Banares R, Nevens F, Larsen FS, Jalan R, Albillos A, Dollinger M, et al.Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology 2013;57: 1153-1162.[9] Kribben A, Gerken G, Haag S, Herget-Rosenthal S, Treichel U, Betz C, et al.Effects of fractionated plasma separation and adsorption on survival in patients with acute-on-chronic liver failure. Gastroenterology 2012;142:782-789 e783.

[0010] Thompson J, Jones N, Al-Khafaji A, Malik S, Reich D, Munoz S, et al.Extracorporeal cellular therapy (ELAD) in severe alcoholic hepatitis: A multinational, prospective, controlled, randomized trial. Liver Transpl 2018;24:380-393.

[0011] Sundaram V, Jalan R, Wu T, Volk ML, Asrani SK, Klein AS, et al. Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation. Gastroenterology 2019;156: 1381-1391 el383.

[0012] Lee KC, Baker LA, Stanzani G, Alibhai H, Chang YM, Jimenez Palacios C, et al. Extracorporeal liver assist device to exchange albumin and remove endotoxin in acute liver failure: Results of a pivotal pre-clinical study. J Hepatol 2015;63:634-642.

[0013] Jalan R, Schnurr K, Mookerjee RP, Sen S, Cheshire L, Hodges S, et al.Alterations in the functional capacity of albumin in patients with decompensated cirrhosis is associated with increased mortality. Hepatology 2009;50:555-564.

[0014] Alcaraz-Quiles J, Casulleras M, Oettl K, Titos E, Flores-Costa R, Duran-Guell M, et al. Oxidized Albumin Triggers a Cytokine Storm in Leukocytes Through P38 Mitogen-Activated Protein Kinase: Role in Systemic Inflammation in Decompensated Cirrhosis. Hepatology 2018;68: 1937-1952.

[0015] Mookerjee RP, Stadlbauer V, Lidder S, Wright GA, Hodges SJ, Davies NA, et al. Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts the outcome. Hepatology 2007;46:831-840.

[0016] Macdonald S, Andreola F, Bachtiger P, Amoros A, Pavesi M, Mookerjee R, et al. Cell death markers in patients with cirrhosis and acute decompensation.Hepatology 2018;67:989-1002.

[0017] Crabb DW, Bataller R, Chalasani NP, Kamath PS, Lucey M, Mathurin P, et al. Standard Definitions and Common Data Elements for Clinical Trials in Patients With Alcoholic Hepatitis: Recommendation From the NIAAA Alcoholic Hepatitis Consortia. Gastroenterol ogy 2016;150:785-790.

[0018] Agarwal B, Shaw S, Shankar Hari M, Burroughs AK, Davenport A. Continuous renal replacement therapy (CRRT) in patients with liver disease: is circuit life different? J Hepatol 2009;51 :504-509.

[0019] Nanchal R, Subramanian R, Karvellas CJ, Hollenberg SM, Peppard WJ, Singbartl K, et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations. Crit Care Med 2020;48:el73-el91.

[0020] Bernardi M, Angeli P, Claria J, Moreau R, Gines P, Jalan R, et al. Albumin in decompensated cirrhosis: new concepts and perspectives. Gut 2020;69: 1127-1138.

[0021] Garcia-Martinez R, Caraceni P, Bernardi M, Gines P, Arroyo V, Jalan R.Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications. Hepatology 2013;58: 1836-1846.

[0022] Caraceni P, Abraldes JG, Gines P, Newsome PN, Sarin SK. The search for disease-modifying agents in decompensated cirrhosis: From drug repurposing to drug discovery. J Hepatol 2021;75 Suppl 1 :S118-S134.

[0023] Wiest R, Albillos A, Trauner M, Bajaj JS, Jalan R. Targeting the gut-liver axis in liver disease. J Hepatol 2017;67: 1084-1103.

[0024] Trebicka J, Macnaughtan J, Schnabl B, Shawcross DL, Bajaj JS. The microbiota in cirrhosis and its role in hepatic decompensation. J Hepatol 2021;75 Suppl 1 :S67-S81.

[0025] Michelena J, Altamirano J, Abraldes JG, Affo S, Morales-Ibanez O, Sancho- Bru P, et al. Systemic inflammatory response and serum lipopolysaccharide levels predict multiple organ failure and death in alcoholic hepatitis. Hepatology 2015;62:762-772.

[0026] Sundaram V, Kogachi S, Wong RJ, Karvellas CJ, Fortune BE, Mahmud N, et al. Effect of the clinical course of acute-on-chronic liver failure prior to liver transplantation on post-transplant survival. J Hepatol 2020;72:481-488.

[0027] Shubham S, Kumar D, Rooge S, Maras JS, Maheshwari D, Nautiyal N, et al.Cellular and functional loss of liver endothelial cells correlates with poor hepatocyte regeneration in acute-on-chronic liver failure. Hepatol Int 2019;13:777-787.

[0028] Chen LZ, Q.; Yu, C.; Wang, F.; Kong, X. Functional roles of CCL5 / RANTES in liver disease. Liver Research 2020;4:28-34.

Claims

CLAIMS1. A method of treating an individual with liver disease, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is about >1.0 g / L.

2. The method of claim 1, wherein steps (a) and (b) comprise different means for removing albumin and reducing the level of endotoxin.

3. The method of claim 1 or claim 2, wherein the method comprises:(d) removing cytokines from the blood of the individual.

4. The method of any one of the preceding claims, wherein the method comprises:(e) removing toxins bound to albumin from the blood of the individual.

5. The method of any one of the preceding claims, wherein said step (a) comprises the use of a solid support capable of selectively binding albumin.

6. The method of any one of the preceding claims, wherein said step (b) comprises the use of a solid support capable of selectively binding endotoxin.

7. The method of any one of the preceding claims, wherein the albumin of part (c) is pharmaceutical grade albumin.

8. The method of any one of the preceding claims, wherein after treating said individual’s blood the blood within the means for dialysis is returned to the patient.

9. The method of any one of the preceding claims, wherein fibrinogen levels are detected in a blood sample taken from the individual before the method as described in any one of the preceding claims is carried out.

10. The method of claim 9, wherein the method as described in any one of claims 1 to 8 is only carried out if the fibrinogen levels detected in the blood sample are about >1.0 g / L.

11. The method of any one of the preceding claims, wherein a platelet count is carried out on a blood sample taken from the individual before the method as described in any one of the claims 1 to 8 is carried out.

12. The method of claim 11, wherein the method as described in any one of claims 1 to 8 is only carried out if a platelet count of about > 30,000 platelets / mm3is detected in the blood sample.

13. The method of any one of the preceding claims, which is carried out ex vivo.

14. The method of any one of the preceding claims, wherein other components removed with the albumin are returned to the blood of the individual.

15. The method of any one of the preceding claims, wherein the method of treatment also comprises the following whilst the individual’s blood is treated:(f) anti coagulation of the means of for dialysis with unfractionated heparin and / or prostacycline analogues; and / or(g) continuous measurement of mean arterial pressure (MAP) of the individual.

16. A method of treating an individual with liver disease, said method comprising treating said individual’s blood by:(a) removing albumin from the blood of the individual;(b) selectively removing endotoxin from the blood of the individual; and(c) simultaneously supplying albumin that does not derive from the individual to the blood of the individual; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the method is stopped if the platelet count in the blood of the individual is about 30,000 platelets / mm3or lower and the fibrinogen level is about 1.0 g / L or lower.

17. An ex vivo method of treating blood extracorporeally by removing albumin and endotoxin from the blood, wherein the blood is from an individual having liver disease, the method comprising:(a) contacting the blood with a solid support which binds albumin and thereby removing albumin from the blood;(b) contacting the blood with a solid support which selectively binds endotoxin and thereby removing endotoxin from the blood;(c) simultaneously adding to the blood albumin that does not derive from the same individual as the blood; wherein said step (a) comprises use of means for dialysis of albumin, said means comprising a membrane having a pore size of greater than 45 kDa and less than 100 kDa; and wherein the blood has a platelet count of about > 30,000 platelets / mm3and a fibrinogen level of about >1.0 g / L.

18. The method according to claim 17, wherein:(i) steps (a) and (b) of the method comprise different means for removing albumin and removing endotoxin; and / or(ii) the solid support of (a) comprises an antibody that specifically binds albumin.

19. Albumin that does not derive from the blood of an individual to be treated for use in a method of liver disease, said method comprising the steps of:(a) removing albumin from the blood of the individual;(b) reducing the level of endotoxin in the blood of the individual; and(c) introducing said albumin that does not derive from the individual to be treated into the blood of the individual; wherein step (a) is carried out by dialysis using means comprising a membrane having a pore size of greater than 45kDa and less than 100 kDa; and wherein the platelet count in the blood of the individual is about > 30,000 platelets / mm3and the fibrinogen level is about >1.0 g / L.

20. The albumin for use according to claim 19, wherein steps (a) and (b) comprise different means for removing albumin and reducing the level of endotoxin.

21. The albumin for use according to claim 19 or claim 20, wherein the method comprises:(d) removing cytokines from the blood of the individual.

22. The albumin for use according to any one of claims 19 to 21, wherein the method comprises:(e) removing toxins bound to albumin from the blood of the individual.

23. The albumin for use according to any one of claims 19 to 22, wherein said step (a) comprises the use of a solid support capable of selectively binding albumin.

24. The albumin for use according to any one of claims 19 to 23, wherein said step (b) comprises the use of a solid support capable of selectively binding endotoxin.

25. The albumin for use according to any one of claims 19 to 24, wherein the albumin of part (c) is pharmaceutical grade albumin.

Images