Plasma exchange (PEX) can be used as liver support system in acute liver failure (ALF), as well as desensitization protocols in liver transplantation. Other apheresis modalities are also used in gastroenterology, e.g., adsorptive cytapheresis (inflammatory bowel disease). Briefly the use of liver assist devices [molecular adsorbents recirculation system (MARS), fractionated plasma separation, and adsorption System (Prometheus) and single pass albumin dialysis (SPAD)] will be reviewed in ALF.