Acute liver failure: spontaneous recovery or transplantation?

BACKGROUND

Decision-making in acute liver failure. Acute liver failure is a disease with multiple organ involvement and a high mortality rate. Conservative management alone will only partly influence the outcome. The option of emergency liver transplantation has greatly improved survival rates, but unables spontaneous recovery. A set of prognostic criteria enables selection of patients who will benefit the most from emergency liver transplantation.

METHODS

Retrospective review and survey of the Groningen results.

RESULTS

Of 52 patients (33 adults and 19 children) admitted for acute liver failure 2 were beyond recovery and died, 9 were treated conservatively and recovered and 41 were listed for emergency liver transplantation because of an estimated survival rate < 20%. Of these, 3 died and 1 recovered spontaneously while waiting and 37 were transplanted. Survival rate for 41 patients listed for transplantation was 23 (56%) and was similar for children and adults.

CONCLUSIONS

In patients with acute liver failure, management and decision-making in a specialized liver unit with the possibility of emergency liver transplantation is mandatory.

Liver transplantation in New Zealand: the first four years

AIM

To summarise the transplant-related activity of the New Zealand Liver Transplant Unit over the first four years.

METHODS

The records of all patients assessed for liver transplantation between 1 December 1997 and 30 December 2001 were examined. Listing criteria, demographics, waiting time, transplant-hospitalisation details and long-term outcome for those who underwent liver transplantation were recorded.

RESULTS

One hundred and eighty six patients over 14 years of age (acute liver failure 28, chronic liver disease 158) were assessed and 150 were listed for liver transplantation. Fifteen died waiting, 13 were de-listed (6 for cancer progression) and 14 remain listed. One hundred and nine liver transplants (including 1 combined heart-liver, 1 sequential liver-bone marrow and 5 re-transplants) were performed on 104 patients (13 acute liver failure, 96 chronic liver failure or hepatocellular carcinoma). The median waiting time was 2 days (range 0 5) for acute liver failure and 62 days (range 0 320) for other patients. Median age at transplant was 50 years (range 14-70); 73 patients (66%) were male; 71 (65%) were European; 13 (12%) Maori; 12 (11%) Pacific Islander; and 8 (7%) Asian. Median duration of surgery was 480 minutes (range 300 720 minutes); red cell transfusion 5 units (0 32); intensive care and total hospital stays were 2 (range 1 17) and 11 days (range 6 91). One transplanted patient died in hospital, 1- and 3-year patient survival was 94% and 87% and corresponding graft survival was 91% and 83%. Ninety three transplanted patients (89%) are alive. Of the 92 patients at least three months post-transplant, 62 (67%) were employed.

CONCLUSION

Liver transplantation is now established in New Zealand as treatment of choice for acute and chronic liver failure and small hepatocellular carcinoma. Excellent outcomes have been attained in those transplanted to date. Reduction in waiting list mortality will require identification of and investment in strategies that will expand the donor organ availability.

[Therapeutic effect of liver transplantation on acute liver failure]

OBJECTIVE

To evaluate the short-term and long-term outcomes of emergent liver transplantation recipients with acute liver failure and to identify factors that influenced these outcomes.

METHODS

318 consecutive patients who underwent liver transplantations between January 2001 and December 2004 were analyzed retrospectively (all the cases were followed up to December 2005). According to UNOS grading scale, all recipients preoperative status were evaluated. 54 patients were acute liver failure (Group I, UNOS 1 and 2A), and the other 264 cases were chronic liver diseases (Group II, UNOS 2B and 3). The postoperative effects in different groups were compared, including the survival rates, incidences of complications, rates and causes of retransplantation, rates and causes of death.

RESULTS

Comparing UNOS2B/3 to UNOS1/2A, the perioperative mortality were 3.7%; 22.6%, the rate of complications 16.7%; 55.6%, 1 year survival rate 91.3%; 74.1%, 3 year survival rate 86.4%; 68.5%, the retransplantation rate 1.1%; 18.5% respectively.

CONCLUSION

Since the technique of liver transplant is very advanced, the effect of surgery is mainly depended on the function of liver and other organs in patients. The recipients with UNOS2B/3 have better short-term and long-term outcomes as comparing to UNOS1/2A. In addition, the recipients with UNOS1/2A are burdened with much higher mortality.

Clinical Features of Hepatic Manifestations among Adult Patients with Hemophagocytic Lymphohistiocytosis: A Retrospective Study

INTRODUCTION

Liver dysfunction is common in patients with hemophagocytic lymphohistiocytosis (HLH). However, whether the severity of liver injury is associated with the prognosis of patients with HLH remains to be determined. This study aims to assess the association of the severity of liver involvement with short-term prognosis among adult patients with HLH.

METHODS

A retrospective study was performed from January 2012 to December 2020, including 150 patients with newly diagnosed HLH and liver injury.

RESULTS

The majority of our cohort suffered from mild to moderate hepatic damage, presenting with Child-Turcotte-Pugh (CTP) class A (55, 36.7%) or B (74, 49.3%). The prevalence of acute liver failure (ALF) was 9.3% in our cohort. The overall 30-day mortality rate was 49.3% among the study population. HLH patients with ALF showed an extremely adverse prognosis, with a mortality rate as high as 92.9%. In a multivariate analysis, age ≥60 years (p = 0.016), blood urea nitrogen (BUN) ≥7 μmol/L (p < 0.001), and malignancy-associated HLH (p < 0.001) at the diagnosis of HLH were identified as being strongly correlated with 30-day prognosis. An excellent predictive power was found. Among the predictive scores used to assess early death of HLH patients with liver injury, the prognostic efficiency of chronic liver failure-sequential organ failure assessment (CLIF-SOFA) (AUROC: 0.936 ± 0.0211) and SOFA score (0.901 ± 0.026) were significantly better than those of the APACHE II (p < 0.001), model for end-stage liver disease score (p < 0.001) and CTP scores (p < 0.001).

CONCLUSION

Patients with old age, elevated BUN, and malignancy had inferior survival. CLIF-SOFA and SOFA enable more accurate prediction of early death in HLH patients with liver injury than other liver-specific and general prognostic models.

[Features of clinical evolution of severe acute viral hepatitis. Series of 72 cases]

The fulminant hepatic failure is a dramatic complication of acute viral hepatitis. Despite therapeutical efforts, the mortality of these forms of acute hepatitis is rated in most studies from 60 to 90%.

MATERIAL AND METHOD

We made a retrospective study that included 2014 patients hospitalized at the Bacau County Hospital from January 1996 to December 2005 with the diagnosis of acute viral hepatitis. Among these, 72 patients presented severe forms of hepatitis.

RESULTS

13 patients presented fulminant hepatic failure. In most cases, etiology was represented by the B-type virus (66.7%). Defining for the fulminant form of hepatitis are the Quick index under 50%, the increase of total serum bilirubine and the leucocitosis associated with neutrophilia.

CONCLUSIONS

Mortality in fulminant forms of hepatitis was of 61.5%, respectively 75% in the case of the B-type viral hepatitis. Key words: SEVERE

[Surveillance of viral hepatitis: laboratory results. Cuba, 1992-2004]

The results of the surveillance of the viral hepatitis in the period 1992-2004 are presented. The HAV infection is the most frequent association that originates pictures of acute viral hepatitis among the patients under 24 years old with positive HBsAg, followed by the hepatitis B virus. The hepatitis A virus alone or co-infected with the hepatitis B virus accounts for 48.88% of the cases. Only 48.71% of the cases among whom acute hepatitis B is suspected, are confirmed from the virological point of view. These results allow to go deep into the knowledge of the behaviour of hepatitis viruses under the Cuban conditions, making possible to establish better strategies for the control or elimination of viral hepatitis, or both.

[Piggy-back liver transplantation in treating acute liver failure patients: a report of 15 cases]

OBJECTIVE

To study the clinical significance of piggy-back liver transplantation in treating acute liver failure (ALF).

METHODS

Fifteen ALF patients (13 caused by HBV and 2 with acute Wilson disease) had piggy-back liver transplantations (PBLT) in our hospital from Sept 1999 to Feb 2006. The outcomes of these patients were retrospectively analyzed.

RESULTS

One year survival rate of the 15 patients was 87% (13/15). Excellent outcome was achieved in the 2 acute Wilson disease cases: their corneal Kayser-Fleischer rings disappeared and serum ceruloplasmin levels returned to normal. Among the 15 cases, one died of severe pulmonary infection and another died of multiple organ system failure on the 6th and 11th postoperative days. HBsAg positivity was observed in 13 cases before liver transplantation. Eleven patients survived and later received anti-HBV treatment recommended by the American Association for the Study of Liver Diseases. Their HBsAg became negative.

CONCLUSION

Liver transplantation is an effective therapy for ALF and can improve survival rate significantly.

A novel scoring system to predict short-term mortality after living donor liver transplantation for acute liver failure

Liver transplantation is often the only lifesaving option for acute liver failure (ALF); however, the predictors of short-term mortality (death within one year) after living donor liver transplantation (LDLT) for ALF have yet to be defined. We retrospectively collected patients ≥18 years old who underwent LDLT for ALF between 2010 and 2020 at 35 centers in Asia. Univariate and multivariate logistic regression analyses were conducted to identify the clinical variables related to short-term mortality and establish a novel scoring system. The Kaplan-Meier method was performed to explore the association between the score and overall survival. Of the 339 recipients, 46 (13.6%) died within 1 year after LDLT. Multivariate analyses revealed 4 independent risk factors for death: use of vasopressors or mechanical ventilation, the higher model for end-stage liver disease score, and a lower graft-to-recipient weight ratio. The internally validated c-statistic of the short-term mortality after transplant (SMT) score derived from these 4 variables was 0.80 (95% confidence interval: 0.74-0.87). The SMT score successfully stratified recipients into low-, intermediate-, and high-risk groups with 1-year overall survival rates of 96%, 80%, and 50%, respectively. In conclusion, our novel SMT score based on 4 predictors will guide ALF recipient and living donor selection.

[The treatment of acute liver failure due to fulminating hepatitis by total or partial orthotopic liver transplantation. The clinical results]

Indications for liver transplant in acute fulminating hepatitis (AFH) are predominantly affected by the high mortality of this spontaneous evolution (80-100%). At present patients with AFH have priority for transplant since they form part of the 0 emergency group according to the National Transplant Organisation. During the period between 1986 and the end of February 1992, a total of 254 liver transplants were performed in 202 patients (52 retransplants). In 26 patients (12.8%) (16 females and 10 males) the indication was fulminating acute hepatitis. Etiology was unknown in 20 patients, secondary to hepatitis B in 4 and to hepatitis A in 1, and was caused by isonazide ingestion in 1 case. The age limits were 3-60 years (X = 31.5 years). An isogroup graft was performed in 16 patients (61.5%), compatible in 3 (11.6%) and incompatible in 7 (26.9%). Due to anthropometric differences, a partial graft was used in 7 patients (26.9%); in 2 of the latter the graft was taken from the same donor ("split-liver"). Placement was always orthotopic with resection of the retrohepatic vena cava in 25 patients and its preservation in 1 (left lobe of split-liver). Peroperative (30 days) mortality was 23% (6/26); 2 due to cerebral death, 2 due to sepsis, 1 due to multisystemic insufficiency (MSI) and 1 due to acute pancreatitis. Four patients (15.3%) died some time after transplant; 1 after 5 months due to broncho-pulmonary complications, 1 after 7 months due to subacute hepatitis, 1 after 3 months due to respiratory failure and the last after 5 months due to anoxic encephalopathy and lung infection. Ten patients (39.4%) were re-transplanted; 4 following chronic rejection, 4 due to primary graft no function, 1 due to arterial thrombosis and 1 due to recurrent hepatitis (with cirrhosis). Two of the latter patients died intraoperatively due to coagulopathy and hemorrhage, and 3 following surgery (1 due to sepsis, 1 due to respiratory complications and 1 due to respiratory insufficiency). Two patients underwent a second re-transplant (1 due to chronic rejection and 1 due to recurrent hepatitis) and of these 1 died peroperatively due to sepsis and MSF. Overall mortality was therefore 61.5% (16/26) and the actuarial survival rate of 17 patients (10 living + 7 postoperative deaths) was 68% at 12 months and 52.9% at 36 months. Even if peroperative mortality is relatively high, liver transplant is currently the elective treatment for fulminating acute hepatitis.

[Liver transplantation in acute liver failure]

Acute hepatic failure is characterized by jaundice and hepatic encephalopathy within eight weeks after the onset of disease. Although acute hepatic failure is a rare occurrence, its rapid progression and high mortality (50 to 90%, depending on the etiology of disease) necessitate immediate intervention. In the absence of causal therapy, orthotopic liver transplantation is currently the only definitive and effective means of treating acute hepatic failure in Europe, acute hepatic failure accounts for 11% of all liver transplantations. At the University department of transplantation surgery in Vienna a total of 27 patients with acute hepatic failure underwent 31 liver transplantations in the last 10 years (1.1.1987 to 31.12.1996). Twenty (74%) of the 27 patients survived the acute event and were discharged from hospital in good general condition after a median postoperative stay of 25 days (range 14-81 days). Seven patients (26%) died between the first and 34th postoperative day (median 26 days) in the intensive care unit, although all potential modern options of intensive care and surgery were used. The causes of death were irreversible cerebral edema (n = 3), multiple organ failure due to bacterial sepsis (n = 3) and uncontrollable haemolysis (n = 1). With a 3-year graft survival rate of 70% the 3-year patient survival rate was 74%. A retrospective analysis of our patients revealed that the postoperative graft function and the incidence of re-transplantation were significant prognostic factors (p < 0.05) for survival following orthotopic liver transplantation for acute hepatic failure. In the absence of further prognostically relevant preoperative indices and in consideration of the potentially fulminant progression of disease, we strongly recommend that any patient, in whom acute hepatic failure is suspected, is immediately transferred to a specialized center with experience both in the conservative treatment of acute hepatic failure and emergency liver transplantation.

Outcome of acute liver failure due to acute hepatitis E in pregnant women

INTRODUCTION

Acute liver failure due to acute hepatitis E carries a high mortality.

METHODS

Clinical and laboratory parameters of 42 pregnant women (median age 25.5 years) with acute liver failure due to acute hepatitis E were retrospectively analyzed.

RESULTS

22 women delivered, whereas pregnancy continued in 20 women. The maternal mortality in these two groups was similar (9/22 [41%] versus 14/20 [70%], p=0.056). However, in patients with grade I, II or III hepatic encephalopathy, delivery of fetus was associated with reduced mortality in those who delivered as against those who continued pregnancy (5/16 (31%) vs. 13/20 (65%), p=0.046). On multivariate analysis, higher grade of encephalopathy at admission was associated with risk of death (p=0.005).

CONCLUSION

Mortality in pregnant women with acute liver failure with acute hepatitis E is high, especially in patients who present with higher grades of encephalopathy.

Course and therapy of acute liver failure

OBJECTIVES AND METHODS

Despite liver transplantation and advances in intensive care medicine fulminant hepatic failure [FHF] remains a life-threatening condition. Actual observations of the clinical course of these patients are rare. Therefore, we analyzed course of disease and survival in all patients treated for FHF at the University of Bonn between 1998 and 2004 and compared it to the patients treated for FHF during 1992-1997.

RESULTS

35 patients were treated for FHF during this period. FHF was viral induced in 13 patients (HBV n = 11, HAV n = 2), toxic in nine, cryptogenic in eleven and autoimmune and hyperthermia in one patient each. According to London- and/or Clichy criteria 16 patients were transplanted. Four of them died during the first year after transplantation due to infectious and hemorrhagic complications. Three patients died without liver-transplantation. All together, 1-year survival was 80%. When compared to patients with FHF analyzed in the period 1992-1997 numbers of patients with FHF in our centre had increased from 16 to 35 patients and 1-year survival improved from 67.5% to 80%. This improved survival was associated with a lower proportion of transplanted patients (45% versus 68%).

CONCLUSIONS

These changes reflect advances in therapy of patients with FHF, which enables a greater proportion of patients to survive without the need for transplantation.

Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score-matched analysis

OBJECTIVES

This study aimed to evaluate the safety and efficacy of therapeutic plasma exchange (TPE) in pediatric acute liver failure (PALF).

METHODS

All children aged 2-18 years with PALF were included. The intervention cohort included a subset of PALF patients undergoing complete three sessions of TPE, whereas the matching controls were derived by propensity score matching from the patient cohort who did not receive any TPE. Propensity matching was performed based on the international normalized ratio (INR), grade of hepatic encephalopathy (HE), age, bilirubin, and ammonia levels. The primary outcome measure was native liver survival (NLS) in the two arms on day 28.

RESULTS

Of the total cohort of 403 patients with PALF, 65 patients who received TPE and 65 propensity-matched controls were included in analysis. The 2 groups were well balanced with comparable baseline parameters. On day 4, patients in the TPE group had significantly lower INR (P = 0.001), lower bilirubin (P = 0.008), and higher mean arterial pressure (MAP) (P = 0.033) than controls. The NLS was 46.15% in the TPE arm and 26.15% in the control arm. The overall survival (OS) was 50.8% in the TPE arm and 35.4% in the control arm. Kaplan-Meier survival analysis showed a significantly higher NLS in patients receiving TPE than controls (P = 0.001). On subgroup analysis, NLS benefit was predominantly seen in hepatitis A-related and indeterminate PALF.

CONCLUSION

TPE improved NLS and OS in a propensity-matched cohort of patients with PALF. Patients receiving TPE had lower INR and bilirubin levels and higher MAP on day 4.

Role of high-volume plasmapheresis in the management of paediatric acute liver failure

OBJECTIVES

Paediatric acute liver failure (PALF) is a life-threatening disease. Management aims to support hepatic regeneration or to bridge to liver transplantation. High-volume plasmapheresis (HVP) removes protein-bound substances, alleviates inflammation, and improves survival in adult acute liver failure. However, experience with HVP in PALF is limited. Aim of this study is to report on feasibility, safety, efficacy and outcomes of HVP in PALF.

METHODS

Retrospective observational study in children with PALF. HVP was performed upon identification of negative prognostic indicators, in toxic aetiology or multiorgan failure (MOF). Exchanged volume with fresh-frozen plasma corresponded to 1.5-2.0 times the patient's estimated plasma volume. One daily cycle was performed until the patient met criteria for discontinuation, that is, liver regeneration, liver transplantation, or death.

RESULTS

Twenty-two children with PALF (body weight 2.5-106 kg) received 1-7 HVP cycles. No bleeding or procedure-related mortality occurred. Alkalosis, hypothermia and reduction in platelets were observed. Haemolysis led to HVP termination in one infant. Seven children (32%) survived with their native livers, 13 patients (59%) underwent liver transplantation. Two infants died due to MOF. Overall survival was 86%. International normalization ratio (INR), alanine aminotransaminases (ALT), bilirubin and inotropic support were reduced significantly (p < 0.05) after the first HVP-cycle (median): INR 2.85 versus 1.5; ALT 1280 versus 434 U/L; bilirubin 12.7 versus 6.7 mg/dL; norepinephrine dosage 0.083 versus 0.009 µg/kg/min. Median soluble-interleukin-2-receptor dropped significantly following HVP (n = 7): 2407 versus 950 U/mL (p < 0.02).

CONCLUSIONS

HVP in PALF is feasible, safe, improves markers of liver failure and inflammation and is associated with lowering inotropic support. Prospective and controlled studies are required to confirm efficacy of HVP in PALF.

[Orthotopic liver transplantation in clinical materials]

The authors present their own experience in orthotopic liver transplantation as a treatment of acute and chronic liver failure. 18 transplantations were performed in 16 patients. The indications for transplantation: acute liver failure-3 cases, chronic advanced disease of the liver-13 cases, graft failure requiring retransplantation-2 cases. All 3 patients with acute failure died after transplantation. Out of 13 patients after elective transplantations 11 remain alive, (in this number both retransplanted). The longest follow-up period is 2.5 years.

Nevirapine-induced fulminant hepatitis

Nevirapine induced hepatotoxicity is known but fatality is rare. We report a case of a young individual who developed nevirapine (NVP) induced fatal hepatitis without apparent risk factors or preceding rash. Exacerbation of underlying silent chronic liver dysfunction possibly contributed to the fatal outcome. This case stresses the need for careful evaluation, regular monitoring and prompt omission of drug on suspicion of hepatotoxicity.

Discrepancies between clinical and autopsy diagnosis in liver transplant recipients - a case series

The utility of the autopsy in patients who have undergone prior orthotopic liver transplantation (OLT) has not previously been defined. We sought to investigate the role of the autopsy in liver transplantation by comparing the clinically derived cause of death with the autopsy cause of death in a cohort of liver transplant recipients at our institution. This study was undertaken in the setting of declining autopsy rates worldwide. Between 2006 and 2011 twenty-nine patients died who had previously undergone OLT, of on whom 19 postmortem examinations were performed. We retrospectively reviewed all post mortem findings, and separately we examined the corresponding medical records to determine the clinical impression of the cause of death. Discrepancies between the post mortem and clinical findings were categorised according to a modification of Goldman's criteria. Our case series demonstrated a discrepancy between the clinical and post mortem examination (PME) findings in 54% of patients. Two patients had major diagnoses (Goldman Class 1) not detected clinically and in seven patients the PME revealed additional undetected minor diagnoses. This case series demonstrates that, even in the modern era of advanced diagnostic imaging techniques, the post mortem examination continues to be a valuable tool in confirming diagnostic accuracy and improving standards in the care of liver transplant recipients.

Prognostic indicators and outcome in patients with acute liver failure, sepsis and with and without shock: a retrospective cohort study

BACKGROUND

Sepsis or septic shock is associated with severe morbidity and mortality in patients with acute liver failure (ALF). This study aimed to explore the potential prognostic value of common clinical indicators in patients with ALF, sepsis and with and without shock.

PATIENTS AND METHODS

The clinical, laboratory, and microbiological data of patients with ALF and sepsis or septic shock who were admitted to the intensive care unit from January 2014 to December 2019 were collected retrospectively. Clinical indicators, outcomes and the associations among them were analyzed and defined.

RESULTS

Of 150 patients, 64 (42.7%) and 86 (57.3%) were divided into the shock and non-shock groups, respectively. Plasma procalcitonin (PCT), C-reactive protein (CRP), and creatinine (Cre) levels, aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio, and prothrombin time (PT) in the shock group and plasma PCT and Cre levels in the non-shock group were positively correlated with 30-day, 60-day, and 90-day mortality. Furthermore, plasma ALT levels were positively correlated with 60-day and 90-day mortality, and PTA showed negative correlations with 30-day, 60-day, and 90-day mortality in both groups. Multivariate logistic regression analysis revealed that the combination of plasma PCT and CRP levels, the combination of plasma PCT and ALT levels, and the combination of plasma ALT levels and PTA were found to be associated with 90-day mortality.

CONCLUSIONS

Clinical indicators, especially plasma PCT, CRP, and ALT levels, PTA, and their combinations were associated with poor outcomes in patients with ALF, sepsis and with and without shock.

Ammonia and urea metabolism in acute liver failure: A multicentre cohort study

BACKGROUND & AIMS

Ammonia is metabolized into urea in the liver. In acute liver failure (ALF), ammonia has been associated with survival. However, urea variation has been poorly studied.

METHODS

Observational cohort including ALF patients from Curry Cabral Hospital (Lisbon, Portugal) and Clinic Hospital (Barcelona, Spain) between 10/2010 and 01/2023. The United States ALF Study Group cohort was used for external validation. Primary exposures were serum ammonia and urea on ICU admission. Primary endpoint was 30-day transplant-free survival (TFS). Secondary endpoint was explanted liver weight.

RESULTS

Among 191 ALF patients, median (IQR) age was 46 (32; 57) years and 85 (44.5%) were males. Overall, 86 (45.0%) patients were transplanted and 75 (39.3%) died. Among all ALF patients, following adjustment for age, sex, body weight, and aetiology, higher ammonia or lower urea was independently associated with higher INR on ICU admission (p < .009). Among all ALF patients, following adjustment for sex, aetiology, and lactate, higher ammonia was independently associated with lower TFS (adjusted odds ratio (95% confidence interval [CI]) = 0.991 (0.985; 0.997); p = .004). This model predicted TFS with good discrimination (area under receiver operating curve [95% CI] = 0.78 [0.75; 0.82]) and reasonable calibration (R2 of 0.43 and Brier score of 0.20) after external validation. Among transplanted patients, following adjustment for age, sex, actual body weight, and aetiology, higher ammonia (p = .024) or lower (p < .001) urea was independently associated with lower explanted liver weight.

CONCLUSIONS

Among ALF patients, serum ammonia and urea were associated with ALF severity. A score incorporating serum ammonia predicted TFS reasonably well.

Prognostic markers in hepatitis A-related pediatric acute liver failure and validation of the Peds-hepatitis A virus prognostic model

OBJECTIVES

Hepatitis A virus (HAV) is the commonest cause for pediatric acute liver failure (PALF) in India. The objective of the study was to identify the predictors of mortality and to evaluate the utility of Peds-HAV model in a cohort of non-LT HAV-PALF.

METHODS

The study included HAV-related PALF from two non-transplant centers. The predictors of outcome were identified by univariate analysis followed by Cox regression analysis. The prognostic accuracy of Peds-HAV model, King's College Hospital (KCH) criteria and pediatric end-stage liver disease score (PELD) were evaluated.

RESULTS

As many as 140 children with PALF were included, of whom 96 (68.6%) children had HAV-PALF. On Cox regression analysis, international normalized ratio (INR) (p < 0.001), jaundice to encephalopathy (JE) interval (p < 0.001) and hepatic encephalopathy (HE) grade 3/4 (p = 0.01) were independent predictors of mortality. The mortality rates were 0% (0/42), 14.3% (3/21), 60% (9/15) and 94.4% (17/18) when none, 1, 2 or 3 criteria of the Peds-HAV were met, respectively. Peds-HAV model at a listing cut-off of  ≥ 2 criteria predicted death with 89.7% sensitivity and 89.6% specificity. In contrast, KCH criteria had a lower sensitivity of 62.1%. PELD score had a sensitivity of 89.7% and specificity of 85.1% at a cut-off of 30. The overall prognostic accuracy of Peds-HAV model (89.6%) was higher than those of KCH (83.3%) and PELD (86.5%).

CONCLUSION

INR, HE grade and JE interval were independent predictors of mortality. The study provides an external validation of Peds-HAV model as a prognostic score in HAV-PALF.

CLINICAL TRIAL REGISTRY NUMBER

Not applicable as this is a retrospective study.