Comparison scoring model of severe viral hepatitis and model of end stage liver disease for the prognosis of patients with liver failure in China

AIM: To estimate the prognosis of patients with liver failure using a scoring model of severe viral hepatitis (SMSVH) and a model of end stage liver disease (MELD) to provide a scientific basis for clinical decision of treatment.

METHODS: One hundred and twenty patients with liver failure due to severe viral hepatitis were investigated with SMSVH established. Patients with acute, subacute, and chronic liver failure were 40, 46 and 34, respectively. The follow-up time was 6 mo. The survival rates of patients with liver failure in 2 wk, 4 wk, 3 mo and 6 mo were estimated with Kaplan-Meier method. Comparison between SMSVH and MELD was made using ROC statistic analysis.

RESULTS: The survival curves of group A (at low risk, SMSVH score ≤ 4) and group B (at high risk, SMSVH score ≥ 5) were significantly different (The 4-wk, 3-mo, 6-mo survival rates were 94.59%, 54.05%, 43.24% in group A, and 51.81%, 20.48%, 12.05% in group B, respectively, P < 0.001). The survival curves of group C (SMSVH scores unchanged or increased), group D (SMSVH scores decreased by 1) and group E (SMSVH scores decreased by 2 or more) were significantly different .The survival rates of groups C, D and E were 66.15%, 100%, 100% in 2-wk; 40.0%, 91.18%, 100% in 4-wk; 0%, 58.82%, 80.95% in 3-mo and 0%, 38.24%, 61.90% in 6-mo, respectively, P < 0.001). The area under the ROC curve (AUC) of SMSVH scores at baseline and after 2 wk of therapy was significantly higher than that under the ROC curve of MELD scores (0.804 and 0.934 vs 0.689, P < 0.001).

CONCLUSION: SMSVH is superior to MELD in the estimation of the prognosis of patients with severe viral hepatitis within 6 mo. SMSVH may be regarded as a criterion for estimation of the efficacy of medical treatment and the decision of clinical treatment.

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.

Elevated troponin I levels in acute liver failure: is myocardial injury an integral part of acute liver failure?

Although rare instances of cardiac injury or arrhythmias have been reported in acute liver failure (ALF), overall, the heart is considered to be spared in this condition. Troponin I, a sensitive and specific marker of myocardial injury, may be elevated in patients with sepsis and acute stroke without underlying acute coronary syndrome, indicating unrecognized cardiac injury in these settings. We sought to determine whether subclinical cardiac injury might also occur in acute liver failure. Serum troponin I levels were measured in 187 patients enrolled in the US Acute Liver Failure Study Group registry, and correlated with clinical variables and outcomes. Diagnoses were representative of the larger group of >1000 patients thus far enrolled and included 80 with acetaminophen-related injury, 26 with viral hepatitis, 19 with ischemic injury, and 62 others. Overall, 74% of patients had elevated troponin I levels (>0.1 ng/ml). Patients with elevated troponin I levels were more likely to have advanced hepatic coma (grades III or IV) or to die (for troponin I levels >0.1 ng/ml, odds ratio 3.88 and 4.69 for advanced coma or death, respectively).

CONCLUSION

In acute liver failure, subclinical myocardial injury appears to occur more commonly than has been recognized, and its pathogenesis in the context of acute liver failure is unclear. Elevated troponin levels are associated with a significant increase in morbidity and mortality. Measurement of troponin I levels may be helpful in patients with acute liver failure, to detect unrecognized myocardial damage and as a marker of unfavorable outcome.

Comparison of the applicability of two prognostic scoring systems in patients with fulminant hepatic failure

BACKGROUND

Distinguishing those patients with fulminant hepatic failure (FHF) and who require transplantation from those FHF patients who will survive with receiving only intensive medical care remains problematic, and this distinction is important because of the chronic shortage of donor livers.

METHODS

To assess the applicability of two prognostic scoring systems, referred to as the London and Clichy criteria, we compared using both systems, at the time of admission, for 43 FHF patients (15 M/28 F; age: 3716 yrs). Acetaminophen (ACM) was the etiology for 16 patients, while the remaining 27 had other etiologies. All the patients received intensive care, and 18 (8 ACM/10 non-ACM) had investigational BAL support.

RESULTS

For the ACM toxicity, neither the London nor the Clichy criteria exhibited acceptable sensitivity (71 vs 86%, respectively), specificity (78 vs 56%, respectively), a positive predictive value (71 vs 60%, respectively), a negative predictive value (78 vs 83%, respectively) or predictive accuracy (75 vs 69%, respectively) to predict patient survival without transplantation. In contrast, applying the London and Clichy criteria to the FHF patients with non-ACM etiologies showed a sensitivity of 96 vs 80%, respectively, a specificity of 100 vs 100%, respectively, a positive predictive value of 100 vs 100%, respectively a negative predictive value of 67 vs 29%, respectively and a predictive accuracy of 96% vs 82%, respectively.

CONCLUSIONS

Overall, the London criteria more accurately predicted the need for transplantation, and neither the London criteria nor the Clichy prognostic criteria accurately predicted the outcome of those patients who suffered with FHF due to ACM. BAL support may have contributed to the survival of the patients with ACM toxicity and who didn't undergo transplantation, and this survival exceeded the predictions of both prognostic systems. Additional multicenter studies should be conducted to refine these prognostic scoring systems, and this will help physicians rapidly identify those FHF patients who can survive without undergoing liver transplantation.

Prognostic factors for fatal outcomes prior to receiving liver transplantation in patients with non-acetaminophen-related fulminant hepatic failure

BACKGROUND AND AIM

Many patients continue to die due to the rapid development of cerebral edema and/or multiple organ failure prior to receiving a liver transplantation.

METHODS

We investigated the prognostic factors associated with 1-week fatal outcomes after the diagnosis of fulminant hepatic failure, which were associated with fatal outcomes prior to receiving liver transplantation, in 104 patients with non-acetaminophen-related fulminant hepatic failure.

RESULTS

With a multivariate logistic regression analysis, age (>40 years), systemic inflammatory response syndrome (SIRS) and plasma prothrombin activities (<or=10%) were significantly associated with fatal outcomes at 1 week after diagnosis in 104 patients. At the time of diagnosis, 50 patients (48%) were in a state of SIRS. Significant differences were observed between patients with and without SIRS regarding the period from the initial symptoms to the diagnosis of fulminant hepatic failure, hepatic coma grade, serum alanine aminotransferase level, serum creatinine level and plasma prothrombin activity. With a multivariate logistic regression analysis, age (>40 years), cause of fulminant hepatic failure (viral hepatitis), plasma prothrombin activity (<or=10%) and no administration of protease inhibitor were significantly associated with the 1-week fatal outcomes of 50 patients with SIRS.

CONCLUSIONS

Patients with SIRS exhibited hepatic failure of increased severity and SIRS may reduce the probability of receiving a liver transplantation. In order to estimate the efficacy of protease inhibitor for patients with SIRS, a prospective randomized trial is required.

Systemic inflammatory response syndrome strongly affects the prognosis of patients with fulminant hepatitis B

BACKGROUND

Hepatitis B virus infection is the most frequent cause of fulminant hepatic failure. Recently, systemic inflammatory response syndrome has been reported to be important in patients with fulminant hepatic failure. However, prognostic factors for fulminant hepatitis B have not been fully examined. In this study, we analyzed prognostic factors for fulminant hepatitis B in order to accurately identify patients with fatal outcomes.

METHODS

Of 110 consecutive patients with fulminant hepatic failure, 36 (33%) were diagnosed with fulminant hepatitis B. Five of the 36 patients received liver transplants, and we analyzed prognostic factors associated with fatal outcomes in the other 31 patients, who consisted of 15 men and 16 women with a median age of 45 (range, 20-74) years.

RESULTS

Eleven patients (35%) survived without liver transplantation, and the remaining 20 (65%) died. Nonsurvivors were older and had a higher prevalence ratio of systemic inflammatory response syndrome than survivors. Treatments were similar between survivors and nonsurvivors. Using a multivariate Cox proportional hazard model, age (>45 years), systemic inflammatory response syndrome, and ratio of total to direct bilirubin (>2.0) were associated with fatal outcomes. In particular, 1-week and overall survival rates of patients with systemic inflammatory response syndrome at the time of diagnosis were 39% and 8%, respectively, while those of patients without systemic inflammatory response syndrome were 94% and 56%, respectively.

CONCLUSIONS

Systemic inflammatory response syndrome strongly affects the short-term prognosis of patients with fulminant hepatitis B, and patients with systemic inflammatory response syndrome might need urgent liver transplantation.

Hepatitis E virus infection and fulminant hepatic failure during pregnancy

BACKGROUND AND AIM

Hepatitis E virus (HEV) infection leading to fulminant hepatic failure (FHF) and high mortality is a common feature in Indian women during the second and third trimesters of pregnancy. An altered status of hormones and immunity are observed during pregnancy but the actual cause of high mortality is still unknown. The present study was carried out to analyze CD3, CD4 and CD8 T cell counts and to assay the level of pregnancy-related hormones such as estrogen, progesterone and beta-HCG in order to discover the role played by these factors.

METHODS

One hundred patients (50 pregnant and 50 non-pregnant women) with FHF and 150 pregnant healthy females without liver disease as controls were recruited for the study. Serological tests for all viral markers using ELISA kits and detection of HEV RNA by reverse transcription-polymerase chain reaction (RT-PCR) were carried out in all cases. CD3, CD4 and CD8 T cell counts were analyzed by fluorescence activated cell sorter (FACS) while hormone assay was performed by commercially available RIA kits.

RESULTS

Serologically (38/50; 76%) as well as by RT-PCR (28/50; 56%), a significantly higher HEV positivity rate was found in pregnant FHF patients compared to non-pregnant women (serologically 15/50; 30%; RT-PCR 7/50; 14%). CD4 counts were lower (P < 0.05), while CD8 counts were higher (P < 0.05), and their ratio (CD4/CD8) in HEV positive pregnant FHF patients was significantly lower (P < 0.01) when compared to that of HEV negative pregnant FHF women or controls. Levels of estrogen, progesterone and beta-HCG were also found to be higher (P < 0.001) in HEV positive pregnant FHF patients when compared to HEV negative patients or controls. HEV infected pregnant FHF patients had a significantly higher mortality rate of 65.8% (25/38) compared to 23.5% (4/15) in HEV positive non-pregnant women (P < 0.001).

CONCLUSIONS

Pregnancy appears to be a potential risk factor for viral replication and an extreme low immune status of Indian/Asian pregnant women. It is suggested that diminished cellular immunity (indicated by a decrease in CD4, an increase in CD8 cell counts and lowered CD4/CD8 cell ratio) and a high level of steroid hormones that influence viral replication/expression during pregnancy appear to be the plausible reasons for severity of the disease.

Modern management of acute liver failure

Liver transplantation has revolutionized the management of acute or fulminant liver failure. Overall success rates of liver transplantation are satisfactory, although not as high as for elective transplantation. Although the bulk of liver transplants use standard whole grafts, interesting data are emerging on auxiliary liver grafts and donations from living donors. Liver transplantation is an integral part of management protocols complementing the sophisticated critical care protocols that have contributed significantly to the overall improved outcomes seen in acute liver failure. The potential for liver support devices to have an impact on the need for liver transplantation and outcomes after transplantation remains exciting.

Fulminant liver failure from acute autochthonous hepatitis E in France: description of seven patients with acute hepatitis E and encephalopathy

Fulminant hepatitis E has not been well characterized in industrialized countries. The aim of this study was to prospectively describe patients with acute hepatitis E presenting as fulminant hepatic failure, i.e. with encephalopathy and prothrombin index <50%. Between February 1997 and April 2005, seven patients with encephalopathy were diagnosed with acute hepatitis E using viral RNA detection. These patients were compared with 33 patients diagnosed with a mild form (absence of encephalopathy) of acute hepatitis E during the same time period. Patients were 65 +/- 11 years old. Five were active drinkers and six had chronic liver disease. All hepatitis E virus sequences evaluated (5/7) were of genotype 3. All patients but two died (71%). Four patients had no travel history. When compared with patients with a mild form of acute hepatitis E, active alcohol abuse and chronic liver disease were more frequent in patients with the severe form. Duration of hospitalization was longer. Aspartate transferase and bilirubin levels were significantly higher. Prothrombin index and accelerin levels were lower and death was more frequent. Acute nontravel-associated hepatitis E can appear as fulminant hepatitis with encephalopathy and coagulation disorders. Prognosis is severe and this may be due to the age at which it occurs and frequent underlying chronic liver disease.

[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.

[Living related liver transplantation - analysis of the first 102 cases]

THE AIM

of the study was to analyse the first 102 living-related liver transplantations performed in Poland at the Children's Memorial Health Institute.

MATERIAL

between November 1999 and January 2007 102 living-related liver transplantations were carried out in 101 patients. In 63 the patients the indication for liver transplantation was biliary atresia, in 7 - intrahepatic cholestasis, in 11 - acute liver failure, in 9 - hepatic tumour, in two - graft insufficiency. The remaining indications included hepatic cirrosis in course of cystic fibrosis, Caroli disease and biliary cysts. There were 61 girls and 40 boys aged from 4 months to 11 years (mean 2.5 years). The body weight ranged from 4.5 to 31 kg (mean 12 kg).

RESULTS

eighty seven children are alive (86%). Five died in the early posttranplant period (between 2 and 11 days after operation), 9 died in the later period (from 36 days to 5 years and 10 months after the operation). The most serious, life threatening early and late complications were bacterial infections. The most frequent scheme of immunosuppressive treatment was tacrolimus and corticosteroids (64%) and tacrolimus and mycophenolate mofetil (16%).

CONCLUSION

living-related liver transplantation is an effective method of treatment of acute and end-stage liver diseases in children with low body mass.

MELD score to predict outcome in adult patients with non-acetaminophen-induced acute liver failure

AIMS/BACKGROUND

A model for end stage liver disease (MELD) score >30 was proposed as an excellent predictor of mortality in patients with non-acetaminophen-induced acute liver failure (ALF). We analyzed the prognostic value of MELD score in our patients with ALF who were prospectively registered in our database since 1990.

METHODS

Overall, 106 patients met the criteria of ALF. Excluding seven patients with acetaminophen etiology, 99 patients (42+/-15 years, 40M/59F) were studied.

RESULTS

Causes were cryptogenic (n=38), viral (n=29), drugs (n=20) and miscellaneous (n=12). Of these, 37% (n=37) survived with medical management alone (group I), 16% (n=16) died (group II) and 46% (n=46) underwent liver transplantation (group III). The strongest predictors of poor outcome were advanced encephalopathy, cryptogenic/drug-induced/hepatitis B etiology and a high MELD score. At the time of diagnosis, King's College Hospital criteria and MELD score >30 had similar high negative predictive value (92% and 91%, respectively) and low positive predictive value (52% and 56%, respectively). The predictive values improved only slightly during follow-up. The best cut-off point for MELD score to discriminate between survivors and nonsurvivors was >35, with a sensitivity and specificity of 86% and 75%, respectively.

CONCLUSIONS

MELD score, which mostly takes into consideration the degree of liver impairment, has a similar prognostic value as King's College Hospital criteria to predict outcome in adult patients with nonacetaminophen-induced ALF. Overall, all current scores miss accuracy and therefore there is a clear need for factors that can better predict the regeneration of the liver in this setting.

Clinical heterogeneity in autoimmune acute liver failure

AIM

To describe the outcome and prognosis in a cohort of patients with acute liver failure due to autoimmune hepatitis without liver transplantation.

METHODS

A retrospective trial was conducted in 11 patients with acute liver failure due to autoimmune hepatitis who attended the Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran. Demographic, biochemical and severity indexes, and treatment and outcome were assessed.

RESULTS

Among the 11 patients, with a median age of 31 years, 72% had inflammatory response syndrome, and six patients received corticosteroids. The mortality rate within four weeks was 56%, and the one-year survival was 27%. In the survivors, severity indexes were lower and 83% received corticosteroids.

CONCLUSION

We observed a relatively high survival rate in patients with acute liver failure due to autoimmune hepatitis. This survival rate could be influenced by severity of the disease and/or use of corticosteroids.

Cadaveric liver transplantation for non-acetaminophen fulminant hepatic failure: A 20-year experience

AIM: To investigate the long-term results of liver transplantation (LT) for non-acetaminophen fulminant hepatic failure (FHF).

METHODS: Over a 20-year period, 29 FHF patients underwent cadaveric whole LT. Most frequent causes of FHF were hepatitis B virus and drug-related (not acetaminophen) liver failure. All surviving patients were regularly controlled at the out-patient clinic and none was lost to follow-up. Mean follow-up was 101 mo.

RESULTS: One month, one-, five- and ten-year patient survival was 79%, 72%, 68% and 68%, respectively. One month, one-, five- and ten-year graft survival was 69%, 65%, 51% and 38%, respectively. Six patients needed early (< 2 mo) retransplantation, four for primary non-function, one for early acute refractory rejection because of ABO blood group incompatibility, and one for a malignant tumor found in the donor. Two patients with hepatitis B FHF developed cerebral lesions peri-transplantion: One developed irreversible and extensive brain damage leading to death, and one suffered from deep deficits leading to continuous medical care in a specialized institution.

CONCLUSION: Long-term outcome of patients transplanted for non-acetaminophen FHF may be excellent. As the quality of life of these patients is also particularly good, LT for FHF is clearly justified, despite lower graft survival compared with LT for other liver diseases.

MELD score as a predictor of liver failure and death in patients with acetaminophen-induced liver injury

The Model for End-Stage Liver Disease (MELD) scoring system has been established as a reliable measure of short-term mortality risk in patients with end-stage chronic liver disease. The aim of this study was to evaluate the prognostic value of the MELD scoring as a predictor of fulminant hepatic failure (FHF) and death in patients with acetaminophen poisoning. Prospectively, serial measurements of the 3 MELD components--INR, bilirubin, and creatinine--were performed in 460 patients with acetaminophen-induced liver injury. Starting on the first day after the day of overdose, MELD score was significantly higher in patients who eventually developed hepatic encephalopathy (HE) than in those who did not. HE developed in 63 of 142 patients with a MELD score above 18 at 48-72 hours after the overdose (positive predictive value 44%) compared with 2 of 182 patients with a MELD score of 18 or below (negative predictive value 99%). Among 124 patients with FHF, a threshold MELD score of 33 on the day after the onset of HE had sensitivity of 60%, specificity of 69%, positive predictive value of 65%, and negative predictive value of 63%. However, the discriminative power of MELD score was not superior to that of INR alone or of the King's College Hospital criteria.

CONCLUSION

MELD score may be useful as a predictor of FHF in patients admitted with acetaminophen toxicity. However, as a predictor of death from FHF, MELD score did not provide more information than the King's College Hospital criteria or INR alone.

Outcomes after identical and compatible orthotopic liver transplantation for fulminant hepatic failure: a single center experience in UK

To analyze the outcomes between identical and compatible liver transplantation (OLT) for fulminant hepatic failure (FHF) from September 1984 to November 2005. The patients were divided in three groups; group 1 (identical), group 2 (compatible) and group 3 (incompatible), according to the donor-recipient blood type matching. We analyzed several outcomes regarding mortality, patient and graft survival, incidence of acute graft rejection during the first postoperative month (30 days), incidence of biliary complications and indications of re-transplantation. We also analyzed the relationship of Coomb's positive test with postoperative hemolysis to all the above mentioned factors. During the study period, 168 males and 112 females underwent their first OLT for FHF, with 37.1% overall mortality and 42.1% overall graft failure rate. The results between group 1 (203 patients) and group 2 (73 patients) were comparable. A statistically significant difference was recorded in 1 year and overall graft survival between group 1 and group 2 (P = 0.049 and log-rank = 0.035 respectively). Coomb's positive test did not influence the outcomes. OLT in FHF can be safely carried out whether the donor organs are identical or compatible. Hemolysis (Coomb's positive test) after identical or compatible OLT does not influence the outcomes.

Acute liver failure in children

OBJECTIVE

To review the incidence, etiologies, pathophysiology, and treatment of acute liver failure (ALF) in children. Emphasis will be placed on the initial management of the multiple organ system involvement of ALF.

METHOD

MEDLINE search from 1970 to March 2005 was performed. Search headings were as follows: acute liver failure, fulminant liver failure, pediatric liver failure, hepatic encephalopathy, and liver transplantation. Studies written in English were selected. Pediatric studies were emphasized. Adult studies were referenced if there were no pediatric studies available in regard to a specific aspect of liver failure.

CONCLUSIONS

Pediatric acute liver failure is a rare but life-threatening disease. The common etiologies differ for given age groups. Management includes treating specific causes and supporting multiple organ system failure. Commonly associated disorders that require initial recognition and treatment include energy production deficiencies (hypoglycemia), coagulation abnormalities, immune system dysfunctions, encephalopathy, and cerebral edema. Criteria used to determine the need for liver transplant are reviewed as well as the difficulties associated with predicting which patients will meet these criteria and how rapidly liver transplant will become the only option. Finally, experimental procedures that may provide additional time for the liver to recover are briefly reported.

[Prognosis factors in acute hepatic insufficiency]

INTRODUCTION

Acute Hepatic Insufficiency (AHI) is a rare syndrome but has a high mortality rate. The purpose of this study was to determine the clinico-epidemiological characteristics of AHI.

MATERIALS AND METHODS

Open study, prospective, descriptive of patients diagnosed with AHI in the Liver Unit of the Edgardo Rebagliati Martins State Hospital (HNERM) from February 1999 until January 2003.

RESULTS

Fifteen (15) cases were studied. The average age was 63 (30-81), the M-F ratio was 2/1. The diagnosis was viral Hepatitis B (53.3%), toxic idiosyncratic reactions (20%), undetermined (20%) and Hepatitis A (6.7%). At the time of diagnosis 80% had Grade I encephalopathy and 20% Grade III encephalopathy; 13.3% did not have ascites and 86.7% had mild-moderate ascites; 53.3% had a history of chronic illness (diabetes, chronic renal insufficiency, cardiopathy and others). Average laboratory values were: albumin 2.5 gr./dl, bilirubin 25.9 mg/dl, prothrombin time 29 and Factor V 40.7%. The most frequent complications were sepsis and cerebral oedema. Global mortality was 80%. The average survival time was 16.6 days.

CONCLUSIONS

In most cases the patients were over 60 years of age. The main cause of AHI was viral Hepatitis B, a disease which can be prevented with active immunisation. Infection and cerebral oedema were common causes of death. AHI, although rare, is a rapidly degenerative and fatal condition.

MELD score as a prognostic model for listing acute liver failure patients for liver transplantation

OBJECTIVES

The King's College Hospital (KCH) criteria are widely used for listing patients with acute liver failure (ALF) for liver transplantation (LT). Recent reports have suggested that the Model for End-Stage Liver Disease (MELD) score may be useful in assessing prognosis in ALF (nonparacetamol). This study compares prognostic accuracy of the two systems in patients with paracetamol (POD)-induced ALF treated in this unit.

METHODS

Seventy-two patients (average age 38 years; F:M ratio 2:1) admitted from 1994 to 2005 with POD-related ALF were studied. Clinical and biochemical parameters were recorded. The effect of applying a MELD score of greater than 30 as listing criteria for LT was calculated and compared with the KCH criteria. Outcomes were defined as LT, death, or full recovery.

RESULTS

Thirty-one patients (43%) recovered with medical therapy, 29 (40%) patients died, and 12 (17%) underwent LT. Sixty five percent of patients had a MELD > 30 and therefore could potentially be listed on admission; however, using KCH criteria only 24% patients were listed immediately. Sensitivity and negative predictive value of MELD was higher then KCH; however, we found KCH to have much higher specificity and positive predictive value.

CONCLUSION

MELD has higher sensitivity and negative predictive value for POD-induced ALF than the KCH criteria. However, the high false-positive rate associated with MELD limits its clinical utility. The high negative predictive value of MELD score may allow it to be used in conjunction with KCH criteria to avoid unneeded LT in patients who will likely recover spontaneously.

Alpha-fetoprotein and prognosis in acute liver failure

Serum concentrations of alpha-fetoprotein (AFP), variably elevated during liver injury, have been suggested to be of prognostic importance in acute liver failure (ALF), higher values being associated with improved outcome. Using a nephelometric assay, we measured AFP in sera obtained on admission from 206 patients prospectively enrolled in the US ALF Study, and on day 3 in 162 of these patients. The AFP ratio was defined as the day 3 AFP concentration divided by that observed on day 1. Median (range) admission serum AFP in all patients was 8.1 (1-1,811) ng/mL and increased to 17.6 (1.1-1,162) ng/mL on day 3 (P < 0.001). Higher absolute levels were not associated with improved outcome. In fact, admission AFP levels were lower in survivors not receiving transplants than in those who died or were transplanted (P < 0.001), whereas there was no difference between the 2 groups on day 3 (P = 0.34). However, a rise in AFP values between day 1 and day 3 indicated a better prognosis: the AFP ratio was 2.2 (0.11-22.1) in spontaneous survivors and 0.87 (0.11-16.4) in nonsurvivors (P < 0.001). An increasing AFP level indicated by an AFP ratio >or=1 was observed in 70 of 98 (71%) survivors, whereas a ratio <1 was observed in 51 of 64 (80%) nonsurvivors. In conclusion, AFP values change dynamically during ALF. In this large prospective study, higher absolute values of AFP did not predict a favorable outcome, but a rising level of AFP over the first 3 hospital days frequently indicated survival.

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.

[Acute liver failure--medical viewpoints]

Acute liver failure is a rare disease that can cause death in the majority of untreated cases. Sudden loss of liver function in the absence of a preexisting liver disease is considered the true form and has to be distinguished from impaired function following exacerbation of an underlying liver disease (acute or chronic failure). Common causes include acute viral hepatitis, drug induced liver injury (DILI) and toxins. The loss of the excretory and synthetic function of the liver marks the clinical presentation and results in icterus, coagulopathy and encephalopathy. Additionally impairment of renal function and sepsis occur and contribute to the high mortality of this disease. The activation of cell death mechanisms (apoptosis) leading to a reductio of viable, functional liver tissue is considered to be an important pathophysiologic mechanism. Curative therapy of this disease includes liver transplantation that has been performed in Germany for the first time in 1969. In the year 2004 a total of 91 liver transplantation were performed for acute liver failure (10.3% of all transplants) in German transplant centers.

[Acute liver failure--surgical approach]

Emergency liver transplantation is the only therapy of proven benefit for patients suffering from acute liver failure. The decision-making for transplantation mostly relies on clinical experience. The positive predictive value of prognostic scoring systems is reliable whereas the negative predictive value reaches only 60%. Due to a high postoperative mortality of 20-30%, the overall results after liver transplantation for acute liver failure are inferior to those obtained after transplantation for chronic liver diseases. The most important prognostic parameters are the severity of multi organ failures and the degree of encephalopathy prior to transplantation. However, long-term survival thereafter is mostly excellent.