Acute liver failure

Hyper-IL-6 gene therapy reverses fulminant hepatic failure

Fulminant hepatic failure is a catastrophic condition caused by massive hepatocellular apoptosis and necrosis. Inhibition of hepatocyte apoptosis and the enhancement of the endogenous potential for liver regeneration could potentially form an effective basis for treatment of this condition. In response to injury in the liver, IL-6 mediates the acute-phase response and induces both cytoprotective and mitogenic functions. Hyper-IL-6 is a superagonistic designer cytokine consisting of human IL-6 linked by a flexible peptide chain to the secreted form of the IL-6 receptor. In a mouse model of acute liver failure induced by d-galactosamine administration, a single low dose of a hyper-IL-6-encoding adenoviral vector, in contrast to an adeno-IL-6 vector, maintained liver function, prevented the progression of liver necrosis, and induced liver regeneration, leading to dramatically enhanced survival. Thus, hyper-IL-6 gene therapy may be useful for the treatment of fulminant hepatic failure, which is often fatal even following treatment by transplantation.

Orthotopic liver transplantation in a patient with severe portopulmonary hypertension

Liver transplantation in patients with severe portopulmonary hypertension (PPH) has been associated with mortality rates in the range of 70% to 80%. Preoperative long-term epoprostenol therapy reverses pulmonary hypertension and may be a valuable possibility to reduce mortality in patients with severe PPH undergoing orthotopic liver transplantation. We want to report a patient with severe PPH, who was treated with intravenous epoprostenol for an 8-month period, after which pulmonary vascular resistance had decreased from 12 to 3 Wood units. Nevertheless, the patient developed intractable perioperative right heart failure necessitating transient mechanical circulatory support. The patient was weaned from mechanical circulatory support, but died from another episode of acute right heart failure after 28 days. Complicated liver transplantation associated with major cardiovascular stress is obviously not tolerated in patients with severe portopulmonary hypertension even after preoperative long-term epoprostenol therapy.

ODC. MODELOS EXPERIMENTAIS CIRÚRGICOS DE FALÊNCIA HEPÁTICA FULMINANTE

Os autores fazem uma revisão pormenorizada sobre os principais modelos cirúrgicos experimentais de falência hepática fulminante. Abordam aspectos da indução experimental das vantagens e desvantagens dos diferentes modelos, tecendo comentários sobre os modelos de indução da falência hepática, e das possíveis formas de diagnóstico e tratamento.

Ascites and spontaneous bacterial peritonitis in fulminant hepatic failure

OBJECTIVE

Although presence of ascites has been reported in patients with fulminant hepatic failure (FHF), spontaneous bacterial peritonitis (SBP) has not been studied in a large group of such patients. Hence, the present study was conducted to evaluate the prevalence and prognostic significance of ascites and SBP in FHF patients.

METHODS

Two hundred ninety-eight consecutive patients (mean age 32.9+/-14.8 yr) with FHF were studied. There were 133 (44.6%) men and 165 (55.4%) women. Acute viral hepatitis accounted for 91.6% of the patients and were analyzed in the present study.

RESULTS

Ascites was clinically detected in 79 (28.9%) patients. The patients with ascites were older (p = 0.005), had longer jaundice-encephalopathy interval (p<0.0000001), lesser grade of encephalopathy on admission (p = 0.0000043), and a lower incidence of raised intracranial pressure on admission (p = 0.0007). Patients with ascites had significantly lower serum albumin (p = 0.021), ALT (p = 0.0005), AST (p = 0.00017), and PT (p = 0.002) on admission than in patients without ascites. Multivariate logistic regression analysis showed that jaundice-encephalopathy interval (> or =14 days) and serum albumin (< or =2.5 g/dl) were the only independent predictors of ascites. SBP was detected in 14 (17.7%) patients (neutrocytic culture positive, 4; neutrocytic culture negative, 9; and monomicrobial bacterascites, 1). Escherichia coli was identified in three patients. Survival was no different between patients with and those without ascites and also between patients with and those without SBP.

CONCLUSIONS

Ascites is a frequent accompaniment of FHF and is complicated by SBP. Jaundice-encephalopathy interval of 14 days or more and serum albumin (< or =2.5 g/dl) on admission predicts the development of ascites in these patients.

Albumin dialysis: effective removal of copper in a patient with fulminant Wilson disease and successful bridging to liver transplantation: a new possibility for the elimination of protein-bound toxins

BACKGROUND

Acute liver failure may be the first manifestation of Wilson disease. If copper elimination fails, liver transplantation is the only remaining therapeutic option. Albumin dialysis, a new method for the removal of protein-bound toxins, was performed in a patient with fulminant Wilson disease.

METHODS

An 18-year-old man with Wilson disease presented with hyperacute liver failure, hepatic encephalopathy III, oligo-anuric renal failure, haemolytic anaemia, rhabdomyolysis, pancreatitis and thrombocytopenia. He was treated with albumin dialysis using a 44 g/l albumin-containing dialysate and a slow dialysate flow rate (1-2 l/h). The other details of the technique used are similar to routine continuous veno-venous haemodiafiltration.

RESULTS

One hundred and five milligrams of copper were removed by albumin dialysis within the first six treatments, resulting in normalisation of blood-copper levels. Successful treatment of the multiorgan failure was achieved. Hepatic encephalopathy improved within 2 days. The patient initially refused liver transplantation. Therefore 35 additional albumin dialysis treatments were performed. Forty-three grams of bilirubin (an indicator of detoxified substances in the liver) and 196 mg of copper were removed. Multiorgan failure, in particular hepatic encephalopathy, did not recur during 59 days of treatment. Eventually, the patient agreed to liver transplantation and that was successful.

CONCLUSION

Albumin dialysis is a new method for the effective treatment of fulminant Wilson disease, resulting in the removal of protein-bound toxins copper and bilirubin. It may serve as a new treatment option in hyperacute liver failure of other origin, acting as an extracorporeal detoxifier.

Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration

Cerebral edema leading to cerebral herniation (CH) is a common cause of death in acute liver failure (ALF). Animal studies have related ammonia with this complication. During liver failure, hepatic ammonia removal can be expected to determine the arterial ammonia level. In patients with ALF, we examined the hypotheses that high arterial ammonia is related to later death by CH, and that impaired removal in the hepatic circulation is related to high arterial ammonia. Twenty-two patients with ALF were studied retrospectively. In addition, prospective studies with liver vein catheterization were performed after development of hepatic encephalopathy (HE) in 22 patients with ALF and 9 with acute on chronic liver disease (AOCLD). Cerebral arterial-venous ammonia difference was studied in 13 patients with ALF. In all patients with ALF (n = 44), those who developed CH (n = 14) had higher arterial plasma ammonia than the non-CH (n = 30) patients (230 +/- 58 vs. 118 +/- 48 micromol/L; P <. 001). In contrast, galactose elimination capacity, bilirubin, creatinine, and prothrombin time were not different (NS). Cerebral arterial-venous differences increased with increasing arterial ammonia (P <.001). Arterial plasma ammonia was lower than hepatic venous in ALF (148 +/- 73 vs. 203 +/- 108 micromol/L; P <.001). In contrast, arterial plasma ammonia was higher than hepatic venous in patients with AOCLD (91 +/- 26 vs. 66 +/- 18 micromol/L; P <.05). Net ammonia release from the hepatic-splanchnic region was 6.5 +/- 6. 4 mmol/h in ALF, and arterial ammonia increased with increasing release. In contrast, there was a net hepatic-splanchnic removal of ammonia (2.8 +/- 3.3 mmol/h) in patients with AOCLD. We interpret these data that in ALF in humans, vast amounts of ammonia escape hepatic metabolism, leading to high arterial ammonia concentrations, which in turn is associated with increased cerebral ammonia uptake and CH.

Brain lactate by magnetic resonance spectroscopy during fulminant hepatic failure in the dog

A noninvasive test is needed to assess the severity of encephalopathy during fulminant hepatic failure. This feasibility study was designed to compare a noninvasive test, brain lactate measurement by magnetic resonance spectroscopy, with intracranial pressure monitoring in a large animal model of fulminant hepatic failure. Five dogs received an intraventricular catheter for intracranial pressure measurement. Liver injury was induced by intravenous bolus of D-galactosamine. Brain lactate concentrations were determined by magnetic resonance spectroscopy for up to 48 hours after D-galactosamine administration (t = 0 hour). A dose of D-galactosamine exceeding 1.5 g/kg resulted in fulminant hepatic failure. Brain lactate levels increased to > 10 mmol/L in the two dogs that developed severe intracranial hypertension of > 50 mm Hg and sustained cerebral perfusion pressures of < 40 mm Hg. Both dogs experienced brain death, 42 and 48 hours after the administration of D-galactosamine. Brain lactate concentrations determined by magnetic resonance spectroscopy were in agreement with brain tissue concentrations of lactate determined by high-performance liquid chromatography at necropsy. Plasma lactate concentrations were only mildly elevated (3.2 and 4.2 mmol/L) at the time of brain death. Elevated levels of brain lactate are associated with intracranial hypertension and poor neurological outcome during fulminant hepatic failure.

Preventive effects of the deleted form of hepatocyte growth factor against various liver injuries

The effects of a naturally occurring deleted form of hepatocyte growth factor (HGF) on hepatic disorder were studied in various models of hepatic failure. The pretreatment of rats and mice with the deleted form of HGF prevented the liver injuries and coagulopathy induced by endotoxin, dimethylnitrosamine and acetaminophen and reduced the mortality due to hepatic dysfunction induced by these hepatotoxins. The concurrent administration of the deleted form of HGF also prevented the liver injury and hepatic fibrosis in mice treated with alpha-naphthylisothiocyanate and in rats treated with dimethylnitrosamine. Moreover, the deleted form of HGF normalized the results of the bromosulphalein-clearance test and ameliorated jaundice in rats with periportal cholangiolitic hepatopathy induced by alpha-naphthylisothiocyanate. The deleted form of HGF also reversed the coagulopathy in rats with hepatic disorder induced by dimethylnitrosamine or by 70% resection of cirrhotic liver (induced by carbon tetrachloride). In Long Evans cinnamon rats receiving vehicle, 20 out of 21 animals died within 4 days after the onset of jaundice. After infusion of the deleted form of HGF for 4 days, 7 out of 20 Long-Evans cinnamon rats survived. These results indicate that the deleted form of HGF could have therapeutic potency in patients with severe hepatic failure.

Effect of endotracheal suctioning on the intracerebral haemodynamics of patients in fulminant hepatic failure

Fulminant hepatic failure is a severe impairment of liver function in someone who has had previously normal liver function. The patients presenting to intensive therapy units have generally had a rapid deterioration which requires prompt intervention and treatment. The first part of this paper gives a detailed review of the aetiology, physiology and management of the disease process. Medical and nursing care of these patients is critical; any adverse intervention may affect outcome. A literature review and small study of the intervention of endotracheal suctioning and its effects on intracranial pressure and cerebral perfusion pressure is described.

Fulminant liver failure in association with the emetic toxin of Bacillus cereus

BACKGROUND

A 17-year-old boy and his father had acute gastroenteritis after eating spaghetti and pesto that had been prepared four days earlier. Within two days, fulminant liver failure and rhabdomyolysis developed in the boy and he died. The father had hyperbilirubinemia and rhabdomyolysis but recovered. We investigated the cause of these illnesses.

METHODS

Bacteria were isolated and characterized by conventional methods, and bacterial toxins were quantified by immunoassays and cell-culture techniques. The effect of the isolated toxin on the rates of oxidation of various substrates was analyzed in rat-liver mitochondria.

RESULTS

Autopsy of the boy's liver revealed diffuse microvesicular steatosis and midzonal necrosis that suggested impaired beta-oxidation of liver mitochondria due to a mitochondrial toxin. There was no evidence of ingestion of heavy metals, halogenated compounds, hepatotoxic drugs, or staphylococcal enterotoxin. However, high concentrations of Bacillus cereus emetic toxin were found in both the residue from the pan used to reheat the food and the boy's liver and bile. B. cereus was cultured from the intestinal contents and the pan residue. The emetic toxin isolated from the B. cereus cultures was found to be a mitochondrial toxin.

CONCLUSIONS

Fulminant liver failure developed after the ingestion of food contaminated with the B. cereus emetic toxin. The toxin inhibits hepatic mitochondrial fatty-acid oxidation, indicating that it caused liver failure in this patient.

Nonnarcotic analgesics: prevalence and estimated economic impact of toxicities

OBJECTIVE

To review and compare the risks of nonnarcotic analgesic toxicities in adults and estimate the relative healthcare costs of these toxicities, since direct comparison of costs is not possible.

DATA SOURCES

A MEDLINE search of the literature from 1969 to 1995 was used to identify pertinent data. Additional references were identified from articles obtained in the search. Information was obtained from prospective, retrospective, controlled, and uncontrolled studies; case reports; and review articles.

DATA EXTRACTION

Estimates of annual US costs of toxicities were extrapolated and synthesized from data from diagnosis-related groups, published information about the incidence of toxicity, or local data.

DATA SYNTHESIS

Chronic use of nonsteroidal antiinflammatory drugs (NSAIDs) is associated with a high incidence of acute renal toxicity and gastrointestinal toxicity. The most common problems associated with acetaminophen use are hepatoxicity after acute problems ingestion of large doses (> 10 g) or habitual use of smaller doses (< 4 g), particularly in alcoholic patients, and chronic analgesic nephropathy. Aspirin use is associated with a high incidence of gastrointestinal and acute renal toxicity in certain patient groups. Available data suggest that acetaminophen, used intermittently, remains the nonnarcotic analgesic of choice in many patient populations, including those with impaired renal function, gastrointestinal disease, and bleeding disorders. Estimated annual US costs associated with the toxicities of acetaminophen (excluding hepatotoxicity), aspirin (acute upper gastrointestinal bleeding only), and NSAIDs (excluding non-upper gastrointestinal hemorrhagic complications and hepatotoxicity) are about $51.5 million, $358.6 million, and $1.35 billion, respectively.

CONCLUSIONS

Intermittent use of most nonnarcotic analgesics produces a small risk of chronic renal or hepatic toxicity. Gastrointestinal toxicity, especially upper gastrointestinal bleeding, remains a significant problem with NSAIDs and aspirin. Acetaminophen remains the nonnarcotic analgesic of choice for intermittent use by most patient groups. The toxicities associated with NSAIDs constitute about 72.6% of the total toxicities (costs $1.86 billion) caused by NSAIDs, acetaminophen, and aspirin.

Auxiliary partial orthotopic liver transplantation for fulminant hepatitis. The Paul Brousse experience

OBJECTIVE

The authors objective is to report their experience with auxiliary partial orthotopic liver transplantation in fulminant hepatitis (FH) and to discuss the principles that may help in its safe application.

SUMMARY BACKGROUND DATA

Auxiliary partial orthotopic liver transplantation is an attractive therapeutic method in FH because it provides hepatic function, whereas the remaining native liver is given the possibility to recover. Despite early encouraging reports, its place in the treatment of FH remains to be defined.

METHODS

Evaluation of 5 cases of FH treated with auxiliary partial orthotopic liver transplantation from a collective of 22 transplantations for 35 cases of FH referred to the authors' center from January 1994 to November 1995. The grafts were one left lobe, two left livers, and two right livers.

RESULTS

The native liver regenerated in three patients: one with Reye's syndrome who died of irreversible neurologic damage, one with FH caused by the hepatitis B virus who is alive 20 months after ABO incompatible graft removal, and one with FH caused by the hepatitis A virus who had her graft removed at 4 months. In two patients, regeneration did not occur: one with drug-induced FH who died of sepsis 3 months after surgery and one with FH of unknown origin who was retransplanted with a standard liver transplantation at 4 months for uncontrollable biliary rejection of an ABO incompatible graft (alive at 10 months). Two of the three patients who survived suffered severe neurologic complications.

CONCLUSIONS

Auxiliary partial orthotopic liver transplantation is an attractive treatment for FH, especially in the presence of good prognostic factors for native liver regeneration: a young patient, rapid onset of the disease, and viral hepatitis. It should be considered cautiously in patients with advanced encephalopathy. By providing a smaller mass of liver tissue than with standard orthotopic liver transplantation, and as a more complex operative procedure, auxiliary partial orthotopic liver transplantation may not be as effective in arresting the progression of neurologic damage.

Use of mammalian liver cells for artificial liver support

Advances in orthotopic liver transplantation have improved the survival rate of both acute and chronic liver failure patients to nearly 70%. However, the success of this treatment modality has created an international organ shortage. Many patients die while awaiting transplantation in part due to the minimal capacity to store viable transplantable livers beyond 24 h. Additionally, for many areas of the world, routine use of whole liver transplantation to treat liver disease is impractical due to the demands on both financial and technical resources. Potentially, these issues may be alleviated, at least in part, by the use of liver cell transplantation or cellular-based liver assist devices. The well-documented regenerative capacity of the liver may obviate the need for whole organ transplantation in some instances of acute failure, if the patient may be provided temporary metabolic support. Although other patients ultimately may require transplantation, a longer period of time to find a suitable organ for transplantation may be gained by that supportive therapy. The field of liver cell transplantation may offer solutions to patients with inherited metabolic deficiencies or chronic liver disease. The potential to treat an hepatic disorder by using only a fraction of the whole liver would increase the number of whole organs available for orthotopic liver transplantation. Research in the fields of hepatocyte based intra- and extra-corporeal liver support is providing evidence that these therapeutic modalities may ultimately become routine in the treatment of severe liver disease. A historic overview of that technology along with its current status is discussed.

Liver transplantation for fulminant hepatic failure: importance of renal failure

One hundred eighty-one consecutive patients with fulminant hepatic failure (FHF) presenting in a 2-year period were reviewed. In this cohort we examined the impact of pretransplant renal failure on mortality and morbidity following orthotopic liver transplantation (OLTx). Twenty-seven patients (18 female, 9 male) with a median age of 43.5 years (range 19-65 years) underwent OLTx. FHF was due to idiosyncratic drug reaction (n = 4), paracetamol overdose (n = 3), seronegative hepatitis (n = 17), hepatitis B (n = 1), veno-occlusive disease (n = 1), and Wilson's disease (n = 1). Renal failure was present in 14 patients, 7 of whom died (whereas there was 100% survival in patients without renal failure). Pretransplant renal failure was associated with prolonged mechanical ventilation (13 days vs 6 days, P = 0.05), prolonged intensive care stay (17 days vs 8 days, P = 0.01) and prolonged hospital stay (27 vs 21 days, P = NS). Pretransplant renal failure did not predict renal dysfunction at 1 year after OLTx. We conclude that the survival of patients transplanted for FHF is inferior to that of patients transplanted for chronic liver disease (67% vs 88% 1-year survival in Birmingham). For patients with FHF undergoing transplantation, pretransplant renal failure strongly predicts poor outcome with significantly greater consumption of resources.