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Artru F, Samuel D. Approaches for patients with very high MELD scores. JHEP Rep 2019; 1:53-65. [PMID: 32039352 PMCID: PMC7001538 DOI: 10.1016/j.jhepr.2019.02.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/31/2019] [Accepted: 02/04/2019] [Indexed: 02/08/2023] Open
Abstract
In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.
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Affiliation(s)
- Florent Artru
- Liver Unit, CHRU Lille, France, University of Lille, LIRIC team, Inserm unit 995
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Sud, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; Hepatinov, Villejuif, F-94800, France
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202
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Hernaez R, Kramer JR, Liu Y, Tansel A, Natarajan Y, Hussain KB, Ginès P, Solà E, Moreau R, Gerbes A, El-Serag HB, Kanwal F. Prevalence and short-term mortality of acute-on-chronic liver failure: A national cohort study from the USA. J Hepatol 2019; 70:639-647. [PMID: 30590100 DOI: 10.1016/j.jhep.2018.12.018] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/21/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterised by the presence of organ failure in patients with decompensated cirrhosis and is associated with high short-term mortality. However, there are limited data on the prevalence and short-term outcomes of ACLF in patients with cirrhosis seen in the US. We aimed to study the prevalence and risk factors associated with the development and short term mortality in a large cohort of patients in the US. METHODS Using the US Department of Veterans Affairs (VA) Corporate Data Warehouse, we identified patients with ACLF during hospitalisation for decompensated cirrhosis at any of the 127 VA hospitals between January 1, 2004, and December 31, 2014. We examined the prevalence of ACLF and variables associated with 28- and 90-day mortality in ACLF, and trends in prevalence and survival over time. RESULTS Of 72,316 patients hospitalised for decompensated cirrhosis, 19,082 (26.4%) patients met the criteria of ACLF on admission. Of these, 12.8% had 1, 10.1% had 2, and 3.5% had 3 or more organ failures. Overall, 25.5% and 40.0% of ACLF patients died within 28 days and 90 days of admission, respectively. Older age, White race, liver cancer, higher model for end-stage liver disease sodium corrected score, and non-liver transplant centre were associated with increased risk of death in ACLF. Over the study period, the prevalence of ACLF decreased, and all grades but ACLF-3 had improvement in survival. CONCLUSIONS In a US cohort of hospitalised patients with decompensated cirrhosis, ACLF was common and associated with high short-term mortality. Over a decade, ACLF prevalence decreased but survival improvement of ACLF-3 was not seen. Early recognition and aggressive management including timely referral to transplant centres may lead to improved outcomes in ACLF. LAY SUMMARY Acute-on-chronic liver failure (ACLF) is a condition marked by multiple organ failures in patients with cirrhosis and associated with a high risk of death. In this study of US patients hospitalised with cirrhosis, 1 in 4 patients developed ACLF. In total, 25% of patients with ACLF died within 1 month and 40% died within 3 months. Thus, early recognition of ACLF is important for the initiation of aggressive management, which is required to save these patients' lives.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Jennifer R Kramer
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yan Liu
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aylin Tansel
- Section of Gastroenterology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Yamini Natarajan
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Khozema B Hussain
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain; Inserm, U1149, Centre de Recerche sur l'inflammation (CRI), Paris, France; Faculté de Médicine, Université Paris Diderot, Paris, France; Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Alexander Gerbes
- Liver Centre Munich, Department of Medicine II, University Hospital, LMU Munich, Germany
| | - Hashem B El-Serag
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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203
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O’Leary JG, Bajaj JS, Tandon P, Biggins SW, Wong F, Kamath PS, Garcia-Tsao G, Maliakkal B, Lai J, Fallon M, Vargas HE, Thuluvath P, Subramanian R, Thacker LR, Reddy KR. Outcomes After Listing for Liver Transplant in Patients With Acute-on-Chronic Liver Failure: The Multicenter North American Consortium for the Study of End-Stage Liver Disease Experience. Liver Transpl 2019; 25:571-579. [PMID: 30724010 PMCID: PMC11075742 DOI: 10.1002/lt.25426] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 01/08/2019] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) characterized with ≥2 extrahepatic organ failures in cirrhosis carries a high mortality. Outcomes of patients listed for liver transplantation (LT) after ACLF and after LT are largely unknown. The North American Consortium for the Study of End-Stage Liver Disease prospectively enrolled 2793 nonelectively hospitalized patients with cirrhosis; 768 were listed for LT. Within 3 months, 265 (35%) received a LT, 395 remained alive without LT, and 108 died/delisted. Compared with nonlisted patients, those listed were younger and more often had ACLF, acute kidney injury, and a higher admission Model for End-Stage Liver Disease (MELD) score. ACLF was most common in patients who died/delisted, followed by those alive with and without LT respectively, (30%, 22%, and 7%, respectively; P < 0.001). At LT, median MELD was 27.9% and 70% were inpatients; median time from hospitalization to LT was 26 days. Post-LT survival at 6 months was unchanged between those with and without ACLF (93% each at 6 months). There was no difference in 3- and 6-month mean post-LT creatinine in those with and without ACLF, despite those with ACLF having a higher mean pre-LT creatinine and a higher rate of perioperative dialysis (61%). In conclusion, patients with and without ACLF had similar survival after transplant with excellent renal recovery in both groups.
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Affiliation(s)
| | - Jasmohan S. Bajaj
- Medicine, Virginia Commonwealth University and McGuire VA
Medical Center, Richmond, VA
| | | | | | | | | | | | | | | | | | | | - Paul Thuluvath
- Mercy Medical Center, University of Maryland School of
Medicine, Baltimore, MD
| | | | - Leroy R. Thacker
- Biostatistics, Virginia Commonwealth University and McGuire
VA Medical Center, Richmond, VA
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204
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Arroyo V. Acute-on-Chronic Liver Failure in Cirrhosis Requires Expedited Decisions for Liver Transplantation. Gastroenterology 2019; 156:1248-1249. [PMID: 30849314 DOI: 10.1053/j.gastro.2019.03.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
- Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure (EFClif), Barcelona, Spain.
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205
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Sundaram V, Jalan R, Wu T, Volk ML, Asrani SK, Klein AS, Wong RJ. Factors Associated with Survival of Patients With Severe Acute-On-Chronic Liver Failure Before and After Liver Transplantation. Gastroenterology 2019; 156:1381-1391.e3. [PMID: 30576643 DOI: 10.1053/j.gastro.2018.12.007] [Citation(s) in RCA: 206] [Impact Index Per Article: 41.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/04/2018] [Accepted: 12/07/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Liver transplantation for patients with acute-on-chronic liver failure (ACLF) with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. METHODS We analyzed data from the United Network for Organ Sharing (UNOS) from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the European Association for the Study of the Liver-chronic liver failure criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-sodium (MELD-Na) score, compared with the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR] 1.49; 95% confidence interval [CI] 1.22-1.84), donor risk index above 1.7 (HR 1.22; 95% CI 1.09-1.35), and liver transplantation within 30 days of listing (HR 0.89; 95% CI 0.81-0.98) were independently associated with survival for 1 year after liver transplantation CONCLUSIONS: In an analysis of data from the UNOS registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist, even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.
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Affiliation(s)
- Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California.
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Tiffany Wu
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Michael L Volk
- Division of Gastroenterology and Transplantation Institute, Loma Linda University, Loma Linda, California
| | | | - Andrew S Klein
- Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Highland Hospital, Oakland, California
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206
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Roy A, Taneja S. Type of organ failure and acute insult have important bearings in outcomes of liver transplantation: A pragmatic discourse. J Hepatol 2019; 70:548-549. [PMID: 30401589 DOI: 10.1016/j.jhep.2018.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2018] [Accepted: 09/03/2018] [Indexed: 01/06/2023]
Affiliation(s)
- Akash Roy
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh, India.
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207
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Report of the 24th Annual Congress of the International Liver Transplantation Society. Transplantation 2019; 103:465-469. [DOI: 10.1097/tp.0000000000002549] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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208
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Jaber S, De Jong A. 10 tips for intensive care management of transplanted liver patients. Intensive Care Med 2019; 45:377-379. [PMID: 30820582 DOI: 10.1007/s00134-019-05579-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Accepted: 02/21/2019] [Indexed: 01/05/2023]
Affiliation(s)
- Samir Jaber
- Intensive Care Unit and Anaesthesiology Department, PhyMedExp, University of Montpellier Saint-Eloi Hospital, INSERM U1046, CNRS, UMR 9214, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France.
- Anesthesia and Critical Care Department B, Centre Hospitalier Universitaire Montpellier, Saint Eloi Teaching Hospital, 34295, Montpellier Cedex 5, France.
| | - Audrey De Jong
- Intensive Care Unit and Anaesthesiology Department, PhyMedExp, University of Montpellier Saint-Eloi Hospital, INSERM U1046, CNRS, UMR 9214, 80 avenue Augustin Fliche, 34295, Montpellier Cedex 5, France
- Anesthesia and Critical Care Department B, Centre Hospitalier Universitaire Montpellier, Saint Eloi Teaching Hospital, 34295, Montpellier Cedex 5, France
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209
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Gustot T, Jalan R. Acute-on-chronic liver failure in patients with alcohol-related liver disease. J Hepatol 2019; 70:319-327. [PMID: 30658733 DOI: 10.1016/j.jhep.2018.12.008] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 12/11/2018] [Indexed: 12/16/2022]
Abstract
The spectrum of alcohol-related liver diseases (ALD) includes steatosis, steatohepatitis, progressive liver fibrosis, and cirrhosis. Acute-on-chronic liver failure (ACLF) is a recently defined entity that occurs in patients with chronic liver diseases and is characterised by acute decompensation, organ failures and a high risk of short-term mortality. Active alcohol consumption, alcoholic hepatitis and bacterial infections are the most frequent events precipitating the development of ACLF in the context of ALD (ALD-ACLF). The specific management of this entity remains unknown and the place of salvage liver transplantation controversial. This overview details the current knowledge on specific aspects of epidemiology, pathophysiology, prognosis and management of ALD-ACLF.
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Affiliation(s)
- Thierry Gustot
- Dept. Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain.
| | - Rajiv Jalan
- The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain; Liver Failure Group, Insitute for Liver and Digestive Health, University College London, London, UK
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210
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Artzner T, Michard B, Besch C, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals. World J Gastroenterol 2018; 24:5203-5214. [PMID: 30581269 PMCID: PMC6295835 DOI: 10.3748/wjg.v24.i46.5203] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/12/2018] [Accepted: 11/13/2018] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
| | - Eric Levesque
- Service d’Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil 94000, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg 67000, France
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211
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Gustot T, Moreau R. Acute-on-chronic liver failure vs. traditional acute decompensation of cirrhosis. J Hepatol 2018; 69:1384-1393. [PMID: 30195459 DOI: 10.1016/j.jhep.2018.08.024] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 08/22/2018] [Accepted: 08/30/2018] [Indexed: 12/15/2022]
Affiliation(s)
- Thierry Gustot
- Dept. Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain.
| | - Richard Moreau
- Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain; Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France; Laboratoire d'Excellence (Labex) Inflamex, CUE Sorbonne Paris Cité, Paris, France
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212
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Thuluvath PJ, Thuluvath AJ, Hanish S, Savva Y. Liver transplantation in patients with multiple organ failures: Feasibility and outcomes. J Hepatol 2018; 69:1047-1056. [PMID: 30071241 DOI: 10.1016/j.jhep.2018.07.007] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 07/06/2018] [Accepted: 07/12/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Multiple organ failures (OFs) are common in patients with cirrhosis, but the independent effect of the number or type of OFs on liver transplantation (LT) outcomes is not well defined. METHOD United Network for Organ Sharing data were analyzed from 2002 to 2016 for all adults listed for LT who received an LT within 30 days after listing. We estimated post-LT survival stratified by number and type of pre-transplant OFs before and after adjusting for confounding variables. RESULTS During the study period, 4,714 (4.1%) patients died and 19,375 (16.6%) patients were transplanted within 30 days of listing. One or more OF were more common in those who were transplanted (57.4%) compared to those without LT (9.5%). The probability of staying alive more than 30 days on the waiting list without LT decreased with increasing number of OFs; while 90% were alive without OF, only 20% were alive with two OFs, and 2-8% with three or more OFs. The interval between listing and transplantation decreased with an increase in OFs, and the median time to transplant after listing was only 4-5 days with three or more OFs. Although the risk of post-LT mortality increased with increasing number of OFs, the 90-day patient survival was 90% and one-year survival was 81% in the presence of 5-6 OFs. The number of OFs was an independent predictor of survival, but the maximum difference in one-year graft or patient survival between those without OF and those with 5-6 OFs was only 9%. Additionally, the type of OF had minimal impact on outcomes. CONCLUSIONS Liver transplantation is feasible with excellent outcomes, even in the presence of five or six OFs. LAY SUMMARY Multiple organ failures, ranging from 1-6, are common in hospitalized patients with cirrhosis. The survival without liver transplant is dismal in the presence of three or more organ failures. Small retrospective studies have shown that liver transplant is feasible with good outcomes even in the presence of multiple organ failures. In this study, using a large national dataset, we show that survival chances for more than 30 days in those with three or more organ failures are less than 8%. However, if a liver transplant is performed quickly, the survival chances are very high with one-year survival ranging from 84% with three organ failures to 81% with 5-6 organ failures.
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Affiliation(s)
- Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States; University of Maryland School of Medicine, Baltimore, MD, United States.
| | - Avesh J Thuluvath
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Steven Hanish
- University of Maryland School of Medicine, Baltimore, MD, United States
| | - Yulia Savva
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
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213
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Khaldi M, Lemaitre E, Louvet A, Artru F. Insuffisance rénale aiguë et syndrome hépatorénal chez le patient cirrhotique : actualités diagnostiques et thérapeutiques. MEDECINE INTENSIVE REANIMATION 2018. [DOI: 10.3166/rea-2018-0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
La survenue d’une insuffisance rénale aiguë ou AKI (acute kidney injury) chez un patient cirrhotique est un événement de mauvais pronostic. Parmi les AKI, une entité spécifique au patient cirrhotique décompensé est le syndrome hépatorénal (SHR) dont la définition ainsi que la stratégie thérapeutique ont été réactualisées récemment. La prise en charge de l’AKI hors SHR n’est pas spécifique au patient cirrhotique. La prise en charge du SHR repose sur l’association d’un traitement vasoconstricteur intraveineux et d’un remplissage vasculaire par sérum d’albumine concentrée. Cette association thérapeutique permet d’améliorer le pronostic des patients répondeurs. En contexte d’AKI chez le patient cirrhotique, l’épuration extrarénale (EER) peut être envisagée en cas de non-réponse au traitement médical. La décision de débuter une prise en charge invasive avec EER dépend principalement de la présence d’un projet de transplantation hépatique (TH). En l’absence d’un tel projet, cette décision devrait être prise après évaluation du pronostic à court terme du patient dépendant du nombre de défaillance d’organes et d’autres variables telles que l’âge ou les comorbidités. L’objectif de cette mise au point est de discuter des récentes modifications de la définition de l’AKI et en particulier du SHR chez les patients cirrhotiques, de détailler la prise en charge spécifique du SHR et d’évoquer les processus décisionnels menant ou non à l’instauration d’une EER chez les patients non répondeurs au traitement médical en milieu réanimatoire.
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Fernández J, Saliba F. Liver transplantation in patients with ACLF and multiple organ failure: Time for priority after initial stabilization. J Hepatol 2018; 69:1004-1006. [PMID: 30241881 DOI: 10.1016/j.jhep.2018.09.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/03/2018] [Accepted: 09/04/2018] [Indexed: 12/30/2022]
Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Faouzi Saliba
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; Université Paris Sud and University Paris Saclay, Paris XI, France; Unité INSERM U 935 and U 1193, Villejuif, France.
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215
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When Should We Stop Treatment With Terlipressin and Albumin for Patients With Hepatorenal Syndrome? Clin Gastroenterol Hepatol 2018; 16:1710-1711. [PMID: 29684461 DOI: 10.1016/j.cgh.2018.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Revised: 04/09/2018] [Accepted: 04/13/2018] [Indexed: 02/07/2023]
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216
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Engelmann C, Thomsen KL, Zakeri N, Sheikh M, Agarwal B, Jalan R, Mookerjee RP. Validation of CLIF-C ACLF score to define a threshold for futility of intensive care support for patients with acute-on-chronic liver failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:254. [PMID: 30305132 PMCID: PMC6180662 DOI: 10.1186/s13054-018-2156-0] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Accepted: 08/10/2018] [Indexed: 02/07/2023]
Abstract
Background Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis and is defined by organ failure and high rates of short-term mortality. Patients with ACLF are managed with multiorgan support in the intensive care unit (ICU). Currently, it is unclear when this supportive care becomes futile, particularly in patients who are not candidates for liver transplant. The aim of this study was to determine whether the currently available prognostic scores can identify patients with ACLF in whom prolonged ICU care is likely to be futile despite maximal treatment efforts. Methods Data of 202 consecutive patients with ACLF admitted to the ICU at the Royal Free Hospital London between 2005 and 2012 were retrospectively analyzed. Prognostic scores for chronic liver diseases, such as Child-Pugh, Model for End-Stage Liver Disease (MELD), European Foundation for the study of chronic liver failure (CLIF-C) organ failure (OF), and CLIF-C ACLF, were calculated 48 hours after ICU admission and correlated with patient outcome after 28 days. Results The CLIF-C ACLF score, compared with all other scores, most accurately predicted 28-day mortality, with an area under the receiver operator characteristic of 0.8 (CLIF-C OF, 0.75; MELD, 0.68; Child-Pugh, 0.66). A CLIF-C ACLF score cutoff ≥ 70 identified patients with a 100% mortality within 28 days. These patients had elevated inflammatory parameters representing a systemic inflammatory response, most often renal failure, compared with patients below this cutoff. Conclusions Patients with ACLF and high CLIF-C ACLF score (≥ 70) after 48 hours of intensive care may reach a threshold of futility for further ongoing intensive support. The best treatment options in this scenario remain to be determined but may include palliative care. Electronic supplementary material The online version of this article (10.1186/s13054-018-2156-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Cornelius Engelmann
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK.,Section of Hepatology, Department of Internal Medicine, Neurology, Dermatology, University Hospital Leipzig, Liebigstrasse 20, 04103, Leipzig, Germany
| | - Karen Louise Thomsen
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK.,Department of Hepatology and Gastroenterology, Aarhus University Hospital, Nørrebrogade 44, 8000, Aarhus C, Denmark
| | - Nekisa Zakeri
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK
| | - Mohammed Sheikh
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK
| | - Banwari Agarwal
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK.,Intensive Care Medicine, Royal Free Hospital, Pond Street, London, NW32QG, UK
| | - Rajiv Jalan
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK
| | - Rajeshwar P Mookerjee
- Institute for Liver and Digestive Health, University College London, Royal Free Campus, Rowland Hill Street, London, NW32PF, UK.
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Toniutto P, Bitetto D, Fornasiere E, Fumolo E. Challenges and future developments in liver transplantation. MINERVA GASTROENTERO 2018; 65:136-152. [PMID: 30303340 DOI: 10.23736/s1121-421x.18.02529-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Liver transplantation (LT) has become the treatment of choice for a wide range of liver diseases in both adult and pediatric patients. Until recently, the largest proportion of LT in adults, were performed in patients with hepatitis C (HCV) related cirrhosis. The recent availability of safe and effective direct antiviral agents to cure HCV infection in almost all patients whatever the HCV genotype and severity of liver disease, will reduce the need for LT in this category of recipients. Thus, it is presumed that in the next 1 to 2 decades HCV related liver disease will diminish substantially, whereas non-alcoholic steato-hepatitis (NASH) will correspondingly escalate as an indication for LT. The greatest challenges facing LT remain the limited supply of donor organs, and the need for chronic immunosuppression, which represent the true obstacles to the greater application and durable success of the LT procedure. This review aimed to highlight, in different sections, the main open issues and future developments in LT. These will be focused to explore current and future strategies to maximize the use of limited organs, to offer an update on potential new approaches to immunosuppression and to imagine new indications for LT when the number of patients awaiting transplants for HCV related liver disease is reduced.
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Affiliation(s)
- Pierluigi Toniutto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy -
| | - Davide Bitetto
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Ezio Fornasiere
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
| | - Elisa Fumolo
- Unit of Hepatology and Liver Transplantation, Department of Medical Area (DAME), University of Udine, Udine, Italy
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218
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Bajaj JS, Moreau R, Kamath PS, Vargas HE, Arroyo V, Reddy KR, Szabo G, Tandon P, Olson J, Karvellas C, Gustot T, Lai JC, Wong F. Acute-on-Chronic Liver Failure: Getting Ready for Prime Time? Hepatology 2018; 68:1621-1632. [PMID: 29689120 DOI: 10.1002/hep.30056] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/19/2018] [Indexed: 02/06/2023]
Abstract
UNLABELLED Acute on chronic liver failure (ACLF) is the culmination of chronic liver disease and extrahepatic organ failures, which is associated with a high short-term mortality and immense health care expenditure. There are varying definitions for organ failures and ACLF in Europe, North America, and Asia. These differing definitions need to be reconciled to enhance progress in the field. The pathogenesis of ACLF is multifactorial and related to interactions between the immunoinflammatory system, microbiota, and the various precipitating factors. Individual organ failures related to the kidney, brain, lungs, and circulation have cumulative adverse effects on mortality and are often complicated or precipitated by infections. Strategies to prevent and rapidly treat these organ failures are paramount in improving survival. With the aging population and paucity of organs for liver transplant, the prognosis of ACLF patients is poor, highlighting the need for novel therapeutic strategies. The role of liver transplant in ACLF is evolving and needs further investigation across large consortia. A role for early palliative care and management of frailty as approaches to alleviate disease burden and improve patient-reported outcomes is being increasingly recognized. CONCLUSION ACLF is a clinically relevant syndrome that is epidemic worldwide and requires a dedicated multinational approach focused on prognostication and management; investigations are underway worldwide to prepare ACLF for prime time. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Jasmohan S Bajaj
- Virginia Commonwealth University and McGuire VA Medical Center, Richmond, VA
| | - Richard Moreau
- INSERM, Université Paris Diderot-Paris 7, Centre de Recherche sur l'Inflammation, Paris, France; Département Hospitalo-Universitaire UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
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Meersseman P, Langouche L, du Plessis J, Korf H, Mekeirele M, Laleman W, Nevens F, Wilmer A, Van den Berghe G, van der Merwe SW. The intensive care unit course and outcome in acute-on-chronic liver failure are comparable to other populations. J Hepatol 2018; 69:803-809. [PMID: 29730473 DOI: 10.1016/j.jhep.2018.04.025] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 04/04/2018] [Accepted: 04/23/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation of cirrhosis, development of organ failure and high short-term mortality. Whether the outcome in patients admitted to the intensive care unit (ICU) with ACLF differs from other ICU populations is unknown. We compared the clinical course and host response in ICU patients with or without ACLF, matched for baseline severity of illness scores and characteristics. METHODS From the large prospective EPaNIC randomized control trial database (n = 4,640), 133 patients were identified with cirrhosis of whom 71 fulfilled the Chronic Liver Failure Consortium criteria for ACLF. These patients were matched for type and severity of illness and demographics to 71 septic and 71 medical ICU patients from the same database without chronic liver disease. Clinical, biochemical and outcome parameters were compared in this cohort study of 213 patients. In a subset of 100 patients, day 1 serum cytokines were quantified. RESULTS The outcome of ACLF, when compared to septic or medical ICU patients, matched for baseline parameters of illness severity, was similar regarding length of ICU stay, development of new infections, organ failure and septic shock. ICU, hospital and 90-day mortality were similar between the groups. C-reactive protein and platelet levels were lower in patients with ACLF throughout the first week. Cytokines, including IL-10, IL-1β, IL-6, and IL-8, were similarly elevated in ACLF and septic ICU patients on day 1. However, TNF-α levels were higher in patients with ACLF. CONCLUSION Patients with ACLF admitted to the ICU showed comparable clinical and ICU outcomes as ICU patients without chronic liver disease, but with similar baseline severity of illness characteristics. This suggests that ICU admission criteria should not be different in ACLF populations. LAY SUMMARY Liver function may abruptly deteriorate in patients with chronic liver disease with cirrhosis, often resulting in these patients being admitted to an intensive care unit (ICU) with organ failure. Previous studies have indicated that this sudden deterioration, called acute-on-chronic liver failure is associated with very high mortality rates, which often resulted in deferred ICU care because of a perception of futility. Our study now shows that the ICU course and outcome are not different when patients with acute-on-chronic liver failure are compared to other ICU patients matched for severity of illness. This demonstrates that patients with acute-on-chronic liver failure deserve the same ICU care given to other ICU populations.
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Affiliation(s)
- Philippe Meersseman
- Department of Internal Medicine, University Hospitals Leuven [KU Leuven], Belgium.
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University of Leuven [KU Leuven], Belgium
| | | | - Hannelie Korf
- Laboratory of Hepatology, University of Leuven [KU Leuven], Belgium
| | - Michaël Mekeirele
- Department of Internal Medicine, University Hospitals Leuven [KU Leuven], Belgium
| | - Wim Laleman
- Laboratory of Hepatology, University of Leuven [KU Leuven], Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven [KU Leuven], Belgium
| | - Frederik Nevens
- Laboratory of Hepatology, University of Leuven [KU Leuven], Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven [KU Leuven], Belgium
| | - Alexander Wilmer
- Department of Internal Medicine, University Hospitals Leuven [KU Leuven], Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, University of Leuven [KU Leuven], Belgium
| | - Schalk W van der Merwe
- Laboratory of Hepatology, University of Leuven [KU Leuven], Belgium; Department of Gastroenterology and Hepatology, University Hospitals Leuven [KU Leuven], Belgium.
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Sarin SK, Choudhury A. Management of acute-on-chronic liver failure: an algorithmic approach. Hepatol Int 2018; 12:402-416. [PMID: 30116993 DOI: 10.1007/s12072-018-9887-5] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 07/13/2018] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a distinct syndrome of liver failure in a patient with chronic liver disease presenting with jaundice, coagulopathy and ascites and/or hepatic encephalopathy, developing following an acute hepatic insult and associated with high 28-day mortality. The definition though lacks global consensus, excludes patients with known distinct entities such as acute liver failure and those with end-stage liver disease. The initial Systemic Inflammatory Response Syndrome (SIRS) because of cytokine storm in relation to acute insult and/or subsequent development of sepsis due to immunoparalysis leads to extrahepatic organ failure. These cascades of events progress through a 'Golden Window' period of about 7 days, subsequent to which majority of the patients develop complications, such as sepsis and extrahepatic organ failure. Prevention of sepsis, support of organs and management of organ failure (commonly hepatic, renal, cerebral, coagulation) and early referral for transplant is crucial. The APASL ACLF research consortium (AARC) liver failure score is a dynamic prognostic model for management decisions and is superior to existing models. Aggressive multidisciplinary approach can lead to a transplant-free survival in nearly half of the cases. The present review provides an algorithmic approach to management of organ failure, sepsis prevention, use of dynamic prognostic models for management decision and is aimed to improve the skills for managing and improving the outcomes of such critically ill patients.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Hepatology and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India.
| | - Ashok Choudhury
- Department of Hepatology and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
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221
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Heise M, Weiler N, Iken S, Welker MW, Zeuzem S, Bechstein WO, Schnitzbauer AA. Liver Transplantation in Acute-on-Chronic Liver Failure: Considerations for a Systematic Approach to Decision Making. Visc Med 2018; 34:291-294. [PMID: 30345287 DOI: 10.1159/000492137] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) is a complex disease with deteriorating liver and kidney function and associated organ failure in patients with chronic liver disease. Methods This is a concise overview for bedside and algorithmic decision making in patients with ACLF based on the most recent literature. Results Diagnosis and dynamics of ACLF can be easily monitored with the CLIF-C-ACLF calculator, which delivers grading for ACLF and estimates the risk of mortality, as the natural transplant-free course of ACLF is often fatal. Transplantation offers the best results in patients with ACLF that do not recover spontaneously. However, marginal donor organs should be avoided. Conclusion ACLF is an increasingly relevant indication with good outcome after liver transplantation. Adequate donor rates may reduce the incidence by means of timely transplantation of acute decompensated patients in lower stages of urgency. Future challenges comprise specific allocation of donor organs to this group of patients that are at a similar risk of mortality when compared to acute liver failure.
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Affiliation(s)
- Michael Heise
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Nina Weiler
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Sonja Iken
- Clinic for Anesthesiology, Intensive Care and Pain Care, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Martin-Walter Welker
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Stefan Zeuzem
- Clinic for Medicine I, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Wolf O Bechstein
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
| | - Andreas A Schnitzbauer
- Clinic for General and Visceral Surgery, University Hospital Frankfurt, Goethe-University Frankfurt, Frankfurt/M., Germany
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222
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Samuel D, Coilly A. Management of patients with liver diseases on the waiting list for transplantation: a major impact to the success of liver transplantation. BMC Med 2018; 16:113. [PMID: 30064414 PMCID: PMC6069832 DOI: 10.1186/s12916-018-1110-y] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 06/25/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND The results of liver transplantation are excellent, with survival rates of over 90 and 80% at 1 and 5 years, respectively. The success of liver transplantation has led to an increase in the indications for liver transplantation. Generally, priorities are given to cirrhotic patients with a high Model for End-Stage Liver Disease (MELD) score on the principle of the sickest first and to patients with hepatocellular carcinoma (HCC) on the principle of priority points according to the size and number of nodules of HCC. These criteria can lead to a 'competition' on the waiting list between the above patients and those who are cirrhotic and have an intermediate MELD score or with life-threatening liver diseases not well described by the MELD score. For this latter group of patients, 'MELD exception' points can be arbitrarily given. DISCUSSION The management of patients on the waiting list is of prime importance to avoid death and drop out from the waiting list as well as to improve post-transplant survival rates. For the more severe cases who may swiftly access liver transplantation, it is essential to rapidly determine whether liver transplantation is indeed indicated, and to organise a fast workup ahead of this. It is also essential to identify the ideal timing for liver transplantation in order to minimise mortality rates. For patients with HCC, a bridge therapy is frequently required to avoid progression of HCC and to maintain patients within the criteria of liver transplantation as well as to reduce the risk of post-transplant recurrence of HCC. For patients with cirrhosis and intermediate MELD score, waiting time can exceed 1 year; therefore, regular follow-up and management are essential to maintain the patient alive on the waiting list and to achieve a good survival after liver transplantation. CONCLUSION There is a diversity of patients on the waiting list for transplantation and equity should be preserved between those with cirrhosis of high and intermediate severity and those with HCC. The management of patients on the waiting list is an essential component of the success of liver transplantation.
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Affiliation(s)
- Didier Samuel
- Centre Hépatobiliaire, Paul Brousse Hospital, University Paris South, Inserm-Paris South Research Unit 1193, 12 Avenue Paul-Vaillant Couturier, Villejuif, 94800, Paris, France.
| | - Audrey Coilly
- Centre Hépatobiliaire, Paul Brousse Hospital, University Paris South, Inserm-Paris South Research Unit 1193, 12 Avenue Paul-Vaillant Couturier, Villejuif, 94800, Paris, France
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Lange CM, Bechstein WO, Berg T, Engelmann C, Bruns T, Canbay A, Moreau R, Trebicka J. Acute-on-Chronic Liver Failure. Visc Med 2018; 34:296-300. [PMID: 30345288 PMCID: PMC6189541 DOI: 10.1159/000491406] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Christian M. Lange
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Wolf Otto Bechstein
- Department of General and Visceral Surgery, Goethe-University Hospital Frankfurt, Frankfurt/M., Germany
| | - Thomas Berg
- Department of Gastroenterology, Rheumatology and Hepatology, University Hospital Leipzig, Leipzig, Germany
| | - Cornelius Engelmann
- Department of Gastroenterology, Rheumatology and Hepatology, University Hospital Leipzig, Leipzig, Germany
| | - Tony Bruns
- Department of Internal Medicine IV, University Hospital Jena, Jena, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg A.ö.R., Magdeburg, Germany
| | - Richard Moreau
- Centre de Recherche sur l'Inflammation (CRI), Institut National de la Santé et de la Recherche Médicale (INSERM), Université Paris-Diderot, Paris, France
| | - Jonel Trebicka
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
- Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
- Institute for Bioengineering of Catalonia, Barcelona, Spain
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de Mattos ÂZ, de Mattos AA. Evaluating Prognosis of Patients With Acute-On-Chronic Liver Failure: Is the Simplest Score Good Enough? Hepatology 2018; 68:790. [PMID: 29663473 DOI: 10.1002/hep.30033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Ângelo Zambam de Mattos
- Graduate Program in Medicine: Hepatology - Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.,Gastroenterology and Hepatology Unit - Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
| | - Angelo Alves de Mattos
- Graduate Program in Medicine: Hepatology - Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.,Gastroenterology and Hepatology Unit - Irmandade Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, Brazil
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225
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1515] [Impact Index Per Article: 252.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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226
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Engelmann C, Berg T. Management of Infectious Complications Associated with Acute-on-Chronic Liver Failure. Visc Med 2018; 34:261-268. [PMID: 30345283 DOI: 10.1159/000491107] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Introduction Acute-on-chronic liver failure (ACLF) is associated with a high susceptibility to infections leading to complications and poor prognosis. The sensitized immune system overwhelmingly responds to invading bacteria leading to organ damage. After resolution of infection or prolonged disease duration, the phagocytic system becomes irresponsive with a reduced bacterial clearance capacity promoting secondary infection. Methods This review focuses on the best management strategies for patients with ACLF and infections. Using the following terms, an extensive literature research on the Medline database was performed: 'acute-on-chronic liver failure', 'infection', 'ACLF', 'bacteria', 'multi-resistance'. Results Analysis of the literature confirmed that delayed diagnosis and treatment of infections in patients with ACLF results in a poor prognosis. Patients with ACLF should be considered as having a potential infection and should undergo a complete screening for sepsis. Once biochemical analysis indicates a potential infection, such as abnormal levels of C-reactive protein and procalcitonin, antibiotic treatment should be initiated immediately without microbiological culture results. For community-acquired infections third-generation cephalosporins are still the first choice, whereas in the nosocomial setting antibiotics with broader spectrum, such as piperacillin/combactam or carbapenems ± glycopeptides, are preferred. The patient should be re-assessed 48 h after treatment initiation in order to tailor the treatment. Non-response is suspicious, likely due to bacterial resistance or fungal infection, which should be considered when choosing further treatment strategies. Albumin substitution to prevent hepatorenal syndrome and to improve patients' outcome is mandatory in patients with spontaneous bacterial peritonitis. Prophylactic antibiotic therapy is suitable to prevent infections in high-risk patients. Conclusion The screening for infections and its treatment is an essential part of managing patients with ACLF. In order to improve patients' prognosis, antibiotic treatment should be initiated once an infection is suspected. However, preventive strategies are already established and should be applied according to the guidelines.
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Affiliation(s)
- Cornelius Engelmann
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Berg
- Section Hepatology, Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
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Crespo G, Trota N, Londoño MC, Mauro E, Baliellas C, Castells L, Castellote J, Tort J, Forns X, Navasa M. The efficacy of direct anti-HCV drugs improves early post-liver transplant survival and induces significant changes in waiting list composition. J Hepatol 2018; 69:11-17. [PMID: 29481821 DOI: 10.1016/j.jhep.2018.02.012] [Citation(s) in RCA: 64] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Revised: 02/01/2018] [Accepted: 02/11/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS The efficacy of direct-acting antivirals (DAAs) has dramatically changed the prognosis of patients with chronic hepatitis C. We aimed to evaluate the impact of DAA therapy on the composition of the liver transplant (LT) waiting list and the early post-transplant survival. METHODS We evaluated all patients admitted to the waiting list for a primary LT between 1st January 2008 and 31st of December 2016 in Catalonia, Spain. Time span was divided into two periods according to the availability of different antiviral therapies: 2008-2013 (interferon-based therapies) and 2014-2016 (DAA). Changes in the indications of LT and the aetiology of liver disease, as well as post-LT patient survival, were evaluated according to the year of inclusion and transplantation, respectively. RESULTS We included 1,483 patients. Admissions in the waiting list for hepatitis C virus (HCV)-related liver disease decreased significantly, from 47% in 2008-2013 to 35% in 2014-2016 (p <0.001), particularly because of a reduction in patients with decompensated cirrhosis. In contrast, NASH-related inclusions increased from 4% to 7% (p = 0.003). Three-year post-LT patient survival increased significantly in the second period in the whole cohort (82% vs. 91%, p = 0.002), because of better survival in anti-HCV positive patients (76% vs. 91%, p = 0.001), but not in anti-HCV negative patients (88% vs. 91% p = 0.359). Anti-HCV positive serology, the time period of 2008-2013 and higher donor age were independently associated with post-LT mortality in the whole cohort; while time period and donor age were independently associated with post-LT mortality in anti-HCV positive recipients. CONCLUSIONS The high efficacy of DAAs is associated with significant changes in the composition of the LT waiting list and, more importantly, results in improved post-transplant survival. LAY SUMMARY The efficacy of the new direct-acting antivirals is associated with a significant improvement in survival of patients undergoing liver transplantation because of hepatitis C virus-related liver disease. In addition, it has decreased the number of patients with hepatitis C that need a liver transplant.
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Affiliation(s)
- Gonzalo Crespo
- Liver Transplant Unit, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Spain.
| | - Núria Trota
- Organització Catalana de Trasplantaments, Servei Català de la Salut, Catalonia, Spain
| | | | - Ezequiel Mauro
- Liver Transplant Unit, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Spain; Liver Unit, Hospital Italiano, Buenos Aires, Argentina
| | - Carme Baliellas
- Liver Transplant Unit, Liver Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Spain
| | - Lluís Castells
- Liver Unit, Department of Internal Medicine, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Spain
| | - Jose Castellote
- Liver Transplant Unit, Liver Unit, Hospital Universitari de Bellvitge, IDIBELL, Universitat de Barcelona, Spain
| | - Jaume Tort
- Organització Catalana de Trasplantaments, Servei Català de la Salut, Catalonia, Spain
| | - Xavier Forns
- Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Spain
| | - Miquel Navasa
- Liver Transplant Unit, Liver Unit, Hospital Clínic, IDIBAPS, CIBERehd, Universitat de Barcelona, Spain
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228
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Huebener P, Sterneck M, Fuhrmann V. Editorial: transplantation in the setting of acute-on-chronic liver failure-calculating chances. Authors' reply. Aliment Pharmacol Ther 2018; 48:100-101. [PMID: 29882978 DOI: 10.1111/apt.14804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2022]
Affiliation(s)
- P Huebener
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Sterneck
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - V Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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229
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Izzy M, Watt KD. Editorial: transplantation in the setting of acute-on-chronic liver failure-calculating chances. Aliment Pharmacol Ther 2018; 48:99-100. [PMID: 29882980 DOI: 10.1111/apt.14679] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- M Izzy
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
| | - K D Watt
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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230
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Cillo U, Bechstein WO, Berlakovich G, Dutkowski P, Lehner F, Nadalin S, Saliba F, Schlitt HJ, Pratschke J. Identifying risk profiles in liver transplant candidates and implications for induction immunosuppression. Transplant Rev (Orlando) 2018; 32:142-150. [DOI: 10.1016/j.trre.2018.04.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/03/2018] [Accepted: 04/05/2018] [Indexed: 12/16/2022]
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231
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Obed A, Bashir A, Jarrad A. A Case of Live Donor Liver Transplantation in Acute-on-Chronic Liver Failure with Budd-Chiari Syndrome: Donor and Recipient with Antiphospholipid Antibody Syndrome. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:767-772. [PMID: 29959308 PMCID: PMC6055578 DOI: 10.12659/ajcr.909694] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Patient: Female, 47 Final Diagnosis: Antiphospholipid antibody syndrome Symptoms: Liver failure • pneumonia • renal failure Medication: — Clinical Procedure: Live donor liver transplantation Specialty: Transplantology
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Affiliation(s)
- Aiman Obed
- Department of Hepatobiliary and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Abdalla Bashir
- Department of General and Transplant Surgery, Jordan Hospital, Amman, Jordan
| | - Anwar Jarrad
- Department of Hepatology, Gastroenterology and Hepatobiliary/Transplant Unit, Jordan Hospital, Amman, Jordan
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232
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Prognostic factors and treatment effect of standard-volume plasma exchange for acute and acute-on-chronic liver failure: A single-center retrospective study. Transfus Apher Sci 2018; 57:537-543. [PMID: 29880246 DOI: 10.1016/j.transci.2018.05.030] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 12/15/2022]
Abstract
Patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) have a high risk of mortality. Few studies have reported prognostic factors for patients receiving plasma exchange (PE) for liver support. We conducted a retrospective analysis using data of 55 patients with severe ACLF (n = 45) and ALF (n = 10) who received standard-volume PE (1-1.5 plasma volume) in the ICU. Hepatitis B virus infection accounts for the majority of ACLF (87%) and ALF (50%) patients. PE significantly improved the levels of total bilirubin, prothrombin time and liver enzymes (P<0.05). Thirteen ACLF patients (29%) and one ALF patient (10%) underwent liver transplantation. Two ALF patients (20%) recovered spontaneously without transplantation. The overall in-hospital survival rates for ACLF and ALF patients were 24% and 30%, and the transplant-free survival rates were 0% and 20%, respectively. For the 14 transplanted patients, the one-year survival rate was 86%. Multivariate analysis showed that pre-PE hemoglobin (P = 0.008), post-PE hemoglobin (P = 0.039), and post-PE CLIF-C ACLF scores (P = 0.061) were independent predictors of survival in ACLF. The post-PE CLIF-C ACLF scores ≥59 were a discriminator predicting the in-hospital mortality (area under the curve = 0.719, P = 0.030). Cumulative survival rates differed significantly between patients with CLIF-C ACLF scores ≤ 58 and those with CLIF-C ACLF scores ≥ 59 after PE (P< 0.05). The findings suggest that PE is mainly a bridge for liver transplantation and spontaneous recovery is exceptional even in patients treated with PE. A higher improvement in the post-PE CLIF-C ACLF score is associated with a superior in-hospital survival rate.
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233
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Huebener P, Sterneck MR, Bangert K, Drolz A, Lohse AW, Kluge S, Fischer L, Fuhrmann V. Stabilisation of acute-on-chronic liver failure patients before liver transplantation predicts post-transplant survival. Aliment Pharmacol Ther 2018; 47:1502-1510. [PMID: 29611203 DOI: 10.1111/apt.14627] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2017] [Revised: 01/16/2018] [Accepted: 03/03/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe complication of liver cirrhosis associated with excess short-term mortality rates. Orthotopic liver transplantation (OLT) is a potentially life-saving therapeutic modality for acute-on-chronic liver failure patients, but selection of transplant candidates with an acceptable post-transplant outcome is difficult. AIM To assess the risk of liver transplantation in patients with ACLF, and to determine parameters that predict post-transplant survival in this patient cohort. METHODS We retrospectively analysed all 250 patients with cirrhosis who underwent their first liver transplantation between 2009 and 2014 at our institution, and assessed post-transplant outcomes. RESULTS Of 250 cirrhotic liver transplant recipients, 98 patients fulfilled the diagnostic criteria for acute-on-chronic liver failure in the 3-month pre-transplant period. Compared to non-ACLF patients, ACLF was associated with significantly higher short-term morbidity and mortality after liver transplantation (90-day patient survival 96.1% non-ACLF vs 72.4% ACLF patients, P < 0.0001). Clinical improvement in the pre-transplant period, as defined by recovery of at least one previously failed organ system, was observed in 37 of 98 acute-on-chronic liver failure patients, mostly within several days after diagnosis. Most notably, clinical improvement prior to liver transplantation was associated with excellent post-transplant survival rates that approximated non-ACLF transplant recipients. Following the 90-day post-transplant period, patient survival and long-term graft functions were comparable between ACLF and non-ACLF liver transplant recipients for up to 5 years. CONCLUSIONS Acute-on-chronic liver failure predicts adverse outcome after orthotopic liver transplantation. Given the dismal prognosis without transplantation, however, our results indicate that ACLF patients can be transplanted with comparably good outcomes, in particular patients who improve under conservative therapeutic measures.
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Affiliation(s)
- P Huebener
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M R Sterneck
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - K Bangert
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A W Lohse
- Department of Internal Medicine, I. Medical Clinic and Polyclinic, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - L Fischer
- Department of Hepatobiliary Surgery and Transplantation, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - V Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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234
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Ruiz-Margáin A, Pohlmann A, Ryan P, Schierwagen R, Chi-Cervera LA, Jansen C, Mendez-Guerrero O, Flores-García NC, Lehmann J, Torre A, Macías-Rodríguez RU, Trebicka J. Fibroblast growth factor 21 is an early predictor of acute-on-chronic liver failure in critically ill patients with cirrhosis. Liver Transpl 2018; 24:595-605. [PMID: 29476704 DOI: 10.1002/lt.25041] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Revised: 01/26/2018] [Accepted: 02/17/2018] [Indexed: 02/07/2023]
Abstract
Acute-on-chronic liver failure (ACLF) develops in acute decompensation (AD) of cirrhosis and shows high mortality. In critically ill patients, early diagnosis of ACLF could be important for therapeutic decisions (eg, renal replacement, artificial liver support, liver transplantation). This study evaluated fibroblast growth factor 21 (FGF21) as a marker of mitochondrial dysfunction in the context of ACLF. The study included 154 individuals (112 critically patients and 42 healthy controls) divided into a training and a validation cohort. In the training cohort of 42 healthy controls and 34 critically ill patients (of whom 24 were patients with cirrhosis), levels of FGF21, interleukin (IL) 6, and IL8 were measured. In the validation cohort of 78 patients with cirrhosis, 17 patients were admitted with or developed ACLF during follow-up and underwent daily clinical and nutritional assessment. Levels of FGF21 were higher in critically ill patients, especially in patients with cirrhosis admitted to the intensive care unit (ICU). Moreover, FGF21 as well as IL6 and IL8 levels were higher in patients with ACLF, but they did not increase with the severity of ACLF. Interestingly, in the validation cohort, FGF21 was also elevated in the patients who developed ACLF in the next 7 days. In these patients, FGF21 levels were an independent predictor of ACLF presence and development in multivariate analysis together with Child-Pugh score. FGF21 levels had no impact on the survival of critically ill patients with cirrhosis. In conclusion, this study demonstrates that FGF21 levels are of specific diagnostic value regarding the presence and development of ACLF in patients admitted to ICU for AD of liver cirrhosis. Further studies are warranted to address pathophysiological and possible therapeutic implications. Liver Transplantation 24 595-605 2018 AASLD.
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Affiliation(s)
- Astrid Ruiz-Margáin
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", México City, México
| | | | - Patrick Ryan
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Robert Schierwagen
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Luis A Chi-Cervera
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", México City, México
| | - Christian Jansen
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", México City, México
| | - Nayelli C Flores-García
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", México City, México
| | - Jennifer Lehmann
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición "Salvador Zubirán,", México City, México
| | | | - Jonel Trebicka
- Department of Internal Medicine I, University Clinic Bonn, Bonn, Germany.,European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Institute for Bioengineering of Catalonia, Barcelona, Spain
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235
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McPhail MJW, Parrott F, Wendon JA, Harrison DA, Rowan KA, Bernal W. Incidence and Outcomes for Patients With Cirrhosis Admitted to the United Kingdom Critical Care Units. Crit Care Med 2018; 46:705-712. [PMID: 29309369 PMCID: PMC5899891 DOI: 10.1097/ccm.0000000000002961] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To assess the epidemiology and outcome of patients with cirrhosis following critical care unit admission. DESIGN Retrospective cohort study. SETTING Critical care units in England, Wales, and Northern Ireland participating in the U.K. Intensive Care National Audit and Research Centre Case Mix Programme. PATIENTS Thirty-one thousand three hundred sixty-three patients with cirrhosis identified of 1,168,650 total critical care unit admissions (2.7%) admitted to U.K. critical care units between 1998 and 2012. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Ten thousand nine hundred thirty-six patients had alcohol-related liver disease (35%). In total, 1.6% of critical care unit admissions in 1998 had cirrhosis rising to 3.1% in 2012. The crude critical care unit mortality of patients with cirrhosis was 41% in 1998 falling to 31% in 2012 (p < 0.001). Crude hospital mortality fell from 58% to 46% over the study period (p < 0.001). Mean(SD) Acute Physiology and Chronic Health Evaluation II score in 1998 was 20.3 (8.5) and 19.5 (7.1) in 2012. Mean Acute Physiology and Chronic Health Evaluation II score for patients with alcohol-related liver disease in 2012 was 20.6 (7.0) and 19.0 (7.2) for non-alcohol-related liver disease (p < 0.001). In adjusted analysis, alcohol-related liver disease was associated with increased risk of death (odds ratio, 1.51 [95% CI, 1.42-1.62; p < 0.001]) with a year-on-year reduction in hospital mortality (adjusted odds ratio, 0.95/yr, [0.94-0.96, p < 0.001]). CONCLUSIONS More patients with cirrhosis are being admitted to critical care units but with increasing survival rates. Patients with alcohol-related liver disease have reduced survival rates partly explained by higher levels of organ failure at admission. Patients with cirrhosis and organ failure warrant a trial of organ support and universal prognostic pessimism is not justified.
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Affiliation(s)
- Mark JW McPhail
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London
| | | | - Julia A Wendon
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London
| | | | - Kathy A Rowan
- Intensive Care National Audit & Research Centre, London
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, King's College Hospital, Denmark Hill, London
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236
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Zhao RH, Shi Y, Zhao H, Wu W, Sheng JF. Acute-on-chronic liver failure in chronic hepatitis B: an update. Expert Rev Gastroenterol Hepatol 2018; 12:341-350. [PMID: 29334786 DOI: 10.1080/17474124.2018.1426459] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute-on-chronic liver failure is a common pattern of end-stage liver disease in clinical practice and occurs frequently in patients with chronic hepatitis B or HBV-related cirrhosis. New progress in recent years leads to a better understanding of this disease. Areas covered: This review updates the current comprehensive knowledge about HBV-ACLF from epidemiological studies, experimental studies, and clinical studies and provide new insights into the definition, diagnostic criteria, epidemiology, nature history, pathogenesis, treatment and prognostication of HBV-ACLF. Expert commentary: Patients with chronic hepatitis B or HBV-related cirrhosis are at risk of developing acute-on-chronic liver failure, with multi-organ failure and high short-term mortality. The precipitating events can be intra-hepatic or extra-hepatic and the underlying chronic liver injury can be cirrhotic or non-cirrhotic. Host and viral factors contribute to the susceptibility of developing HBV-ACLF. Systemic inflammation is the driver of HBV-ACLF, which can be attributed to non-sterile and sterile factors. Liver transplantation is the definitive treatment for HBV-ACLF. Cell therapy is a promising alternative to LT, but requires validation and still has concern of long-term safety. Other medical therapies, such as nucleoside analogue, artificial liver supporting and glucocorticoid may improve survival in a specific subgroup. New scoring systems improve the accuracy of prognostication in HBV-ACLF, which is critical for early identification of candidates for LT.
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Affiliation(s)
- Rui-Hong Zhao
- a Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Yu Shi
- a Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Hong Zhao
- a Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Wei Wu
- a Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
| | - Ji-Fang Sheng
- a Department of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine , Zhejiang University , Hangzhou , China
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237
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Linecker M, Krones T, Berg T, Niemann CU, Steadman RH, Dutkowski P, Clavien PA, Busuttil RW, Truog RD, Petrowsky H. Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits. J Hepatol 2018; 68:798-813. [PMID: 29133246 DOI: 10.1016/j.jhep.2017.11.008] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/11/2017] [Accepted: 11/06/2017] [Indexed: 12/11/2022]
Abstract
Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.
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Affiliation(s)
- Michael Linecker
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Tanja Krones
- Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland
| | - Thomas Berg
- Division of Hepatology, University of Leipzig, Germany
| | - Claus U Niemann
- Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA
| | - Randolph H Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Philipp Dutkowski
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Pierre-Alain Clavien
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland
| | - Ronald W Busuttil
- Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA
| | - Robert D Truog
- Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA
| | - Henrik Petrowsky
- Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
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238
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Reply to: "Liver transplantation for grade 3 acute-on-chronic liver failure: Type of organ failure is important". J Hepatol 2018; 68:622-623. [PMID: 29100997 DOI: 10.1016/j.jhep.2017.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/20/2017] [Indexed: 12/21/2022]
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239
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Choudhary NS, Saraf N, Soin AS. Liver transplantation for grade 3 acute-on-chronic liver failure: Type of organ failure is important. J Hepatol 2018; 68:621-622. [PMID: 29100998 DOI: 10.1016/j.jhep.2017.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Accepted: 09/13/2017] [Indexed: 12/30/2022]
Affiliation(s)
- Narendra Singh Choudhary
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
| | - Neeraj Saraf
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India.
| | - Arvinder S Soin
- Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Gurgaon, India
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240
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Ferrarese A, Zanetto A, Becchetti C, Sciarrone SS, Shalaby S, Germani G, Gambato M, Russo FP, Burra P, Senzolo M. Management of bacterial infection in the liver transplant candidate. World J Hepatol 2018; 10:222-230. [PMID: 29527258 PMCID: PMC5838441 DOI: 10.4254/wjh.v10.i2.222] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Revised: 12/29/2017] [Accepted: 01/24/2018] [Indexed: 02/06/2023] Open
Abstract
Bacterial infection (BI) is a common cause of impairment of liver function in patients with cirrhosis, especially in the liver transplant candidates. These patients share an immunocompromised state and increased susceptibility to develop community and hospital-acquired infections. The changing epidemiology of BI, with an increase of multidrug resistant strains, especially in healthcare-associated settings, represents a critical issue both in the waiting list and in the post-operative management. This review focused on the role played by BI in patients awaiting liver transplantation, evaluating the risk of drop-out from the waiting list, the possibility to undergo liver transplantation after recovery from infection or during a controlled infection.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Chiara Becchetti
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Salvatore Stefano Sciarrone
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Sarah Shalaby
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Giacomo Germani
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Martina Gambato
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Francesco Paolo Russo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua 35128, Italy
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241
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Fuhrmann V, Whitehouse T, Wendon J. The ten tips to manage critically ill patients with acute-on-chronic liver failure. Intensive Care Med 2018; 44:1932-1935. [DOI: 10.1007/s00134-018-5078-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 01/24/2018] [Indexed: 12/25/2022]
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de Mattos ÂZ, de Mattos AA. Acute-on-chronic liver failure-old concepts made clearer. Transl Gastroenterol Hepatol 2017; 2:111. [PMID: 29354768 DOI: 10.21037/tgh.2017.11.17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Accepted: 11/24/2017] [Indexed: 12/30/2022] Open
Affiliation(s)
- Ângelo Zambam de Mattos
- Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil.,Pontifical Catholic University of Rio Grande do Sul, Porto Alegre, Brazil
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243
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Gustot T, Agarwal B. Selected patients with acute-on-chronic liver failure grade 3 are not too sick to be considered for liver transplantation. J Hepatol 2017; 67:667-668. [PMID: 28923205 DOI: 10.1016/j.jhep.2017.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Revised: 07/21/2017] [Accepted: 07/21/2017] [Indexed: 02/07/2023]
Affiliation(s)
- Thierry Gustot
- Dept. Gastroenterology and Hepato-Pancreatology, C.U.B. Erasme Hospital, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; The EASL-CLIF Consortium, European Foundation-CLIF, Barcelona, Spain.
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, London, UK; Institute for Liver and Digestive Health, University College London, Royal Free Campus, UK
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244
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Choudhary NS, Saraf N, Saigal S, Soin AS. Liver Transplantation for Acute on Chronic Liver Failure. J Clin Exp Hepatol 2017; 7:247-252. [PMID: 28970712 PMCID: PMC5620362 DOI: 10.1016/j.jceh.2017.08.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute-on chronic liver failure (ACLF) is defined as acute insult on previous liver disease that causes sudden worsening of liver functions. METHODS ACLF is characterized by high incidence of organ failure and prognosis is remarkably worse than patients with cirrhosis. Incidence of organ failures is very high despite best medical care and timely liver transplant before development of multi organ failure is associated with good survival rates. RESULTS At present, there are no reliable score or ways to correctly identify patients who are going to recover from patients who will need transplantation. Organ failures are important part of prognosis and to define need or futility of early liver transplantation. CONCLUSION Asian Pacific Association for the Study of the Liver (APASL) published their recommendations regarding ACLF in 2014. Several important studies regarding course/nature of disease and transplantation for ACLF became available after 2014 APASL recommendations and still there are some unanswered areas. The current review discusses various issues regarding liver transplantation in patients with ACLF.
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Affiliation(s)
| | - Neeraj Saraf
- Address for correspondence: Neeraj Saraf, Institute of Liver Transplantation and Regenerative Medicine, Medanta, The Medicity, Sector 38, Gurgaon, Haryana 122001, India.Institute of Liver Transplantation and Regenerative Medicine, Medanta, The MedicitySector 38GurgaonHaryana122001India
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