1
|
Isha S, Jenkins AS, Hanson AJ, Satashia PH, Narra SA, Mundhra GD, Hasan MM, Donepudi A, Giri A, Johnson PW, Villar D, Santos C, Canabal J, Lowman P, Franco PM, Sanghavi DK. The Effect of Molecular Adsorbent Recirculating System in Patients With Liver Failure: A Case Series of 44 Patients. Transplant Proc 2023; 55:2126-2133. [PMID: 37806867 DOI: 10.1016/j.transproceed.2023.07.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Revised: 06/19/2023] [Accepted: 07/04/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Liver failure is associated with a high mortality rate, with many patients requiring transplant for definitive treatment. The Molecular Adsorbent Recirculating System (MARS) is a nonbiologic system that provides extracorporeal support. Literature on MARS therapy is mixed: outcomes support MARS therapy for patients with isolated acute liver failure, but data on patients with chronic disease is varied. Several case studies report success using MARS as a bridging treatment for patients awaiting transplant. The purpose of this case series is to present the outcomes of 44 patients who underwent MARS therapy for liver failure, 19 of whom used MARS therapy as a bridging therapy to transplant. METHODS This study retrospectively identified 44 patients who underwent MARS therapy for liver failure at Mayo Clinic, Jacksonville, between January 2014 and April 2021. Variables of interest included changes in laboratory markers of hepatic functioning, number and length of MARS therapy sessions, transplantation status, and mortality. RESULTS Following MARS therapy, there were improvements in mean serum bilirubin, ammonia, urea, creatinine, International Normalized Ratio, alanine aminotransferase, and aspartate aminotransferase levels. Twenty-seven patients (61.36%) survived the hospital stay; 17 (38.63%) died in the hospital. The majority of surviving patients (n = 19; 73.07%) received liver transplant. Six did not require transplant (22.22%). All but 1 patient who received MARS as a bridging treatment to transplant survived the follow-up period (n = 18; 94.74%). CONCLUSIONS Outcomes of these 44 cases suggest that MARS improves liver failure-associated laboratory parameters and may be effective therapy as a bridge to liver transplant.
Collapse
Affiliation(s)
- Shahin Isha
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Anna S Jenkins
- Mayo Clinic Alix School of Medicine, Jacksonville, Florida
| | - Abby J Hanson
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Sai Abhishek Narra
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Gunjan D Mundhra
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | | | - Ashrita Donepudi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Abishek Giri
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Patrick W Johnson
- Department of Quantitative Health Sciences, Mayo Clinic, Jacksonville, Florida
| | - Dolores Villar
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Christan Santos
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Juan Canabal
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Philip Lowman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida
| | - Pablo Moreno Franco
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida; Department of Transplantation, Mayo Clinic, Jacksonville, Florida
| | - Devang K Sanghavi
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida.
| |
Collapse
|
2
|
Angelico R, Siragusa L, Serenari M, Scalera I, Kauffman E, Lai Q, Vitale A. Rescue liver transplantation after post-hepatectomy acute liver failure: A systematic review and pooled analysis. Transplant Rev (Orlando) 2023; 37:100773. [PMID: 37356212 DOI: 10.1016/j.trre.2023.100773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Revised: 06/14/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Post-hepatectomy liver failure is a severe complication after major liver resection and is associated with a high mortality rate. Nevertheless, there is no effective treatment for severe liver failure. In such a setting, rescue liver transplantation (LT) is used only in extraordinary cases with unclear results. This systematic review aims to define indication of LT in post-hepatectomy liver failure and post-LT outcomes, in terms of patient and disease-free survivals, to assess the procedure's feasibility and effectiveness. METHODS A systematic review of all English language full-text articles published until September 2022 was conducted. Inclusion criteria were articles describing patients undergoing LT for post-hepatectomy liver failure after liver resection, which specified at least one outcome of interest regarding patient/graft survival, postoperative complications, tumour recurrence and cause of death. A pseudo-individual participant data meta-analysis was performed to analyse data. Study quality was assessed with MINORS system. PROSPERO CRD42022349358. RESULTS Postoperative complication rate was 53.6%. All patients transplanted for benign indications survived. For malignant tumours, 1-, 3- and 5-year overall survival was 94.7%, 82.1% and 74.6%, respectively. The causes of death were tumour recurrence in 83.3% of cases and infection-related in 16.7% of LT recipients. At Cox regression, being transplanted for unconventional malignant indications (colorectal liver metastasis, cholangiocarcinoma) was a risk factor for death HR = 8.93 (95%CI = 1.04-76.63; P-value = 0.046). Disease-free survival differs according to different malignant tumours (P-value = 0.045). CONCLUSIONS Post-hepatectomy liver failure is an emergent indication for rescue LT, but it is not universally accepted. In selected patients, LT can be a life-saving procedure with low short-term risks. However, special attention must be given to long-term oncological prognosis before proceeding with rescue LT in an urgent setting, considering the severity of liver malignancy, organ scarcity, the country's organ allocation policies and the resource of living-related donation.
Collapse
Affiliation(s)
- Roberta Angelico
- Department of Surgical Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, 00133 Rome, Italy.
| | - Leandro Siragusa
- Department of Surgical Sciences, Transplant and HPB Unit, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Matteo Serenari
- General Surgery and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Sant'Orsola-Malpighi Hospital, Bologna, Italy; Department of Medical and Surgical Sciences-DIMEC, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Irene Scalera
- Unità di Chirurgia Epatobiliare e Trapianti di Fegato, Azienda Ospedaliero Universitaria -Consorziale Policlinico di Bari, Bari, Italy
| | - Emanuele Kauffman
- Division of General and Transplant Surgery, Pisa University, Pisa, Italy
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University of Rome, AUO Policlinico I of Rome, Rome, Italy
| | - Alessandro Vitale
- Department of Surgical Oncological and Gastroenterological Sciences, Padua University, Padua, Italy
| |
Collapse
|
3
|
Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of liver support systems for adults with acute‐on‐chronic liver failure.
Collapse
|
4
|
Mesenchymal stem cells exosomal let-7a-5p improve autophagic flux and alleviate liver injury in acute-on-chronic liver failure by promoting nuclear expression of TFEB. Cell Death Dis 2022; 13:865. [PMID: 36224178 PMCID: PMC9556718 DOI: 10.1038/s41419-022-05303-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 09/19/2022] [Accepted: 09/26/2022] [Indexed: 01/23/2023]
Abstract
Acute-on-chronic liver failure is a distinct clinical syndrome characterized by a dysregulated immune response and extensive hepatocyte death without satisfactory therapies. As a cytoplasmic degradative and quality-control process, autophagy was implicated in maintaining intracellular homeostasis, and decreased hepatic autophagy was found in many liver diseases and contributes to disease pathogenesis. Previously, we identified the therapeutic potential of mesenchymal stem cells (MSCs) in ACLF patients; however, the intrinsic mechanisms are incompletely understood. Herein, we showed that MSCs restored the impaired autophagic flux and alleviated liver injuries in ACLF mice, but these effects were abolished when autophago-lysosomal maturation was inhibited by leupeptin (leu), suggesting that MSCs exerted their hepatoprotective function in a pro-autophagic dependent manner. Moreover, we described a connection between transcription factor EB (TFEB) and autophagic activity in this context, as evidenced by increased nuclei translocation of TFEB elicited by MSCs were capable of promoting liver autophagy. Mechanistically, we confirmed that let-7a-5p enriched in MSCs derived exosomes (MSC-Exo) could activate autophagy by targeting MAP4K3 to reduce TFEB phosphorylation, and MAP4K3 knockdown partially attenuates the effect of anti-let-7a-5p oligonucleotide via decreasing the inflammatory response, in addition, inducing autophagy. Altogether, these findings revealed that the hepatoprotective effect of MSCs may partially profit from its exosomal let-7a-5p mediating autophagy repairment, which may provide new insights for the therapeutic target of ACLF treatment.
Collapse
|
5
|
Saliba F, Bañares R, Larsen FS, Wilmer A, Parés A, Mitzner S, Stange J, Fuhrmann V, Gilg S, Hassanein T, Samuel D, Torner J, Jaber S. Artificial liver support in patients with liver failure: a modified DELPHI consensus of international experts. Intensive Care Med 2022; 48:1352-1367. [PMID: 36066598 DOI: 10.1007/s00134-022-06802-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023]
Abstract
The present narrative review on albumin dialysis provides evidence-based and expert opinion guidelines for clinicians caring for adult patients with different types of liver failure. The review was prepared by an expert panel of 13 members with liver and ntensive care expertise in extracorporeal liver support therapies for the management of patients with liver failure. The coordinating committee developed the questions according to their importance in the management of patients with liver failure. For each indication, experts conducted a comprehensive review of the literature aiming to identify the best available evidence and assessed the quality of evidence based on the literature and their experience. Summary statements and expert's recommendations covered all indications of albumin dialysis therapy in patients with liver failure, timing and intensity of treatment, efficacy, technical issues related to the device and safety. The panel supports the data from the literature that albumin dialysis showed a beneficial effect on hepatic encephalopathy, refractory pruritus, renal function, reduction of cholestasis and jaundice. However, the trials lacked to show a clear beneficial effect on overall survival. A short-term survival benefit at 15 and 21 days respectively in acute and acute-on-chronic liver failure has been reported in recent studies. The technique should be limited to patients with a transplant project, to centers experienced in the management of advanced liver disease. The use of extracorporeal albumin dialysis could be beneficial in selected patients with advanced liver diseases listed for transplant or with a transplant project. Waiting future large randomized controlled trials, this panel experts' statements may help careful patient selection and better treatment modalities.
Collapse
Affiliation(s)
- Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Center and Liver Transplant ICU, University Paris Saclay, INSERM Unit N°1193, Villejuif, France
| | - Rafael Bañares
- Gastroenterology and Hepatology Department, Hospital General Universitario Gregorio Marañón, IISGM, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain.,CIBERehd, Madrid, Spain
| | - Fin Stolze Larsen
- Department of Hepatology and Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Steffen Mitzner
- Division of Nephrology and Fraunhofer Institute for Cell Therapy and Immunology, Department of Medicine, University Hospital Rostock, Rostock, Germany
| | - Jan Stange
- Center for Extracorporeal Organ Support, Nephrology, Internal Medicine, Rostock University Medical Center, Rostock, Germany.,Albutec GmbH, Rostock, Germany
| | - Valentin Fuhrmann
- Klinik für Innere Medizin, Heilig Geist-Krankenhaus, Cologne, Germany.,Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Solna, Sweden.,Department of HPB Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tarek Hassanein
- Southern California Liver Centers, 131 Orange Avenue, Suite 101, Coronado, CA, 92118, USA
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Center and Liver Transplant ICU, University Paris Saclay, INSERM Unit N°1193, Villejuif, France
| | | | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier Cedex 5, France. .,Département d'Anesthésie Réanimation B (DAR B), 80 Avenue Augustin Fliche, 34295, Montpellier, France.
| |
Collapse
|
6
|
Monet C, De Jong A, Aarab Y, Piron L, Prades A, Carr J, Belafia F, Chanques G, Guiu B, Pageaux GP, Jaber S. Adverse events, short- and long-term outcomes of extra corporeal liver therapy in the intensive care unit: 16 years experience with MARS® in a single center. Crit Care 2022; 26:282. [PMID: 36123713 PMCID: PMC9484245 DOI: 10.1186/s13054-022-04165-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/10/2022] [Indexed: 12/04/2022] Open
Abstract
Background Molecular Adsorbent Recirculating System (MARS®) is a non-biological artificial liver device. The benefit risk ratio between uncertain clinical effects and potential adverse events remains difficult to assess. We sought to describe adverse events related to MARS® therapy as well as biological and clinical effects. Methods All intensive care unit (ICU) admissions to whom MARS® therapy was prescribed from March 2005 to August 2021 were consecutively and prospectively included. The main endpoint was the incidence of adverse events related to MARS® therapy. Secondary endpoints were the biological and clinical effects of MARS® therapy. Results We reported 180 admissions treated with MARS® therapy. Among the 180 admissions, 56 (31.1%) were for acute-on-chronic liver failure, 32 (17.8%) for acute liver failure, 28 (15.5%) for post-surgery liver failure, 52 (28.9%) for pruritus and 12 (6.7%) for drug intoxication. At least one adverse event occurred in 95 (52.8%) admissions. Thrombocytopenia was the most frequent adverse event which was recorded in 55 admissions (30.6%). Overall, platelets count was 131 (± 95) × 109/L before and 106 (± 72) × 109/L after MARS® therapy (p < .001). After MARS® therapy, total bilirubin was significantly decreased in all groups (p < 0.05). Hepatic encephalopathy significantly improved in both the acute-on-chronic and in the acute liver failure group (p = 0.01). In the pruritus group, pruritus intensity score was significantly decreased after MARS® therapy (p < 0.01). Conclusion In this large cohort of patients treated with MARS® therapy we report frequent adverse events. Thrombocytopenia was the most frequent adverse event. In all applications significant clinical and biological improvements were shown with MARS® therapy. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04165-z.
Collapse
|
7
|
Alexander EC, Deep A. Therapeutic plasma exchange in children with acute liver failure (ALF): is it time for incorporation into the ALF armamentarium? Pediatr Nephrol 2022; 37:1775-1788. [PMID: 34647173 PMCID: PMC9239959 DOI: 10.1007/s00467-021-05289-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/08/2021] [Accepted: 09/09/2021] [Indexed: 12/11/2022]
Abstract
Paediatric acute liver failure (PALF) is a rare but devastating condition with high mortality. An exaggerated inflammatory response is now recognised as pivotal in the pathogenesis and prognosis of ALF, with cytokine spill from the liver to systemic circulation implicated in development of multi-organ failure associated with ALF. With advances in medical management, especially critical care, there is an increasing trend towards spontaneous liver regeneration, averting the need for emergency liver transplantation or providing stability to the patient awaiting a graft. Hence, research is ongoing for therapies, including extracorporeal liver support devices, that can bridge patients to transplant or spontaneous liver recovery. Considering the immune-related pathogenesis and inflammatory phenotype of ALF, plasma exchange serves as an ideal liver assist device as it performs both the excretory and synthetic functions of the liver and, in addition, works as an immunomodulatory therapy by suppressing the early innate immune response in ALF. After a recent randomised controlled trial in adults demonstrated a beneficial effect of high-volume plasma exchange on clinical outcomes, this therapy was incorporated in European Association for the Study of Liver (EASL) recommendations for managing adult patients with ALF, but no guidelines exist for PALF. In this review, we discuss rationale, timing, practicalities, and existing evidence regarding the use of plasma exchange as an immunomodulatory treatment in PALF. We discuss controversies in delivery of this therapy as an extracorporeal device, and practicalities of use of plasma exchange as a 'hybrid' therapy alongside other extracorporeal liver assist devices, before finally reviewing outstanding research questions for the future.
Collapse
Affiliation(s)
- Emma C Alexander
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
| |
Collapse
|
8
|
Martí-Carvajal AJ, Gluud C, Gluud LL, Pavlov CS, Mauro E, Monge Martín D, Liu JP, Nicola S, Comunián-Carrasco G, Martí-Amarista CE. Liver support systems for adults with acute liver failure. Hippokratia 2022. [DOI: 10.1002/14651858.cd015059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo; Universidad UTE (Cochrane Ecuador); Quito Ecuador
- Facultad de Medicina, Universidad Francisco de Vitoria (Cochrane Madrid); Madrid Spain
- Cátedra Rectoral de Medicina Basada en la Evidencia; Universidad de Carabobo; Valencia Venezuela
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region, Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Department of Regional Health Research; The Faculty of Health Sciences, University of Southern Denmark; Odense Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
| | - Chavdar S Pavlov
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Department of Therapy ; IM Sechenov First Moscow State Medical University; Moscow Russian Federation
- Department of Gastroenterology; Botkin Hospital; Moscow Russian Federation
| | - Ezequiel Mauro
- Liver Unit & Liver Transplant Unit; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | - Diana Monge Martín
- Facultad de Medicina; Universidad Francisco de Vitoria (Cochrane Madrid); Madrid Spain
| | - Jian Ping Liu
- Centre for Evidence-Based Chinese Medicine; Beijing University of Chinese Medicine; Beijing China
| | - Susana Nicola
- Centro Asociado Cochrane Ecuador, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC); Universidad UTE; Quito Ecuador
| | - Gabriella Comunián-Carrasco
- Cátedra Rectoral de Medicina Basada en la Evidencia; Universidad de Carabobo; Valencia Venezuela
- Departamento de Obstetricia y Ginecología; Universidad de Carabobo; Valencia Venezuela
| | - Cristina Elena Martí-Amarista
- Division of General, Geriatric and Hospital Medicine; Stony Brook University, Renaissance School of Medicine HSC, Level 2, Rm 155; Stony Brook, 11794-8228 New York USA
| |
Collapse
|
9
|
Sparrelid E, Thorsen T, Sauter C, Jorns C, Stål P, Nordin A, de Boer MT, Buis C, Yaqub S, Schultz NA, Larsen PN, Sallinen V, Line PD, Gilg S. Liver transplantation in patients with post-hepatectomy liver failure - A Northern European multicenter cohort study. HPB (Oxford) 2022; 24:1138-1144. [PMID: 35067465 DOI: 10.1016/j.hpb.2021.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 12/02/2021] [Accepted: 12/08/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LTX) has been described as a rescue treatment option in severe, intractable post-hepatectomy liver failure (PHLF), but is not considered to be indicated for this condition by many hepatobiliary and transplant surgeons. In this article we describe the clinical experience of five northern European tertiary centers in using LTX to treat selected patients with severe PHLF. METHODS All patients subjected to LTX due to PHLF at the participating centers were identified from prospective clinical databases. Preoperative variables, surgical outcome (both resection surgery and LTX) and follow-up data were assessed. RESULTS A total of 10 patients treated with LTX due to severe PHLF from September 2008 to May 2020 were identified and included in the study. All patients but one were male and the median age was 70 years (range 49-72). In all patients the indication for liver resection was suspected malignancy, but in six patients post-resection pathology revealed benign or pre-malignant disease. There was no 90-day mortality after LTX. Patients were followed for a median of 49 months (13-153) and eight patients were alive without recurrence at last follow-up. DISCUSSION In selected patients with PHLF LTX can be a life-saving procedure with low short-term risk.
Collapse
Affiliation(s)
- Ernesto Sparrelid
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden.
| | - Trygve Thorsen
- Department of Transplantation Medicine, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Christina Sauter
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Jorns
- Department of Clinical Science, Intervention and Technology, Division of Transplantation Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Per Stål
- Department of Medicine, Division of Hepatology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Arno Nordin
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marieke T de Boer
- Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Carlijn Buis
- Section of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, Department of Surgery, University Medical Center Groningen, Groningen, the Netherlands
| | - Sheraz Yaqub
- Institute of Clinical Medicine, University of Oslo, Norway; Department of Hepato-Pancreato-Biliary Surgery, Oslo University Hospital, Oslo, Norway
| | - Nicolai A Schultz
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Peter N Larsen
- Department of Surgical Gastroenterology and Transplantation, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Ville Sallinen
- Department of Transplantation and Liver Surgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Pål-Dag Line
- Department of Transplantation Medicine, Oslo University Hospital, Norway; Institute of Clinical Medicine, University of Oslo, Norway
| | - Stefan Gilg
- Department of Clinical Science, Intervention and Technology, Division of Surgery, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
10
|
Xiao LL, Wu XX, Chen JJ, Yan D, Shi DY, Huang JR, Xu XW, Li LJ. Progress in hepatitis B virus-related acute-on-chronic liver failure treatment in China: A large, multicenter, retrospective cohort study using a propensity score matching analysis. Hepatobiliary Pancreat Dis Int 2021; 20:535-541. [PMID: 34303609 DOI: 10.1016/j.hbpd.2021.05.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 05/25/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) has a high short-term mortality. However, the treatment progression for HBV-ACLF in China in the past decade has not been well characterized. The present study aimed to determine whether the HBV-ACLF treatment has significantly improved during the past decade. METHODS This study retrospectively compared short-term (28/56 days) survival rates of two different nationwide cohorts (cohort I: 2008-2011 and cohort II: 2012-2015). Eligible HBV-ACLF patients were enrolled retrospectively. Patients in the cohorts I and II were assigned either to the standard medical therapy (SMT) group (cohort I-SMT, cohort II-SMT) or artificial liver support system (ALSS) group (cohort I-ALSS, cohort II-ALSS). Propensity score matching analysis was conducted to eliminate baseline differences, and multivariate logistic regression analysis was used to explore the independent factors for 28-day survival. RESULTS Short-term (28/56 days) survival rates were significantly higher in the ALSS group than those in the SMT group (P < 0.05) and were higher in the cohort II than those in the cohort I (P < 0.001). After propensity score matching, short-term (28/56 days) survival rates were higher in the cohort II than those in the cohort I for both SMT (60.7% vs. 53.0%, 50.0% vs. 39.8%, P < 0.05) and ALSS (66.1% vs. 56.5%, 53.0% vs. 44.4%, P < 0.05) treatments. The 28-day survival rate was higher in patients treated with nucleos(t)ide analogs than in patients without such treatments (P = 0.046). Multivariate logistic regression analysis revealed that ALSS (OR = 0.962, 95% CI: 0.951-0.973, P = 0.038), nucleos(t)ide analogs (OR = 0.927, 95% CI: 0.871-0.983, P = 0.046), old age (OR = 1.028, 95% CI: 1.015-1.041, P < 0.001), total bilirubin (OR = 1.002, 95% CI: 1.001-1.003, P = 0.004), INR (OR = 1.569, 95% CI: 1.044-2.358, P < 0.001), COSSH-ACLF grade (OR = 2.683, 95% CI: 1.792-4.017, P < 0.001), and albumin (OR = 0.952, 95% CI: 0.924-0.982, P = 0.002) were independent factors for 28-day mortality. CONCLUSIONS The treatment for patients with HBV-ACLF has improved in the past decade.
Collapse
Affiliation(s)
- Lan-Lan Xiao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Xiao-Xin Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Jia-Jia Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Dong Yan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Dong-Yan Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Jian-Rong Huang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| | - Xiao-Wei Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China.
| | - Lan-Juan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University, Hangzhou 310003, China
| |
Collapse
|
11
|
Ali S, Haque N, Azhar Z, Saeinasab M, Sefat F. Regenerative Medicine of Liver: Promises, Advances and Challenges. Biomimetics (Basel) 2021; 6:biomimetics6040062. [PMID: 34698078 PMCID: PMC8544204 DOI: 10.3390/biomimetics6040062] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 10/06/2021] [Accepted: 10/14/2021] [Indexed: 12/16/2022] Open
Abstract
Liver tissue engineering is a rapidly developing field which combines the novel use of liver cells, appropriate biochemical factors, and engineering principles, in order to replace or regenerate damaged liver tissue or the organ. The aim of this review paper is to critically investigate different possible methods to tackle issues related with liver diseases/disorders mainly using regenerative medicine. In this work the various regenerative treatment options are discussed, for improving the prognosis of chronic liver disorders. By reviewing existing literature, it is apparent that the current popular treatment option is liver transplantation, although the breakthroughs of stem cell-based therapy and bioartificial liver technology make them a promising alternative.
Collapse
Affiliation(s)
- Saiful Ali
- Department of Biomedical and Electronics Engineering, School of Engineering, University of Bradford, Bradford BD7 1DP, UK; (S.A.); (N.H.); (Z.A.)
| | - Nasira Haque
- Department of Biomedical and Electronics Engineering, School of Engineering, University of Bradford, Bradford BD7 1DP, UK; (S.A.); (N.H.); (Z.A.)
| | - Zohya Azhar
- Department of Biomedical and Electronics Engineering, School of Engineering, University of Bradford, Bradford BD7 1DP, UK; (S.A.); (N.H.); (Z.A.)
| | - Morvarid Saeinasab
- Department of Biology, Faculty of Science, Ferdowsi University of Mashhad, Mashhad 9177948974, Iran;
| | - Farshid Sefat
- Department of Biomedical and Electronics Engineering, School of Engineering, University of Bradford, Bradford BD7 1DP, UK; (S.A.); (N.H.); (Z.A.)
- Interdisciplinary Research Centre in Polymer Science & Technology (Polymer IRC), University of Bradford, Bradford BD7 1DP, UK
- Correspondence: ; Tel.: +44-(0)-1274-233679 or +44-(0)-781-381-7460
| |
Collapse
|
12
|
Pufal K, Lawson A, Hodson J, Bangash M, Patel J, Weston C, Gulik TV, Dasari BV. Role of liver support systems in the management of post hepatectomy liver failure: A systematic review of the literature. Ann Hepatobiliary Pancreat Surg 2021; 25:171-178. [PMID: 34053919 PMCID: PMC8180400 DOI: 10.14701/ahbps.2021.25.2.171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 02/04/2021] [Accepted: 02/05/2021] [Indexed: 01/16/2023] Open
Abstract
Backgrounds/Aims Post-hepatectomy liver failure (PHLF) is a serious complication following liver resection, with limited treatment options, and is associated with high mortality. There is a need to evaluate the role of systems that support the function of the liver after PHLF. Aims The aim of this study was to review the literature and summarize the role of liver support systems (LSS) in the management of PHLF. Publications of interest were identified using systematically designed searches. Following screening, data from the relevant publications was extracted, and pooled where possible. Findings Systematic review identified nine studies, which used either Plasma Exchange (PE) or Molecular Adsorbent Recirculating System (MARS) as LSS after PHLF. Across all studies, the pooled 90-day mortality rate was 38% (95% CI: 9-70%). However, there was substantial heterogeneity, likely since studies used a variety of definitions for PHLF, and had different selection criteria for patient eligibility for LSS treatment. Conclusions The current evidence is insufficient to recommend LSS for the routine management of severe PHLF, with the current literature consisting of only a limited number of studies. There is a definite need for larger, multicenter, prospective studies, evaluating the conventional and newer modalities of support systems, with a view to improve the outcomes in this group of patients.
Collapse
Affiliation(s)
- Kamil Pufal
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - Alexander Lawson
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| | - James Hodson
- Institute of Translational Medicine, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Mansoor Bangash
- University of Birmingham, Birmingham, UK.,Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital, Birmingham, UK
| | - Jaimin Patel
- University of Birmingham, Birmingham, UK.,Department of Anaesthesia and Critical Care, Queen Elizabeth Hospital, Birmingham, UK
| | - Chris Weston
- Centre for Liver & Gastrointestinal Research, Institute of Immunology & Immunotherapy, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK Birmingham, UK
| | - Thomas van Gulik
- Department of Surgery, University Medical Centres (Location Amsterdam Medical Centre), University of Amsterdam, Amsterdam, The Netherlands
| | - Bobby Vm Dasari
- Department of HPB and Liver Transplantation, Queen Elizabeth Hospital, Birmingham, UK.,University of Birmingham, Birmingham, UK
| |
Collapse
|
13
|
A novel prognostic model to predict outcome of artificial liver support system treatment. Sci Rep 2021; 11:7510. [PMID: 33820919 PMCID: PMC8021558 DOI: 10.1038/s41598-021-87055-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 03/17/2021] [Indexed: 02/05/2023] Open
Abstract
The prognosis of Artificial liver support system (ALSS) for hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is hard to be expected, which results in multiple operations of ALSS and excessive consumption of plasma, increase in clinical cost. A total of 375 HBV-ACLF patients receiving ALSS treatment were randomly divided a train set and an independent test set. Logistic regression analysis was conducted and a decision tree was built based on 3-month survival as outcome. The ratio of total bilirubin before and after the first time of ALSS treatment was the most significant prognostic factor, we named it RPTB. Further, a decision tree based on the multivariate logistic regression model using CTP score and the RPTB was built, dividing patients into 3 main groups such as favorable prognosis group, moderate prognosis group and poor prognosis group. A clearly-presented and easily-understood decision tree was built with a good predictive value of prognosis in HBV-related ACLF patients after first-time ALSS treatment. It will help maximal the therapeutic value of ALSS treatment and may play an important role in organ allocation for liver transplantation in the future.
Collapse
|
14
|
Kanjo A, Ocskay K, Gede N, Kiss S, Szakács Z, Párniczky A, Mitzner S, Stange J, Hegyi P, Molnár Z. Efficacy and safety of liver support devices in acute and hyperacute liver failure: a systematic review and network meta-analysis. Sci Rep 2021; 11:4189. [PMID: 33602961 PMCID: PMC7893063 DOI: 10.1038/s41598-021-83292-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 01/28/2021] [Indexed: 12/19/2022] Open
Abstract
Acute liver failure (ALF) is a potentially life-threatening condition. Liver support therapies can be applied as a bridging-to-transplantation or bridging-to-recovery; however, results of clinical trials are controversial. Our aim was to compare liver support systems in acute and hyperacute liver failure with network meta-analysis. After systematic search, randomized controlled trials (RCT) comparing liver support therapies in adults with acute or hyperacute liver failure were included. In-hospital mortality was the primary outcome, the secondary outcomes were hepatic encephalopathy and mortality-by-aetiology. A Bayesian-method was used to perform network meta-analysis and calculate surface under the cumulative ranking curve (SUCRA) values to rank interventions. Eleven RCTs were included. BioLogic-DT and molecular adsorbent recirculating system (MARS) resulted in the lowest mortality (SUCRAs: 76% and 73%, respectively). In non-paracetamol-poisoned patients, BioLogic-DT, charcoal hemoperfusion and MARS may be equally efficient regarding mortality (SUCRAs: 53%, 52% and 52%, respectively). Considering hepatic encephalopathy, extracorporeal liver assist device (ELAD) may be the most effective option (SUCRA: 78%). However, in pairwise meta-analysis, there were no statistically significant differences between the interventions in the outcomes. In conclusion, MARS therapy seems to be the best available option in reducing mortality. Further research is needed on currently available and new therapeutic modalities. (CRD42020160133).
Collapse
Affiliation(s)
- Anna Kanjo
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Steffen Mitzner
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Jan Stange
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary. .,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary. .,Department of Anesthesiology and Intensive Therapy, Poznan University for Medical Sciences, Medical Faculty, Poznan, Poland.
| |
Collapse
|
15
|
Ocskay K, Kanjo A, Gede N, Szakács Z, Pár G, Erőss B, Stange J, Mitzner S, Hegyi P, Molnár Z. Uncertainty in the impact of liver support systems in acute-on-chronic liver failure: a systematic review and network meta-analysis. Ann Intensive Care 2021; 11:10. [PMID: 33462764 PMCID: PMC7813174 DOI: 10.1186/s13613-020-00795-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/18/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND The role of artificial and bioartificial liver support systems in acute-on-chronic liver failure (ACLF) is still controversial. We aimed to perform the first network meta-analysis comparing and ranking different liver support systems and standard medical therapy (SMT) in patients with ACLF. METHODS The study protocol was registered with PROSPERO (CRD42020155850). A systematic search was conducted in five databases. We conducted a Bayesian network meta-analysis of randomized controlled trials assessing the effect of artificial or bioartificial liver support systems on survival in patients with ACLF. Ranking was performed by calculating the surface under cumulative ranking (SUCRA) curve values. The RoB2 tool and a modified GRADE approach were used for the assessment of the risk of bias and quality of evidence (QE). RESULTS In the quantitative synthesis 16 trials were included, using MARS®, Prometheus®, ELAD®, plasma exchange (PE) and BioLogic-DT®. Overall (OS) and transplant-free (TFS) survival were assessed at 1 and 3 months. PE significantly improved 3-month OS compared to SMT (RR 0.74, CrI: 0.6-0.94) and ranked first on the cumulative ranking curves for both OS outcomes (SUCRA: 86% at 3 months; 77% at 1 month) and 3-month TFS (SUCRA: 87%) and second after ELAD for 1-month TFS (SUCRA: 76%). Other comparisons did not reach statistical significance. QE was moderate for PE concerning 1-month OS and both TFS outcomes. Other results were of very low certainty. CONCLUSION PE seems to be the best currently available liver support therapy in ACLF regarding 3-month OS. Based on the low QE, randomized trials are needed to confirm our findings for already existing options and to introduce new devices.
Collapse
Affiliation(s)
- Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary
| | - Anna Kanjo
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary.,Institute of Bioanalysis, Medical School, University of Pécs, Pécs, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary
| | - Gabriella Pár
- Division of Gastroenterology, First Department of Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Bálint Erőss
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary
| | - Jan Stange
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Steffen Mitzner
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary.,First Department of Medicine, University of Szeged, Szeged, Hungary.,Translational Medicine Foundation, Szeged, Hungary
| | - Zsolt Molnár
- Institute for Translational Medicine, Medical School, University of Pécs, Szigeti út 12. 2nd floor, Pécs, 7624, Hungary. .,Department of Anaesthesiology and Intensive Therapy, Faculty of Medicine, Poznan University of Medical Sciences, Poznan, Poland.
| |
Collapse
|
16
|
Cheungpasitporn W, Thongprayoon C, Zoghby ZM, Kashani K. MARS: Should I Use It? Adv Chronic Kidney Dis 2021; 28:47-58. [PMID: 34389137 DOI: 10.1053/j.ackd.2021.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 11/11/2022]
Abstract
Severe liver failure, including acute liver failure and acute-on-chronic liver failure, is associated with high mortality, and many patients die despite aggressive medical therapy. While liver transplantation is a viable treatment option for liver failure patients, a large proportion of these patients die given the shortage in the liver donation and the severity of illness, leading to death while waiting for a liver transplant. Extracorporeal liver support devices, including molecular adsorbent recirculating system (MARS), have been developed as bridge to transplantation (bridge for patients who are decompensating while waiting for liver transplantation) and bridge to recovery (for whom recovery is deemed reasonable). In addition to its uses in acute liver failure and acute-on-chronic liver failure, the MARS system has also been applied in various clinical settings, such as drug overdosing and poisoning and intractable cholestatic pruritus refractory to pharmacological treatment. This review aims to discuss the controversies, potential benefits, practicalities, and disadvantages of using MARS in clinical practice.
Collapse
|
17
|
Søreide JA, Deshpande R. Post hepatectomy liver failure (PHLF) - Recent advances in prevention and clinical management. Eur J Surg Oncol 2020; 47:216-224. [PMID: 32943278 DOI: 10.1016/j.ejso.2020.09.001] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/26/2020] [Accepted: 09/01/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Posthepatectomy liver failure (PHLF) is a relatively rare but feared complication following liver surgery, and associated with high morbidity, mortality and cost implications. Significant advances have been made in detailed preoperative assessment, particularly of the liver function in an attempt to predict and mitigate this complication. METHODS A detailed search of PubMed and Medline was performed using keywords "liver failure", "liver insufficiency", "liver resection", "postoperative", and "post-hepatectomy". Only full texts published in English were considered. Particular emphasis was placed on literature published after 2015. A formal systematic review was not found feasible hence a pragmatic review was performed. RESULTS The reported incidence of PHLF varies widely in reported literature due to a historical absence of a universal definition. Incorporation of the now accepted definition and grading of PHLF would suggest the incidence to be between 8 and 12%. Major risk factors include background liver disease, extent of resection and intraoperative course. The vast majority of mortality associated with PHLF is related to sepsis, organ failure and cerebral events. Despite multiple attempts, there has been little progress in the definitive and specific management of liver failure. This review article discusses recent advances made in detailed preoperative evaluation of liver function and evidence-based targeted approach to managing PHLF. CONCLUSION PHLF remains a major cause of mortality following liver resection. In absence of a specific remedy, the best approach is mitigating the risk of it happening by detailed assessment of liver function, patient selection and general care of a critically ill patient.
Collapse
Affiliation(s)
- Jon Arne Søreide
- Department of Gastrointestinal Surgery, Stavanger University Hospital, Stavanger, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Rahul Deshpande
- Department of HPB Surgery, Manchester Royal Infirmary, Manchester, UK
| |
Collapse
|
18
|
Systematic review of MARS treatment in post-hepatectomy liver failure. HPB (Oxford) 2020; 22:950-960. [PMID: 32249030 DOI: 10.1016/j.hpb.2020.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 01/26/2020] [Accepted: 03/11/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Post-hepatectomy liver failure (PHLF) remains a serious complication after major liver resection with severe 90-day mortality. Molecular adsorbent recirculating system (MARS) is a potential treatment option in PHLF. This systematic review sought to analyze the experiences and results of MARS in PHLF. METHODS Following the PRISMA guidelines, a systematic literature review using PubMed and Embase was performed. Non-randomized trials were assessed by the MINORS criteria. RESULTS 2884 records were screened and 22 studies were extracted (no RCT). They contained 809 patients including 82 patients with PHLF. Five studies (n = 34) specifically investigated the role of MARS in patients with PHLF. In these patients, overall 90-day survival was 47%. Patients with primary PHLF had significantly better 90-day survival compared to patients with secondary PHLF (60% vs 14%, p = 0.03) and treatment was started earlier (median POD 6 (range 2-21) vs median POD 30 (range 15-39); p < 0.001). Number of treatments differed non-significantly in these groups. Safety and feasibility of early MARS treatment following hepatectomy was demonstrated in one prospective study. No major adverse events have been reported. CONCLUSION Early MARS treatment is safe and feasible in patients with PHLF. Currently, MARS cannot be recommended as standard of care in these patients. Further prospective studies are warranted.
Collapse
|
19
|
Ogura Y, Kabacam G, Singhal A, Moon DB. The role of living donor liver transplantation for acute liver failure. Int J Surg 2020; 82S:145-148. [PMID: 32353557 DOI: 10.1016/j.ijsu.2020.04.058] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Revised: 04/16/2020] [Accepted: 04/22/2020] [Indexed: 01/13/2023]
Abstract
Acute liver failure (ALF) is a life-threatening illness that occurs in the absence of pre-existing liver disease. When symptoms seriously progress under continuous supportive medical care, liver transplantation becomes the only therapeutic strategy. However, the available sources of organs for liver transplantation differ worldwide. In regions in which organs from cadaveric donors are more common, deceased donor liver transplantation (DDLT) is performed in this urgent situation. Conversely, in countries where cadaveric donors are scarce, living donor liver transplantation (LDLT) is the only choice. Special considerations must be made for urgent LDLT for ALF, including the expedited evaluation of living donors, technical issues, and the limitations of ABO blood type combinations between recipients and donor candidates. In this review, we highlight the role of LDLT for ALF and the considerations that distinguish it from DDLT. LDLT is well-established as a life-saving procedure for ALF patients and there is often no alternative to LDLT, especially in countries where DDLT is not feasible. However, from a global perspective, an increase in the deceased donor pool might be an urgent and important necessity.
Collapse
Affiliation(s)
- Yasuhiro Ogura
- Department of Transplantation Surgery, Nagoya University Hospital, Aichi, Japan.
| | - Gokhan Kabacam
- Department of Gastroenterology, Guven Hospital, Ankara, Turkey
| | - Ashish Singhal
- Advanced Institute of Liver & Biliary Sciences, Fortis Hospitals, Delhi-NCR, India
| | - Deok-Bok Moon
- Department of Surgery, University of Ulsan College of Medicine, Seoul, South Korea
| |
Collapse
|
20
|
Zhang C, Huang S, Zheng F, Dai Y. Controversial treatments: An updated understanding of the coronavirus disease 2019. J Med Virol 2020; 92:1441-1448. [PMID: 32219882 PMCID: PMC7228369 DOI: 10.1002/jmv.25788] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/16/2020] [Accepted: 03/23/2020] [Indexed: 01/08/2023]
Abstract
An outbreak of severe acute respiratory syndrome-related coronavirus 2 infection has posed significant threats to international health and the economy. In the absence of specific treatment for this virus, there is an urgent need to learn from the experience and lessons in China. To reduce the case-fatality rate among coronavirus disease 2019 patients, we should not ignore the complications, such as RNAaemia, acute respiratory distress syndrome, and multiple organ dysfunction. To help understand the advantages and limitations of differential treatments, we provide a timely review and discuss the complications and corresponding major treatments, especially controversial ones such as antiviral therapy (remdesivir, ribavirin, and chloroquine), glucocorticoid therapy, extracorporeal support including an artificial liver system, and extracorporeal membrane oxygenation based on available evidence. As a result, we suggest that antiviral therapy and organ function support are vital to reduce mortality for mild patients and critical patients, respectively.
Collapse
Affiliation(s)
- Cantong Zhang
- Department of Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Shaoying Huang
- Department of Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Fengping Zheng
- Department of Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, Guangdong, China
| | - Yong Dai
- Department of Clinical Medical Research Center, The Second Clinical Medical College of Jinan University, The First Affiliated Hospital Southern University of Science and Technology, Shenzhen People's Hospital, Shenzhen, Guangdong, China.,Department of Nephrology, Guangxi Key Laboratory of Metabolic Disease Research, Guilin, China
| |
Collapse
|
21
|
Cajanding RJM. MDMA-Associated Liver Toxicity: Pathophysiology, Management, and Current State of Knowledge. AACN Adv Crit Care 2020; 30:232-248. [PMID: 31462520 DOI: 10.4037/aacnacc2019852] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
3,4-Methylenedioxymethamphetamine (MDMA, ecstasy) has become a popular recreational drug of abuse among young adults, partly because of the belief that it is relatively safe compared with other drugs with the same stimulant and hallucinogenic effects. However, MDMA use has been associated with a wide spectrum of organ toxicities, with the liver being severely affected by its deleterious effects. This article discusses the essential pharmacology of MDMA and describes the effects MDMA has on various organ systems of the body, with particular focus on the liver. The putative mechanisms by which MDMA can cause liver damage are explored, with emphasis on patient-related factors that explain why some individuals are more susceptible than others to damage from MDMA. The incidence of hepatotoxicity related to MDMA use is presented, and the nursing management of patients who develop acute liver failure due to MDMA overuse is explored in light of current evidence.
Collapse
Affiliation(s)
- Ruff Joseph Macale Cajanding
- Ruff Joseph Macale Cajanding is Charge Nurse, Adult Critical Care Unit, 6th Floor, King George V Building, St. Bartholomew's Hospital, Barts Health NHS Trust, 2 King Edward Street, London EC1A 1HQ, United Kingdom
| |
Collapse
|
22
|
Toma D, Lazar O, Bontas E. Acute Liver Failure. LIVER DISEASES 2020. [PMCID: PMC7122204 DOI: 10.1007/978-3-030-24432-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acute liver failure is a highly unpredictable disease that can evolve to a life-threatening situation within few hours. In a simplified manner, acute liver failure is the acute liver dysfunction with multiorgan damaging associated with numerous complications, and very poor prognosis, being caused by varied etiologies. Despite the numerous advances on pathophysiology, intensive care treatment, and transplantation techniques from the last decades, is still characterized by increased mortality. At present, the patients with acute liver failure should be managed in Intensive Care Unit where the therapy should be applied based on the specific etiology of the acute liver failure and it should be started as early as possible.
Collapse
|
23
|
da Silva Morais A, Oliveira JM, Reis RL. Biomaterials and Microfluidics for Liver Models. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2020; 1230:65-86. [DOI: 10.1007/978-3-030-36588-2_5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
|
24
|
Alshamsi F, Alshammari K, Belley-Cote E, Dionne J, Albrahim T, Albudoor B, Ismail M, Al-Judaibi B, Baw B, Subramanian RM, Steadman R, Galusca D, Huang DT, Nanchal R, Al Quraini M, Yuan Y, Alhazzani W. Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2019; 46:1-16. [PMID: 31588983 DOI: 10.1007/s00134-019-05783-y] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]
Abstract
PURPOSE Acute liver failure (ALF) and acute on chronic liver failure (ACLF) are associated with significant mortality and morbidity. Extracorporeal liver support (ECLS) devices have been used as a bridge to liver transplant; however, the efficacy and safety of ECLS are unclear. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of ECLS in liver failure. METHODS We searched MEDLINE, EMBASE and Cochrane Central Register of Controlled Trials from inception through March 13, 2019. RCTs comparing ECLS to usual care in ALF or ACLF were included. We used the Grading of Recommendations Assessment, Development and Evaluation approach to assess the certainty of the evidence. RESULTS We identified 25 RCTs (1796 patients). ECLS use was associated with reduction in mortality (RR 0.84; 95% CI 0.74, 0.96, moderate certainty) and improvement in hepatic encephalopathy (HE) (RR 0.71; 95% CI 0.60, 0.84, low certainty) in patients with ALF or ACLF. The effect of ECLS on hypotension (RR 1.46; 95% CI 0.98, 2.2, low certainty), bleeding (RR 1.21; 95% CI 0.88, 1.66, moderate certainty), thrombocytopenia (RR 1.62; 95% CI 1.0, 2.64, very low certainty) and line infection (RR 1.92; 95% CI 0.11, 33.44, low certainty) was uncertain. CONCLUSIONS ECLS may reduce mortality and improve HE in patients with ALF and ACLF. The effect on other outcomes is uncertain. However, the evidence is limited by risk of bias and imprecision, and larger trials are needed to better determine the effect of ECLS on patient-important outcomes.
Collapse
Affiliation(s)
- Fayez Alshamsi
- Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
| | - Khalil Alshammari
- Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
| | - Emilie Belley-Cote
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Joanna Dionne
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Talal Albrahim
- Department of Anesthesiology and Critical Care Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Budoor Albudoor
- Department of Critical Care Medicine, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
| | - Mona Ismail
- Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
| | - Bandar Al-Judaibi
- Transplant Hepatology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, USA, 14642
| | - Bandar Baw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Ram M Subramanian
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
- Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Randolph Steadman
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
| | - Dragos Galusca
- Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
| | - David T Huang
- Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization (MACRO), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Rahul Nanchal
- Department of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Mustafa Al Quraini
- Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Yuhong Yuan
- Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
| | - Waleed Alhazzani
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada.
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada.
| |
Collapse
|
25
|
Stutchfield BM, Bodingbauer MW, Adair A, Wakelin S, Schindl M, Forbes SJ, Wigmore SJ. Quantifying changes in innate immune function following liver transplantation for chronic liver disease. HPB (Oxford) 2019; 21:1322-1326. [PMID: 30850189 DOI: 10.1016/j.hpb.2019.02.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Revised: 01/26/2019] [Accepted: 02/04/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND Liver transplantation (LT) offers patients with cirrhosis long-term survival, however many die from sepsis whilst awaiting LT. The liver's role in innate immunity may be key to improving outcomes, but the immune effects of LT have not been quantified. METHODS Innate immune capacity was assessed by clearance of 99mTc-Albumin nanospheres in patients with chronic liver failure before and after LT. RESULTS Twenty-eight patients with chronic liver disease on the LT waiting list entered the study during the twelve-month study period and nine patients underwent LT and completed the study protocol. One patient developed hepatic artery thrombosis in <7 days and was excluded from the study. Innate immune function was significantly impaired in patients with chronic liver disease on the LT waiting list and this was directly correlated with MELD score. LT normalised innate immune function by day 1 post LT with further improvement occurring by day 7 post LT. Donor liver weight was the only factor correlated with innate immune function at day 1 post LT but this effect was negated by day 7 post LT. CONCLUSION Recognising the immune effects of LT may facilitate treatment of cirrhosis and inform development of extracorporeal liver support systems.
Collapse
Affiliation(s)
- Benjamin M Stutchfield
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | | | - Anya Adair
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Sonia Wakelin
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Martin Schindl
- Department of Surgery, Medical University of Vienna, Vienna, Austria
| | - Stuart J Forbes
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK
| | - Stephen J Wigmore
- The Edinburgh Liver Surgery and Transplantation Experimental Research Group (eLISTER) and the Department of Surgery, Hepatology and Pharmacy, Royal Infirmary and University of Edinburgh, Edinburgh, UK.
| |
Collapse
|
26
|
Chamuleau RAFM, Hoekstra R. End-stage liver failure: filling the treatment gap at the intensive care unit. J Artif Organs 2019; 23:113-123. [PMID: 31535298 PMCID: PMC7228976 DOI: 10.1007/s10047-019-01133-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022]
Abstract
End-stage liver failure is a condition of collapsing liver function with mortality rates up to 80. Liver transplantation is the only lifesaving therapy. There is an unmet need for therapy to extend the waiting time for liver transplantation or regeneration of the native liver. Here we review the state-of-the-art of non-cell based and cell-based artificial liver support systems, cell transplantation and plasma exchange, with the first therapy relying on detoxification, while the others aim to correct also other failing liver functions and/or modulate the immune response. Meta-analyses on the effect of non-cell based systems show contradictory outcomes for different types of albumin purification devices. For bioartificial livers proof of concept has been shown in animals with liver failure. However, large clinical trials with two different systems did not show a survival benefit. Two clinical trials with plasma exchange and one with transplantation of mesenchymal stem cells showed positive outcomes on survival. Detoxification therapies lack adequacy for most patients. Correction of additional liver functions, and also modulation of the immune system hold promise for future therapy of liver failure.
Collapse
Affiliation(s)
- Robert A F M Chamuleau
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, AG&M, Academic Medical Center, Meibergdreef 69-71, S1-176, 1105 BK, Amsterdam, The Netherlands.
| | - Ruurdtje Hoekstra
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, AG&M, Academic Medical Center, Meibergdreef 69-71, S1-176, 1105 BK, Amsterdam, The Netherlands
| |
Collapse
|
27
|
Kabbani AR, Tergast TL, Manns MP, Maasoumy B. [Treatment strategies for acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2019; 116:3-16. [PMID: 31463674 PMCID: PMC7095250 DOI: 10.1007/s00063-019-00613-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is a newly defined syndrome in patients with liver cirrhosis characterized by acute hepatic decompensation (jaundice, ascites, hepatic encephalopathy, bacterial infection and gastrointestinal bleeding), single or multiple organ failure and a high mortality (>15% within 28 days). The affected organ systems include not only the liver but also the circulation, lungs, kidneys, brain and/or coagulation. Pathophysiologically decisive is an uncontrolled inflammation that is induced by specific triggers and on the basis of previously (possibly not diagnosed) compensated as well as already decompensated liver cirrhosis leads to a severe systemic clinical syndrome, ACLF. The course during the first 72 h is decisive for the prognosis. In addition to treatment of the respective organ or system failure, the underlying triggers should be quickly identified and if necessary specifically treated. Often, however, these cannot (no longer) be determined with any certainty, in particular recent alcohol consumption as well as bacterial and viral infections play an important role. A specific treatment for the ACLF is (currently) not established. Some experimental approaches are currently being tested, including administration of granulocyte colony-stimulating factor (GCSF). Additionally, suitable patients should be presented to a liver transplantation center in a timely manner.
Collapse
Affiliation(s)
| | | | | | - B Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
| |
Collapse
|
28
|
He YT, Qi YN, Zhang BQ, Li JB, Bao J. Bioartificial liver support systems for acute liver failure: A systematic review and meta-analysis of the clinical and preclinical literature. World J Gastroenterol 2019; 25:3634-3648. [PMID: 31367162 PMCID: PMC6658398 DOI: 10.3748/wjg.v25.i27.3634] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/03/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) has a high mortality varying from 80% to 85% with rapid progress in multi-organ system failure. Bioartificial liver (BAL) support systems have the potential to provide temporary support to bridge patients with ALF to liver transplantation or spontaneous recovery. In the past decades, several BAL support systems have been conducted in clinical trials. More recently, concerns have been raised on the renovation of high-quality cell sources and configuration of BAL support systems to provide more benefits to ALF models in preclinical experiments.
AIM To investigate the characteristics of studies about BAL support systems for ALF, and to evaluate their effects on mortality.
METHODS Eligible clinical trials and preclinical experiments on large animals were identified on Cochrane Library, PubMed, and EMbase up to March 6, 2019. Two reviewers independently extracted the necessary information, including key BAL indicators, survival and indicating outcomes, and adverse events during treatment. Descriptive analysis was used to identify the characteristics of the included studies, and a meta-analysis including only randomized controlled trial (RCT) studies was done to calculate the overall effect of BAL on mortality among humans and large animals, respectively.
RESULTS Of the 30 selected studies, 18 were clinical trials and 12 were preclinical experiments. The meta-analysis result suggested that BAL might reduce mortality in ALF in large animals, probably due to the recent improvement of BAL, including the type, cell source, cell mass, and bioreactor, but seemed ineffective for humans [BAL vs control: relative risk (95% confidence interval), 0.27 (0.12-0.62) for animals and 0.72 (0.48-1.08) for humans]. Liver and renal functions, hematologic and coagulative parameters, encephalopathy index, and neurological indicators seemed to improve after BAL, with neither meaningful adverse events nor porcine endogenous retrovirus infection.
CONCLUSION BAL may reduce the mortality of ALF by bridging the gap between preclinical experiments and clinical trials. Clinical trials using improved BAL must be designed scientifically and conducted in the future to provide evidence for transformation.
Collapse
Affiliation(s)
- Yu-Ting He
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ya-Na Qi
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing-Qi Zhang
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jian-Bo Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ji Bao
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| |
Collapse
|
29
|
Abstract
Extracorporeal liver support (ECLS) emerged from the need stabilize high-acuity liver failure patients with the highest risk of death. The goal is to optimize the hemodynamic, neurologic, and biochemical parameters in preparation for transplantation or to facilitate spontaneous recovery. Patients with acute liver failure and acute-on-chronic liver failure stand to benefit from these devices, especially because they have lost many of the primary functions of the liver, including detoxifying the blood of various endogenous and exogenous substances, manufacturing circulating proteins, secreting bile, and storing energy. Existing ECLS devices are designed to mimic some of these functions.
Collapse
Affiliation(s)
- Prem A Kandiah
- Division of Neuro Critical Care & co appt. in 5E Surgical/Transplant Critical Care, Department of Neurosurgery, Emory University Hospital, 1364 Clifton Road Northeast, 2nd Floor, 2D ICU- D264, Atlanta, GA 30322, USA; Department of Neurology, Emory University Hospital, 1364 Clifton Road Northeast, 2nd Floor, 2D ICU- D264, Atlanta, GA 30322, USA
| | - Ram M Subramanian
- Critical Care and Hepatology, Emory University, 1364 Clifton Road Northeast, 2nd Floor, 2D ICU- D264, Atlanta, GA 30322, USA.
| |
Collapse
|
30
|
Piechota M, Piechota A, Misztal M, Bernas S, Pietraszek-Grzywaczewska I. An evaluation of the usefulness of extracorporeal liver support techniques in patients with severe liver dysfunction. Arch Med Sci 2019; 15:99-112. [PMID: 30697259 PMCID: PMC6348365 DOI: 10.5114/aoms.2017.67998] [Citation(s) in RCA: 11] [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: 10/31/2016] [Accepted: 01/02/2017] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION The mortality rate in patients with severe liver dysfunction with no option of transplantation is unacceptably high. The main aim of this study was to evaluate the usefulness of applying extracorporeal liver support (ECLS) techniques in this group of patients. MATERIAL AND METHODS Data from hospital admissions of 101 patients with severe liver dysfunction who were admitted to the department of Anaesthesiology and intensive therapy between 2006 and 2015 were retrospectively analysed. The study group was divided into two subgroups. Standard Medical therapy (SMT) was a subgroup of patients receiving standard Medical therapy, and SMT + ECLS was a subgroup containing patients receiving standard medical therapy complemented by at least one extracorporeal liver support procedure. RESULTS Significantly lower intensive care unit (ICU) mortality and 30-day mortality rates were found in the SMT + ECLS subgroup (p = 0.0138 and p = 0.0238 respectively). No difference in 3-month mortality was identified between the two groups. In a multivariate model, independent risk factors for ICU mortality proved to be the SOFA score and prothrombin time. The highest discriminatory power for ICU mortality was demonstrated for the SOFA score, followed by APACHE II, SAPS II, MELD UNOS and GCS scores. For 30-day mortality, however, the best discriminatory power was shown for the SAPS II score, followed by SOFA, APACHE II, MELD UNOS and GCS scores. CONCLUSIONS Further studies are needed to assess the contribution of non-biological extracorporeal liver support procedures to a decrease in mortality rates in the population of patients with severe liver dysfunction.
Collapse
Affiliation(s)
- Mariusz Piechota
- Department of Anaesthesiology and Intensive Therapy – Centre for Artificial Extracorporeal Kidney and Liver Support, Dr Wł. Biegański Regional Specialist Hospital, Lodz, Poland
| | - Anna Piechota
- Department of Insurance, Faculty of Economics and Sociology, University of Lodz, Lodz, Poland
| | - Małgorzata Misztal
- Faculty of Economics and Sociology, Chair of Statistical Methods, University of Lodz, Lodz, Poland
| | - Szymon Bernas
- Department of Anaesthesiology and Intensive Therapy – Centre for Artificial Extracorporeal Kidney and Liver Support, Dr Wł. Biegański Regional Specialist Hospital, Lodz, Poland
| | - Iwona Pietraszek-Grzywaczewska
- Department of Anaesthesiology and Intensive Therapy – Centre for Artificial Extracorporeal Kidney and Liver Support, Dr Wł. Biegański Regional Specialist Hospital, Lodz, Poland
| |
Collapse
|
31
|
García Martínez JJ, Bendjelid K. Artificial liver support systems: what is new over the last decade? Ann Intensive Care 2018; 8:109. [PMID: 30443736 PMCID: PMC6238018 DOI: 10.1186/s13613-018-0453-z] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022] Open
Abstract
The liver is a complex organ that performs vital functions of synthesis, heat production, detoxification and regulation; its failure carries a highly critical risk. At the end of the last century, some artificial liver devices began to develop with the aim of being used as supportive therapy until liver transplantation (bridge-to-transplant) or liver regeneration (bridge-to-recovery). The well-recognized devices are the Molecular Adsorbent Recirculating System™ (MARS™), the Single-Pass Albumin Dialysis system and the Fractionated Plasma Separation and Adsorption system (Prometheus™). In the following years, experimental works and early clinical applications were reported, and to date, many thousands of patients have already been treated with these devices. The ability of artificial liver support systems to replace the liver detoxification function, at least partially, has been proven, and the correction of various biochemical parameters has been demonstrated. However, the complex tasks of regulation and synthesis must be addressed through the use of bioartificial systems, which still face several developmental problems and very high production costs. Moreover, clinical data on improved survival are conflicting. This paper reviews the progress achieved and new data published on artificial liver support systems over the past decade and the prospects for these devices.
Collapse
Affiliation(s)
- Juan José García Martínez
- Intensive Care Unit, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland. .,Faculty of Medicine, University of Geneva, Geneva, Switzerland.
| | - Karim Bendjelid
- Intensive Care Unit, Geneva University Hospitals, 4 Rue Gabrielle-Perret-Gentil, 1205, Geneva, Switzerland.,Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Geneva Hemodynamic Research Group, Geneva, Switzerland
| |
Collapse
|
32
|
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.
Collapse
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
| |
Collapse
|
33
|
Karvellas CJ, Subramanian RM. Current Evidence for Extracorporeal Liver Support Systems in Acute Liver Failure and Acute-on-Chronic Liver Failure. Crit Care Clin 2017; 32:439-51. [PMID: 27339682 DOI: 10.1016/j.ccc.2016.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Artificial (nonbiological) extracorporeal liver support devices aim to remove albumin-bound and water-soluble toxins to restore and preserve hepatic function and mitigate or limit the progression of multiorgan failure while hepatic recovery or liver transplant occurs. The following beneficial effects have been documented: improvement of jaundice, amelioration of hemodynamic instability, reduction of portal hypertension, and improvement of hepatic encephalopathy. The only randomized prospective multicenter controlled trial to show an improvement in transplant-free survival was for high-volume plasmapheresis. Biological (cell-based) extracorporeal liver support systems aim to support the failing liver through detoxification and synthetic function and warrant further study for safety and benefit.
Collapse
Affiliation(s)
- Constantine J Karvellas
- Division of Hepatology, University of Alberta, Edmonton, Alberta, Canada; Division of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada.
| | - Ram M Subramanian
- Division of Hepatology, Emory University, Atlanta, GA, USA; Division of Critical Care Medicine, Emory University, Atlanta, GA, USA
| |
Collapse
|
34
|
Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 495] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
Collapse
|
35
|
Molecular adsorbent recirculating system (MARS) in acute liver injury and graft dysfunction: Results from a case-control study. PLoS One 2017; 12:e0175529. [PMID: 28403210 PMCID: PMC5389829 DOI: 10.1371/journal.pone.0175529] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/27/2017] [Indexed: 12/24/2022] Open
Abstract
Background The primary therapeutic goals in the treatment of liver injury are to support liver regeneration or bridge the gap to liver transplantation (LT). Molecular adsorbent recirculating system (MARS) therapy has shown beneficial effects for specific symptoms of liver failure; however, general survival advantages have not yet been demonstrated. Aim We studied the effects of MARS therapy compared to standard medical treatment (SMT) in two patient cohorts: in patients with an acute liver injury and in those with graft dysfunction (GD). Methods We report on our experience over a 6.5-year period with 73 patients treated with SMT or with SMT and MARS (MARS group). In total, 53 patients suffered from acute liver injury in their native liver without a preexisting liver disease (SMT: n = 31, MARS: n = 22), and 20 patients showed a severe GD after LT (SMT: n = 10, MARS: n = 10). Results The entire cohort was predominantly characterized by hemodynamically and respiratorily stable patients with a low hepatic encephalopathy (HE) grade and a model of end-stage liver disease (MELD) score of 20.57 (MARS) or 22.51 (SMT, p = 0.555). Within the MARS group, the median number of extracorporeal therapy sessions was four (range = 3–5 sessions). Independent of the underlying etiology, MARS improved the patients’ bilirubin values in the short term compared to SMT alone. In patients with acute liver injury, this response was sustained even after the end of MARS therapy. By contrast, the majority of patients with GD and an initial response to MARS therapy experienced worsened hyperbilirubinemia. No differences in 28-day mortality were observed with respect to acute liver injury (MARS 5.3% (95% CI: 0–15.3); SMT 3.3% (95% CI: 0–9.8), p = 0.754) or GD (MARS 20.0% (95% CI: 0–44.7), SMT 11.1% (95% CI: 0–31.7), p = 0.478). Conclusions Although it did not improve 28-day mortality, MARS therapy improved the short-term response in patients with acute liver injury as well as in those with GD. In cases of acute hepatic injury, the use of MARS therapy resulted in the sustained stabilization of liver function and improved liver regeneration. A short-term response to MARS may predict the future course of the disease.
Collapse
|
36
|
Hu T, Yao L, Hu A, Jiang S, Ying H, Deng Q, Hu Y, Zhou W, Xiong T. Nucleos(t)ide analogs improve long-term prognosis in patients with chronic hepatitis B-associated liver failure. Hepatol Res 2017; 47:347-358. [PMID: 27283374 DOI: 10.1111/hepr.12755] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/20/2016] [Accepted: 05/29/2016] [Indexed: 12/12/2022]
Abstract
AIM Chronic hepatitis B-associated liver failure (CHB-LF) is associated with high mortality. Antiviral therapy with nucleoside and nucleotide analogs (NUCs) has been reported to improve the short-term prognosis of patients with CHB-LF. However, the long-term effects of the therapy remain unclear. We undertook a cohort study to investigate the long-term effect of NUC-based antiviral therapy in patients with CHB-LF. METHODS A total of 976 patients with CHB-LF were enrolled between January 2001 and December 2009 at the Liver Disease Center of Ningbo No. 2 Hospital (Ningbo, China). The patients were divided into the NUC treatment group (n = 412) and control group (n = 564). The propensity score matching method was used to match the patients between the two groups to equilibrate the covariates. Survival analysis was carried out using the matched samples. The Cox proportional hazard model was used for the analysis of prognostic factors. RESULTS After propensity matching, 262 pairs were successfully matched. No statistically significant difference was observed in the baseline characteristics of the matching pairs (P > 0.05). The long-term survival rate and survival duration of the NUC treatment group were higher than that of the control group (P < 0.05). Gender, age, Model for End-stage Liver Disease values, cholinesterase levels, white blood cell counts, hepatic encephalopathy, concomitant infection, and treatment with NUCs were found to be the independent factors associated with long-term prognosis. CONCLUSION Antiviral therapy with NUCs may reduce the mortality rate and improve the long-term prognosis of patients with CHB-LF.
Collapse
Affiliation(s)
- Ting Hu
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Lipeng Yao
- Ningbo College of Health Science, Ningbo, China
| | - Airong Hu
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Suwen Jiang
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Hao Ying
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Qinzhi Deng
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Yaoren Hu
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Wenhong Zhou
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| | - Tao Xiong
- Liver Diseases Center, Ningbo No. 2 Hospital, Ningbo University School of Medicine, Ningbo, China
| |
Collapse
|
37
|
Herrine SK, Moayyedi P, Brown RS, Falck-Ytter YT. American Gastroenterological Association Institute Technical Review on Initial Testing and Management of Acute Liver Disease. Gastroenterology 2017; 152:648-664.e5. [PMID: 28061338 DOI: 10.1053/j.gastro.2016.12.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Steven K Herrine
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania.
| | | | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York
| | - Yngve T Falck-Ytter
- Division of Gastroenterology and Hepatology, Department of Medicine, Case and VA Medical Center, Case Western Reserve University, Cleveland, Ohio
| |
Collapse
|
38
|
Abstract
Acute-on-chronic liver failure (ACLF) is a distinct entity that differs from acute liver failure and decompensated cirrhosis in timing, presence of treatable acute precipitant, and course of disease, with a potential for self-recovery. The core concept is acute deterioration of existing liver function in a patient of chronic liver disease with or without cirrhosis in response to an acute insult. The insult should be a hepatic one and presentation in the form of liver failure (jaundice, encephalopathy, coagulopathy, ascites) with or without extrahepatic organ failure in a defined time frame. ACLF is characterized by a state of deregulated inflammation. Initial cytokine burst presenting as SIRS, progression to CARS and associated immunoparalysis leads to sepsis and multi-organ failure. Early identification of the acute insult and mitigation of the same, use of nucleoside analogue in HBV-ACLF, steroid in severe alcoholic hepatitis, steroid in severe autoimmune hepatitis and/or bridging therapy lead to recovery, with a 90-day transplant-free survival rate of up to 50 %. First-week presentation is crucial concerning SIRS/sepsis, development, multiorgan failure and consideration of transplant. A protocol-based multi-disciplinary approach including critical care hepatology, early liver transplant before multi-organ involvement, or priority for organ allocation may improve the outcome. Presentation with extrahepatic organ involvement or inclusion of sepsis as an acute insult in definition restricts the therapy, i.e., liver transplant or bridging therapy, and needs serious consideration. Augmentation of regeneration, cell-based therapy, immunotherapy, and gut microbiota modulation are the emerging areas and need further research.
Collapse
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
| |
Collapse
|
39
|
Affiliation(s)
- Eelco F M Wijdicks
- From the Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
| |
Collapse
|
40
|
Li M, Wang Z, Wang Y, Du C, Li S, Shi Z, Lu B. Part of plasmapheresis with plasma filtration adsorption combined with continuous hemodiafiltration in the treatment of severe acute liver failure. Exp Ther Med 2016; 12:2582-2584. [PMID: 27698760 PMCID: PMC5038865 DOI: 10.3892/etm.2016.3633] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2016] [Accepted: 07/04/2016] [Indexed: 01/01/2023] Open
Abstract
The present study is a retrospective analysis of 11 cases with severe acute liver failure combined with multiple organ dysfunction syndrome (MODS) performed during the period June, 2012 to December, 2014. After part of plasmapheresis with plasma filtration adsorption combined with continuous hemodiafiltration treatment, good curative effects were obtained and the main clinical symptoms and biochemical index were significantly improved. Following treatment, 8 of the 11 patients survived at a survival rate of 72.7%, and 3 patients succumbed with a mortality of 27.3%. The results suggested that part of plasmapheresis with plasma filtration adsorption combined with continuous venovenous hemodiafiltration (CVVHDF) treatment is beneficial in the removal of metabolites and toxins. Additonally, it can effectively improve liver function and clinical symptoms, improve hepatic encephalopathy, correct the disorder of internal environment, and improve the prognosis of patients.
Collapse
Affiliation(s)
- Maoqin Li
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Zhidong Wang
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Yining Wang
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Changhong Du
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Songhai Li
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Zaixiang Shi
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| | - Bo Lu
- Department of Intensive Care Unit, Xuzhou Central Hospital, Xuzhou, Jiangsu 221009, P.R. China
| |
Collapse
|
41
|
Defterevos G, Nastos C, Papalois A, Kalimeris K, Margelos V, Fragulidis G, Pafiti A, Mikrovas A, Nomikos T, Smyrniotis V, Arkadopoulos N. Peritoneal Albumin Dialysis as a Novel Approach for Liver Support: Study in a Porcine Model of Acute Hepatic Failure. Artif Organs 2016; 40:755-64. [PMID: 27094211 DOI: 10.1111/aor.12687] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Revised: 10/23/2015] [Accepted: 11/30/2015] [Indexed: 12/12/2022]
Abstract
Artificial liver support gained considerable interest in recent years due to the development of various albumin dialysis systems, which prolong survival of some patients with acute liver failure (ALF). Τhis study aims to examine the role of peritoneal albumin dialysis in a postoperative ALF model. ALF was induced in 14 female Landrace pigs by a combination of major liver resection (70-75% of total parenchyma) and ischemic-reperfusion injury on the liver remnant. Animals were randomly divided in two groups (n = 7 each). Both were monitored for 12 h of reperfusion and received peritoneal dialysis for 6 h, beginning 6 h after reperfusion. The albumin group received an albumin-rich solution and the control group received albumin-free solution. The control group gradually developed intracranial hypertension, whereas, in the albumin group, rise in the intracranial pressure was substantially attenuated (P < 0.01, t = 12 h). Albumin-treated animals had significantly lower levels of ammonia (P < 0.01), total bile acids (P < 0.01), free fatty acids (P < 0.05), lactate (P < 0.01), and total bilirubin (P < 0.05). Liver malondialdehyde and protein carbonyl were significantly reduced (P = 0.007 and P = 0.001 at t = 12 h) after albumin dialysis. Results suggest that this method may become a useful adjunct in the management of ALF, thus, justifying further study.
Collapse
Affiliation(s)
- Georgios Defterevos
- Experimental Surgical Unit, Fourth Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon Hospital
| | - Constantinos Nastos
- Department of Pathology, Medical School, National and Kapodistrian University of Athens
| | - Apostolos Papalois
- Experimental Surgical Unit, Second Department of Surgery, Medical School, National and Kapodistrian University of Athens, Aretaieion University Hospital
| | - Konstantinos Kalimeris
- Experimental Surgical Unit, Fourth Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon Hospital
| | | | - George Fragulidis
- Department of Pathology, Medical School, National and Kapodistrian University of Athens
| | | | - Aggeliki Mikrovas
- Experimental Surgical Unit, Fourth Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon Hospital
| | - Tzortzis Nomikos
- Department of Nutrition, Harokopeion University of Athens, Athens, Greece
| | - Vassilios Smyrniotis
- Experimental Surgical Unit, Fourth Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon Hospital
| | - Nikolaos Arkadopoulos
- Experimental Surgical Unit, Fourth Department of Surgery, Medical School, National and Kapodistrian University of Athens, Attikon Hospital
| |
Collapse
|
42
|
Donnelly MC, Hayes PC, Simpson KJ. The changing face of liver transplantation for acute liver failure: Assessment of current status and implications for future practice. Liver Transpl 2016; 22:527-35. [PMID: 26823231 DOI: 10.1002/lt.24403] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 01/01/2016] [Accepted: 01/15/2016] [Indexed: 02/07/2023]
Abstract
The etiology and outcomes of acute liver failure (ALF) have changed since the definition of this disease entity in the 1970s. In particular, the role of emergency liver transplantation has evolved over time, with the development of prognostic scoring systems to facilitate listing of appropriate patients, and a better understanding of transplant benefit in patients with ALF. This review examines the changing etiology of ALF, transplant benefit, outcomes following transplantation, and future alternatives to emergency liver transplantation in this devastating condition.
Collapse
Affiliation(s)
- Mhairi C Donnelly
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Peter C Hayes
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Kenneth J Simpson
- Department of Hepatology, Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, United Kingdom.,Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| |
Collapse
|
43
|
Shen Y, Wang XL, Wang B, Shao JG, Liu YM, Qin Y, Wang LJ, Qin G. Survival Benefits With Artificial Liver Support System for Acute-on-Chronic Liver Failure: A Time Series-Based Meta-Analysis. Medicine (Baltimore) 2016; 95:e2506. [PMID: 26817889 PMCID: PMC4998263 DOI: 10.1097/md.0000000000002506] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
The artificial liver support system (ALSS) offers the potential to improve the prognosis of patients with acute-on-chronic liver failure (ACLF). However, the literature has been inconsistent on its survival benefits. We aimed to conduct a time series-based meta-analysis of randomized clinical trials (RCTs) and observational studies which examined differences in mortality in ACLF patients treated with ALSS or not.MEDLINE, EMBASE, OVID, and COCHRANE library database were systemically searched up to December 2014. Quality of included studies was evaluated using the Jadad score. The outcome measure was mortality at different follow-up endpoints. Odds ratios (ORs) and survival curve data were pooled for analysis.Ten studies, 7 RCTs, and 3 controlled cohorts were enrolled, involving a total of 1682 ACLF patients, among whom 842 were treated with ALSS. ALSS was found to reduce the risk of short-term (1-month and 3-month) mortality for patients with ACLF by nearly 30%. Randomized trials and observational studies provided good internal and external validity respectively. The combined Kaplan-Meier curves showed a consistent pattern of findings. Meta-analysis also suggested that ALSS might reduce medium-term (6-month and 1-year) mortality risk by 30% and long-term (3-year) mortality risk by 50% in ACLF patients.ALSS therapy could reduce short-term mortality in patients with ACLF. Meanwhile, its impacts on medium- and long-term survival seem to be promising but remained inconclusive. Clinical utility of this system for survival benefit may be implied.
Collapse
Affiliation(s)
- Yi Shen
- From the Department of Epidemiology and Medical Statistics (YS, X-LW, Y-ML); Center for Liver Diseases, Nantong Third People's Hospital, Nantong University, China (BW, J-GS, L-JW, GQ); and Department of Internal Medicine, Singapore General Hospital, Singapore (YQ)
| | | | | | | | | | | | | | | |
Collapse
|
44
|
Hui W, Wei L, Li Z, Guo X. Treatment of Hepatitis E. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2016; 948:211-221. [PMID: 27738987 DOI: 10.1007/978-94-024-0942-0_12] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Hepatitis E virus (HEV) infections are the most common cause of acute hepatitis, but they can also take a chronic course. There is no specific therapy for acute hepatitis, and current treatment is supportive. Choosing ribavirin as the first-line therapy for chronic HEV is advisable, especially in solid organ transplant patients. Pegylated interferon-α has been used successfully for treatment of hepatitis E but is associated with major side effects. Cholestasis is one of the most common, but devastating, manifestations in hepatitis E. Current therapy for HEV aims to treat symptoms. Therapy generally involves several measures, such as vitamins for adequate nutrition, albumin and plasma for supporting treatment, symptomatic treatment for cutaneous pruritus, and ursodeoxycholic acid and S-adenosylmethionine, and Traditional Chinese medicine for removing jaundice. Patients with underlying liver disease may develop liver failure. For these patients, supportive treatment is the foundation. Ribavirin has successfully been used to prevent liver transplantation. Prevention and treatment of complications are important for treatment of liver failure. Liver support devices are intended to support liver function until such time as native liver function recovers or until liver transplantation. Liver transplantation is widely considered as irreplaceable and definitive treatment for acute-on-chronic liver failure, particularly for patients who do not improve with supportive measures to sustain life.
Collapse
Affiliation(s)
- Wei Hui
- Department of Liver Diseases Endocrine, Youan Hospital, Capital Medical University, No. 8 XitoutiaoYouanmenWai, Fengtai District, Beijing, 100069, China.
| | - Linlin Wei
- Department of Liver Diseases Endocrine, Youan Hospital, Capital Medical University, No. 8 XitoutiaoYouanmenWai, Fengtai District, Beijing, 100069, China
| | - Zhuo Li
- Beijing Institute of Liver Disease, No.8 Xitoutiao Youanmen Wai, Fengtai District, Beijing, 100069, China
| | - Xinhui Guo
- Department of Liver Diseases Endocrine, Youan Hospital, Capital Medical University, No. 8 XitoutiaoYouanmenWai, Fengtai District, Beijing, 100069, China
| |
Collapse
|
45
|
Oberhuber R, Liu G, Heinbokel T, Tullius SG. Emerging issues in transplantation. Transpl Immunol 2015. [DOI: 10.1002/9781119072997.ch14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
46
|
Patel N, Bayliss GP. Developments in extracorporeal therapy for the poisoned patient. Adv Drug Deliv Rev 2015; 90:3-11. [PMID: 26050528 DOI: 10.1016/j.addr.2015.05.017] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2015] [Revised: 05/25/2015] [Accepted: 05/30/2015] [Indexed: 12/18/2022]
Abstract
The modern use of extracorporeal therapies to treat poisoning and drug overdoses dates back to the early 20th century and has evolved along with their use as treatment for acute kidney injury or as maintenance therapy in advanced kidney disease. As our understanding of drug pharmacokinetics and membrane materials has increased, the technologies of extracorporeal therapy and their applications have become more sophisticated. Despite that, there is little robust evidence to guide clinicians on the optimal use of extracorporeal therapy in treating poisoning beyond case reports and series. New efforts are underway to remedy that: the Extracorporeal Treatments in Poisoning Workgroup (EXTRIP) is an international effort on the part of nephrologists, pharmacists and toxicologists to review the available data and formulate evidence-based guidelines on how to use extracorporeal techniques to treat poisoning and improve patient outcomes. Meanwhile, new techniques and membranes are under development. This review will summarize those key scientific and technologic developments, the efforts to optimize their use and new directions in research.
Collapse
|
47
|
Mazza G, De Coppi P, Gissen P, Pinzani M. Hepatic regenerative medicine. J Hepatol 2015; 63:523-4. [PMID: 26070391 DOI: 10.1016/j.jhep.2015.05.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 05/02/2015] [Indexed: 12/04/2022]
Affiliation(s)
- Giuseppe Mazza
- Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Paolo De Coppi
- Institute for Child Health, University College London, London, United Kingdom
| | - Paul Gissen
- Institute for Child Health, University College London, London, United Kingdom
| | - Massimo Pinzani
- Institute for Liver and Digestive Health, University College London, London, United Kingdom
| |
Collapse
|
48
|
Liu XY, Peng F, Pan YJ, Chen J. Advanced therapeutic strategies for HBV-related acute-on-chronic liver failure. Hepatobiliary Pancreat Dis Int 2015; 14:354-60. [PMID: 26256078 DOI: 10.1016/s1499-3872(15)60338-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is increasingly recognized as a distinct clinical entity and is associated with a high short-term mortality. The most common cause of ACLF is chronic hepatitis B worldwide. Currently, there is no standardized approach for the management of ACLF and the efficacy and safety of therapeutic modalities are uncertain. DATA SOURCES PubMed and Web of Science were searched for English-language articles. The search criteria focused on clinical trials and observational studies on the treatment of patients with HBV-related ACLF. RESULTS Therapeutic approaches for ACLF in patients with chronic hepatitis B included nucleos(t)ide analogues, artificial liver support systems, immune regulatory therapy, stem cell therapy and liver transplantation. All of these therapeutic approaches have shown the potential to improve liver function and increase patients' survival rate, but most of the studies were not randomized or controlled. CONCLUSION Substantial challenges for the treatment of HBV-related ACLF remain and further basic research and randomized controlled clinical trials are needed.
Collapse
Affiliation(s)
- Xin-Yu Liu
- Liver Diseases Center, Second Xiangya Hospital, Central South University, Changsha 410011, China.
| | | | | | | |
Collapse
|
49
|
Raschzok N, Sallmon H, Pratschke J, Sauer IM. MicroRNAs in liver tissue engineering - New promises for failing organs. Adv Drug Deliv Rev 2015; 88:67-77. [PMID: 26116880 DOI: 10.1016/j.addr.2015.06.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Revised: 06/10/2015] [Accepted: 06/16/2015] [Indexed: 12/15/2022]
Abstract
miRNA-based technologies provide attractive tools for several liver tissue engineering approaches. Herein, we review the current state of miRNA applications in liver tissue engineering. Several miRNAs have been implicated in hepatic disease and proper hepatocyte function. However, the clinical translation of these findings into tissue engineering has just begun. miRNAs have been successfully used to induce proliferation of mature hepatocytes and improve the differentiation of hepatic precursor cells. Nonetheless, miRNA-based approaches beyond cell generation have not yet entered preclinical or clinical investigations. Moreover, miRNA-based concepts for the biliary tree have yet to be developed. Further research on miRNA based modifications, however, holds the promise of enabling significant improvements to liver tissue engineering approaches due to their ability to regulate and fine-tune all biological processes relevant to hepatic tissue engineering, such as proliferation, differentiation, growth, and cell function.
Collapse
Affiliation(s)
- Nathanael Raschzok
- General, Visceral, and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Hannes Sallmon
- Neonatology, Charité - Universitätsmedizin Berlin, Germany
| | - Johann Pratschke
- General, Visceral, and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Germany
| | - Igor M Sauer
- General, Visceral, and Transplantation Surgery, Charité - Universitätsmedizin Berlin, Germany.
| |
Collapse
|
50
|
Koblihová E, Lukšan O, Mrázová I, Ryska M, Červenka L. Hepatocyte transplantation attenuates the course of acute liver failure induced by thioacetamide in Lewis rats. Physiol Res 2015; 64:689-700. [PMID: 25804092 DOI: 10.33549/physiolres.932914] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Acute liver failure (ALF) is a clinical syndrome resulting from widespread damage of hepatocytes, with extremely high mortality rate. Urgent orthotopic liver transplantation was shown to be the most effective therapy for ALF but this treatment option is limited by scarcity of donor organs. Therefore, hepatocyte transplantation (Tx) has emerged as a new therapeutical measure for ALF, however, the first clinical applications proved unsatisfactory. Apparently, extensive preclinical studies are needed. Our aim was to examine if hepatocytes isolated from transgenic "firefly luciferase" Lewis rats into the recipient liver would attenuate the course of thioacetamide (TAA)-induced ALF in Lewis rats. Untreated Lewis rats after TAA administration showed a profound decrease in survival rate; no animal survived 54 h. The rats showed marked increases in plasma alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activities, in plasma level of bilirubin and ammonia (NH(3)), and in a significant decrease in plasma albumin. Hepatocyte Tx attenuated the course of TAA-induced ALF Lewis rats which was reflected by improved survival rate and reduced degree of liver injury showing as lowering of elevated plasma ALT, AST, NH(3) and bilirubin levels and increasing plasma albumin. In addition, bioluminescence imaging analyses have shown that in the TAA-damaged livers the transplanted hepatocyte were fully viable throughout the experiment. In conclusion, the results show that hepatocyte Tx into the liver can attenuate the course of TAA-induced ALF in Lewis rats. This information should be considered in attempts to develop new therapeutic approaches to the treatment of ALF.
Collapse
Affiliation(s)
- E Koblihová
- Department of Surgery, Second Faculty of Medicine, Charles University and Central Military Hospital, Prague, Czech Republic, Department of Pathophysiology, Second Faculty of Medicine, Charles University, Prague, Czech Republic.
| | | | | | | | | |
Collapse
|