1
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Lee WM, Barnard C, Rule JA, Orandi BJ, James LP, Stravitz RT, Durkalski V, Fontana RJ. Association of Acetaminophen (Paracetamol) Use With Severity and Outcomes in Patients With Viral Hepatitis-Associated Acute Liver Failure. Am J Gastroenterol 2024:00000434-990000000-01245. [PMID: 38994834 DOI: 10.14309/ajg.0000000000002941] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 06/17/2024] [Indexed: 07/13/2024]
Abstract
INTRODUCTION Acute viral hepatitis (AVH) comprises 11% of acute liver failure (ALF) in North America while acetaminophen (APAP) toxicity represents 46%. The use of APAP to treat prodromal hepatitis symptoms is common. It is unknown if concurrent APAP use impacts liver injury in AVH-induced ALF. METHODS In this prospective, multicenter cohort study, 356 patients meeting criteria for AVH including hepatitis A, B, Epstein-Barr virus, and herpes simplex virus, all leading to ALF (hepatic encephalopathy after acute illness, international normalized ratio ≥1.5), or acute liver injury (acute liver injury, international normalized ratio >2.0, no hepatic encephalopathy) were reviewed for evidence of APAP use: APAP ingestion history or measurement of serum APAP level or APAP-CYS adducts, a specific biomarker released into blood with APAP injury. Patients were grouped by APAP exposure level, from high (measurable APAP levels or toxic APAP-CYS), medium (therapeutic APAP-CYS), low (history of APAP ingestion only and/or barely detectable APAP-CYS), or no exposure recorded. RESULTS Two hundred five of 356 patients (57.5%) with AVH-ALF had evidence of APAP use: 87 out of 356 (24%) demonstrated high or medium exposures. The aminotransferase and bilirubin levels of high/medium group resembled a mixed APAP-viral injury. Mortality was the highest (51.6%, 21.4%, 28.8%, and 30.5%), and transplant-free survival was the lowest (22.6%, 44.6%, 41.5%, and 40.4%) in the high exposure group compared with medium, low, and no exposure groups. However, the specific comparisons of mortality and transplant-free survival between the high exposure and no exposure groups were not statistically different even after adjusting for baseline patient characteristics differences. DISCUSSION APAP use in AVH-ALF is common and may negatively impact outcomes compared with little or no APAP exposure. Prospective studies of the safest and effective dose of APAP to use in patients with AVH are needed.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Carson Barnard
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jody A Rule
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Babak J Orandi
- Departments of Surgery and Medicine, New York University, New York, New York, USA
| | - Laura P James
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - R Todd Stravitz
- Section of Hepatology, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Valerie Durkalski
- Department of Public Health, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, Michigan, USA
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2
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Frapard T, Amaddeo G, Decavele M, Abback PS, Gaillet A, Bouzbib C, Vanlemmens C, Younan R, Canet E, Moreau AS, Neuville M, Azoulay E, Sitbon A, Mokart D, Radenne S, Abergel A, Guichon C, Roux O, Bonadona A, Mekontso Dessap A, De Jong A, Dumortier J, de Prost N. Herpes Simplex Virus Hepatitis in Patients Requiring Intensive Care Unit Admission: A Retrospective, Multicenter, Observational Study. Open Forum Infect Dis 2023; 10:ofad484. [PMID: 37942463 PMCID: PMC10629341 DOI: 10.1093/ofid/ofad484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/27/2023] [Indexed: 11/10/2023] Open
Abstract
The clinical features and short-term prognosis of patients admitted to the intensive care unit for herpes hepatitis are lacking. Of 33 patients admitted between 2006 and 2022, 22 were immunocompromised, 4 were pregnant women, and 23 died. Sixteen patients developed a hemophagocytic syndrome. Acyclovir was initiated a median (interquartile range) of 1 (0-3) day after admission.
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Affiliation(s)
- Thomas Frapard
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU ATVB, Service de Médecine Intensive Réanimation,Créteil, France
- Université Paris Est Créteil, Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomédicale—Groupe de Recherche Clinique CARMAS,Créteil, France
| | - Giuliana Amaddeo
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, Service d’Hépatologie,Créteil, France
| | - Maxens Decavele
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique,Paris, France
- Groupe Hospitalier Universitaire APHP-Sorbonne Université, Site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S),Paris, France
| | - Paer-Selim Abback
- Département Anesthésie Réanimation, Université de Tours, CHU de Tours, Tours, France
| | - Antoine Gaillet
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU ATVB, Service de Médecine Intensive Réanimation,Créteil, France
- Université Paris Est Créteil, Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomédicale—Groupe de Recherche Clinique CARMAS,Créteil, France
| | - Charlotte Bouzbib
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Pitié Salpêtrière, Service d’Hépatologie,Paris, France
| | - Claire Vanlemmens
- Centre Hospitalier Universitaire Jean Minjoz, Service d’Hépatologie et Soins Intensifs Digestifs,Besançon, France
| | - Romy Younan
- Assistance Publique—Hôpitaux de Paris, Hôpital Universitaire Saint Louis, Service de Médecine Intensive Réanimation,Paris, France
| | - Emmanuel Canet
- Service de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Nantes, Nantes, France
- Université de Nantes, Nantes, France
| | - Anne Sophie Moreau
- Centre Hospitalier Universitaire de Lille, Service de Réanimation Médicale,Lille, France
| | | | - Elie Azoulay
- Assistance Publique—Hôpitaux de Paris, Hôpital Universitaire Saint Louis, Service de Médecine Intensive Réanimation,Paris, France
| | - Alexandre Sitbon
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Pitié Salpêtrière, Service de Réanimation Chirurgicale,Paris, France
| | - Djamel Mokart
- Institut Paoli-Calmettes, Service de Réanimation Polyvalente,Marseille, France
| | - Sylvie Radenne
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service d’Hépato-Gastroentérologie,Lyon, France
| | - Armand Abergel
- Centre Hospitalier Universitaire de Clermont-Ferrand, Service d’Hépato-Gastroentérologie,Clermont-Ferrand, France
| | - Céline Guichon
- Hospices Civils de Lyon, Hôpital de la Croix-Rousse, Service d’Anesthésie-Réanimation,Lyon, France
| | - Olivier Roux
- Assistance Publique—Hôpitaux de Paris, Hôpital Beaujon, Service d’Hépatologie,Clichy, France
| | - Agnes Bonadona
- Service d’Hépatologie et Greffe, Pôle Digidune, CHU Grenoble Alpes,La Tronche, France
| | - Armand Mekontso Dessap
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU ATVB, Service de Médecine Intensive Réanimation,Créteil, France
- Université Paris Est Créteil, Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomédicale—Groupe de Recherche Clinique CARMAS,Créteil, France
| | - Audrey De Jong
- PhyMedExp, Montpellier University, INSERM, CNRS, CHU de Montpellier, Montpellier, France
- Department of Anesthesia and Intensive Care Unit, St-Eloi Hospital, Montpellier, France
| | - Jerome Dumortier
- Hospices Civils de Lyon, Hôpital Edouard Herriot, Service d’Hépato-Gastroentérologie,Lyon, France
- Université Claude Bernard Lyon 1, Villeurbanne, France
| | - Nicolas de Prost
- Assistance Publique—Hôpitaux de Paris, Hôpitaux Universitaires Henri Mondor, DHU ATVB, Service de Médecine Intensive Réanimation,Créteil, France
- Université Paris Est Créteil, Faculté de Médecine de Créteil, Institut Mondor de Recherche Biomédicale—Groupe de Recherche Clinique CARMAS,Créteil, France
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Stravitz RT, Fontana RJ, Karvellas C, Durkalski V, McGuire B, Rule JA, Tujios S, Lee WM. Future directions in acute liver failure. Hepatology 2023; 78:1266-1289. [PMID: 37183883 PMCID: PMC10521792 DOI: 10.1097/hep.0000000000000458] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Abstract
Acute liver failure (ALF) describes a clinical syndrome of rapid hepatocyte injury leading to liver failure manifested by coagulopathy and encephalopathy in the absence of pre-existing cirrhosis. The hallmark diagnostic features are a prolonged prothrombin time (ie, an international normalized ratio of prothrombin time of ≥1.5) and any degree of mental status alteration (HE). As a rare, orphan disease, it seemed an obvious target for a multicenter network. The Acute Liver Failure Study Group (ALFSG) began in 1997 to more thoroughly study and understand the causes, natural history, and management of ALF. Over the course of 22 years, 3364 adult patients were enrolled in the study registry (2614 ALF and 857 acute liver injury-international normalized ratio 2.0 but no encephalopathy-ALI) and >150,000 biosamples collected, including serum, plasma, urine, DNA, and liver tissue. Within the Registry study sites, 4 prospective substudies were conducted and published, 2 interventional ( N -acetylcysteine and ornithine phenylacetate), 1 prognostic [ 13 C-methacetin breath test (MBT)], and 1 mechanistic (rotational thromboelastometry). To review ALFSG's accomplishments and consider next steps, a 2-day in-person conference was held at UT Southwestern Medical Center, Dallas, TX, entitled "Acute Liver Failure: Science and Practice," in May 2022. To summarize the important findings in the field, this review highlights the current state of understanding of ALF and, more importantly, asks what further studies are needed to improve our understanding of the pathogenesis, natural history, and management of this unique and dramatic condition.
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Affiliation(s)
| | | | | | - Valerie Durkalski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jody A. Rule
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Shannan Tujios
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - William M. Lee
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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4
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Wang Y, Liu Y, Song X, Feng Y, Jing C, Zhang G, Huang Y, Liu W. Dual-targetable fluorescent probe for mapping the fluctuation of peroxynitrite in drug-induced liver injury model. SPECTROCHIMICA ACTA. PART A, MOLECULAR AND BIOMOLECULAR SPECTROSCOPY 2023; 286:121892. [PMID: 36244156 DOI: 10.1016/j.saa.2022.121892] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2022] [Revised: 08/22/2022] [Accepted: 09/12/2022] [Indexed: 06/16/2023]
Abstract
Drug-induced liver injury (DILI) is one of the most common and serious adverse drug reactions which can cause acute liver failure or even death in severe cases. With the incidence rate increasing over the years, DILI has became a frequent clinical liver disease and a global public health problem. As a biomarker of DILI, the detection of peroxynitrite (ONOO-) has became a powerful tool for the early diagnosis of liver injury. Here, we synthesized five mitochondria-targetable probes, 1-5, for detecting endogenous ONOO-. Through dye-screening, probe 5 was stood out by its excellent performance. In the presence of ONOO-, the fluorescence signal of probe 5 reduced 40-fold in 19 s with a low detection limit (9.36 nM). At the same time, the transformation can be observed with the naked eye under sunlight or UV lamp without being affected by the other reactive species. Even better, with low toxicity and high biocompatibility, probe 5 could successfully detect endogenous ONOO- in the mitochondrion of cells. Finally, probe 5 could specifically target the liver, and can be employed for monitoring the therapeutic effect of hepatoprotective medicine after drug-induced hepatotoxicity in vivo. In brief, probe 5 has the practical application capability for diagnosing the severity of the liver injury and researching the therapeutic effect of antidote in complex bio-systems.
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Affiliation(s)
- Yingzhe Wang
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China; Laboratory for Nanomedical Photonics, School of Basic Medical Science, Henan University, Kaifeng 475004, PR China
| | - Yu Liu
- Laboratory for Nanomedical Photonics, School of Basic Medical Science, Henan University, Kaifeng 475004, PR China
| | - Xuerui Song
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China
| | - Yan Feng
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China
| | - Chunlin Jing
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China
| | - Guolin Zhang
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China
| | - Yongwei Huang
- Laboratory for Nanomedical Photonics, School of Basic Medical Science, Henan University, Kaifeng 475004, PR China
| | - Weisheng Liu
- Key Laboratory of Nonferrous Metal Chemistry and Resources Utilization of Gansu Province and State Key Laboratory of Applied Organic Chemistry, College of Chemistry and Chemical Engineering, Lanzhou University, Lanzhou 730000, PR China.
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5
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Matthews PC, Campbell C, Săndulescu O, Matičič M, Ruta SM, Rivero-Juárez A, van Welzen BJ, Tan BK, Garcia F, Gherlan GS, Çınar G, Hasanoğlu İ, Gmizić I, Nicolini LA, Santos L, Sargsyants N, Velikov P, Habibović S, Fourati S, Židovec-Lepej S, Herder V, Dudman S, Miron VD, Irving W, Şahin GÖ. Acute severe hepatitis outbreak in children: A perfect storm. What do we know, and what questions remain? Front Pharmacol 2022; 13:1062408. [PMID: 36506522 PMCID: PMC9732095 DOI: 10.3389/fphar.2022.1062408] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/04/2022] [Indexed: 11/27/2022] Open
Abstract
During the first half of 2022, the World Health Organization reported an outbreak of acute severe hepatitis of unknown aetiology (AS-Hep-UA) in children, following initial alerts from the United Kingdom (UK) where a cluster of cases was first observed in previously well children aged <6 years. Sporadic cases were then reported across Europe and worldwide, although in most countries incidence did not increase above the expected baseline. There were no consistent epidemiological links between cases, and microbiological investigations ruled out known infectious causes of hepatitis. In this review, we explore the evidence for the role of viral infection, superimposed on a specific host genetic background, as a trigger for liver pathology. This hypothesis is based on a high prevalence of Human Adenovirus (HAdV) 41F in affected children, together with metagenomic evidence of adeno-associated virus (Adeno-associated viruses)-2, which is a putative trigger for an immune-mediated liver injury. Roles for superantigen-mediated pathology have also been explored, with a focus on the potential contribution of SARS-CoV-2 infection. Affected children also had a high frequency of the MHC allele HLA-DRB1*04:01, supporting an immunological predisposition, and may have been vulnerable to viral coinfections due to disruption in normal patterns of exposure and immunity as a result of population lockdowns during the COVID-19 pandemic. We discuss areas of ongoing uncertainty, and highlight the need for ongoing scrutiny to inform clinical and public health interventions for this outbreak and for others that may evolve in future.
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Affiliation(s)
- Philippa C. Matthews
- The Francis Crick Institute, London, United Kingdom
- Division of Infection and Immunity, University College London, London, United Kingdom
- Department of Infection, University College London Hospitals, London, United Kingdom
| | - Cori Campbell
- Nuffield Department of Medicine, University of Oxford, Oxford, England
| | - Oana Săndulescu
- Department of Infectious Diseases, National Institute for Infectious Diseases-Prof. Dr. Matei Balş, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - Mojca Matičič
- Faculty of Medicine, Clinic for Infectious Diseases and Febrile Illnesses, University Medical Centre Ljubljana, University of Ljubljana, Ljubljana, Slovenia
| | - Simona Maria Ruta
- Virology Department, Stefan S. Nicolau Institute of Virology, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Antonio Rivero-Juárez
- Hospital Universitario Reina Sofía, Instituto Maimónides de Investigación Biomédica de Córdoba, Universidad de Córdoba, Córdoba, Spain
| | - Berend Joost van Welzen
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Boun Kim Tan
- INSERM U1052, Department of Intensive Care Unit, Hôpital Lyon Sud, Hospices Civils de Lyon, Université Claude Bernard Lyon 1, Lyon, France
| | - Federico Garcia
- Microbiology Department, Instituto de Investigacion Ibs.Granada and Ciber de Enfermedades Infecciosas (CIBERINFEC), University Hospital San Cecilio, Granada, Spain
| | - George Sebastian Gherlan
- Department of Infectious Diseases, “Dr. Victor Babes” Clinical Hospital of Infectious and Tropical Diseases, Bucharest, Romania
| | - Güle Çınar
- Department of Infectious Diseases and Clinical Microbiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - İmran Hasanoğlu
- Department of Infectious Disease and Clinical Microbiology, Ankara City Hospital, Ankara Yıldırım Beyazıt University, Ankara, Turkey
| | - Ivana Gmizić
- Clinic for Infectious and Tropical Diseases, University Clinical Center of Serbia, Belgrade, Serbia
| | - Laura Ambra Nicolini
- Division of Infectious Diseases , Ospedale Policlinico San Martino, Genova, Italy
| | - Lurdes Santos
- Nephrology and Infectious Diseases R&D, Infectious Diseases Intensive Care Unit, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário São João, I3S - Instituto de Investigação e Inovaçãoem Saúde, University of Porto, Porto, Portugal
| | - Narina Sargsyants
- Ministry of Health, National Centre for Infectious Diseases, National Institute of Health, Yerevan, Armenia
| | - Petar Velikov
- Infectious Diseases Hospital Prof. Ivan Kirov and Department of Infectious Diseases, Parasitology and Tropical Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Selma Habibović
- Department of Microbiology, Public Health Institute Novi Pazar, Novi Pazar, Serbia
| | - Slim Fourati
- Department of Virology, INSERM, Henri Mondor Hospital, Assistance Publique-Hôpitaux de Paris, Institut Mondor de Recherche Biomédicale, Université Paris-Est, Créteil, France
| | - Snježana Židovec-Lepej
- Department of Immunological and Molecular Diagnostics, University Hospital for Infectious Diseases “Dr Fran Mihaljevic”, Zagreb, Croatia
| | - Vanessa Herder
- Medical Research Council-University of Glasgow Centre for Virus Research, University of Glasgow, Glasgow, United Kingdom
| | - Susanne Dudman
- Department of Microbiology, Oslo University Hospital, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Victor Daniel Miron
- National Institute for Mother and Child Health “Alessandrescu-Rusescu”, Carol Davila University of Medicine and Pharmacy, Bucharest, Romania
| | - William Irving
- NIHR Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom
| | - Gülşen Özkaya Şahin
- Department of Laboratory Medicine, Section of Clinical Microbiology, Region Skåne, Lund, Sweden
- Department of Translational Medicine, Lund University, Malmö, Sweden
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6
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Spahn S, Riessen R, Berg CP, Malek NP, Emrich MH, Lohrengel K, Ganzenmueller T, Iftner T, Kleymann G, Hamprecht K. Comprehensive clinical and virological characterization of three cases of fulminant liver failure owing to HSV1 primary infection. Liver Int 2022; 42:1005-1011. [PMID: 35230726 DOI: 10.1111/liv.15215] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 12/23/2021] [Accepted: 01/16/2022] [Indexed: 12/13/2022]
Abstract
Herpes simplex virus 1 (HSV-1) is a frequently unrecognized, yet deadly cause of acute liver failure (ALF). We, therefore, analysed three cases of fatal HSV-1-induced ALF. All patients shared clinical (extremely elevated transaminases, LDH and AST/LDH ratio < 1) and virological characteristics (ratio of viral load in plasma versus throat swabs: 60-700-fold, lack of anti-HSV-1-IgG antibodies or low IgG-avidity during primary infection), which may help to identify patients at risk. Additionally, in vitro chemosusceptibility assays revealed high efficacy of the helicase-primase inhibitors (HPI), pritelivir and drug-candidate IM-250 compared to acyclovir (ACV) using HSV-1-isolates from two patients; hence, ACV/HPI-combinations might offer new therapeutic options for HSV-induced ALF.
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Affiliation(s)
- Stephan Spahn
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Reimer Riessen
- Department of Internal Medicine, Medical Intensive Care Unit, University Hospital of Tuebingen, Tübingen, Germany
| | - Christoph P Berg
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Nisar P Malek
- Department Internal Medicine I, University Hospital of Tuebingen, Tuebingen, Germany
| | - Marzena H Emrich
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Kristina Lohrengel
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Tina Ganzenmueller
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Thomas Iftner
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
| | - Gerald Kleymann
- University of Tübingen IFIB, Interfaculty Institute for Biochemistry, Tübingen, Germany.,Innovative Molecules GmbH, Bad-Salzuflen, Germany
| | - Klaus Hamprecht
- Institute for Medical Virology and Epidemiology of Viral Diseases, University Hospital of Tuebingen, Tübingen, Germany
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7
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Casey LC, Fontana RJ, Aday A, Nelson DB, Rule JA, Gottfried M, Tran M, Lee WM. Acute Liver Failure (ALF) in Pregnancy: How Much Is Pregnancy Related? Hepatology 2020; 72:1366-1377. [PMID: 31991493 PMCID: PMC7384942 DOI: 10.1002/hep.31144] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Acute liver failure (ALF), characterized by sudden onset of coagulopathy (international normalized ratio [INR] ≥ 1.5) and encephalopathy, may occur during pregnancy either as a pregnancy-associated etiology or an unrelated and coincidental liver injury. The U.S. Acute Liver Failure Study Group, comprised of 33 tertiary care liver centers, has enrolled consecutive patients with ALF or acute liver injury (ALI; INR ≥ 2.0 with no encephalopathy), over two decades. APPROACH AND RESULTS Etiologies, clinical features, and outcomes of 70 of 3,155 patients (2.2%) who developed ALF or ALI during pregnancy were reviewed to determine how many were pregnancy associated (pregnancy-associated liver disease; PAALD) and how many were attributed to other etiologies. Thirty-five of the 70 were considered PAALD, of whom nearly half were attributed to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and half to acute fatty liver of pregnancy (AFLP), although, in some instances, the distinction was unclear. Virtually all with PAALD had been delivered before hepatology referral, mostly by cesarean section. Acetaminophen toxicity accounted for 21 (60% of the remaining cases), with the remainder resulting from a variety of other causes, but not including viral hepatitis A through E. Although recovery with delivery or supportive measures was possible in most cases, 11 of 70 (16%) required liver transplantation and 8 (11%) died. Swansea criteria to diagnose AFLP were met by all patients with PAALD and also by virtually all women with other forms of ALF. CONCLUSIONS Only half of those with ALF during pregnancy appeared to have HELLP or AFLP. Morbidity and mortality for mother and fetus are strongly associated with etiology of liver failure.
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Affiliation(s)
- Lisa C. Casey
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Ariel Aday
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - David B. Nelson
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Jody A. Rule
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston SC
| | - Minh Tran
- Department of Medicine, University of Texas Medical Branch, Galveston TX
| | - William M. Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
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8
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Anand AC, Nandi B, Acharya SK, Arora A, Babu S, Batra Y, Chawla YK, Chowdhury A, Chaoudhuri A, Eapen EC, Devarbhavi H, Dhiman RK, Datta Gupta S, Duseja A, Jothimani D, Kapoor D, Kar P, Khuroo MS, Kumar A, Madan K, Mallick B, Maiwall R, Mohan N, Nagral A, Nath P, Panigrahi SC, Pawar A, Philips CA, Prahraj D, Puri P, Rastogi A, Saraswat VA, Saigal S, Shalimar, Shukla A, Singh SP, Verghese T, Wadhawan M. Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure. J Clin Exp Hepatol 2020; 10:477-517. [PMID: 33029057 PMCID: PMC7527855 DOI: 10.1016/j.jceh.2020.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/12/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.
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Key Words
- ACLF, Acute on Chronic liver Failure
- AKI, Acute kidney injury
- ALF, Acute Liver Failure
- ALFED score
- ALT, alanine transaminase
- AST, aspartate transaminase
- CNS, central nervous system
- CT, Computerized tomography
- HELLP, Hemolysis, elevated liver enzymes, and low platelets
- ICH, Intracrainial hypertension
- ICP, Intracrainial Pressure
- ICU, Intensive care unit
- INR, International normalised ratio
- LAD, Liver assist device
- LDLT, Living donor liver transplantation
- LT, Liver transplantation
- MAP, Mean arterial pressure
- MELD, model for end-stage liver disease
- MLD, Metabolic liver disease
- NAC, N-acetyl cysteine
- PALF, Pediatric ALF
- WD, Wilson's Disease
- acute liver failure
- artificial liver support
- liver transplantation
- plasmapheresis
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Affiliation(s)
- Anil C. Anand
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Bhaskar Nandi
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sethu Babu
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
| | - Yogesh Batra
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
| | - Ashok Chaoudhuri
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Eapen C. Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
| | | | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Mohamad S. Khuroo
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kaushal Madan
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
| | - Bipadabhanjan Mallick
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Rakhi Maiwall
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Aabha Nagral
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Preetam Nath
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Sarat C. Panigrahi
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Ankush Pawar
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
| | - Cyriac A. Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
| | - Dibyalochan Prahraj
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Pankaj Puri
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
| | - Amit Rastogi
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Sanjiv Saigal
- Department of Hepatology, Department of Liver Transplantation, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
| | - Akash Shukla
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Thomas Verghese
- Department of Gastroenterology, Government Medical College, Kozikhode, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
| | - The INASL Task-Force on Acute Liver Failure
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Hepatology, Christian Medical College, Vellore, India
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
- Gleneagles Global Hospitals, Hyderabad, Telangana, India
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
- Department of Hepatology, Department of Liver Transplantation, India
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
- Department of Gastroenterology, Government Medical College, Kozikhode, India
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
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9
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Imperatrice B, Giudici G, Marzano A. Human herpes viruses as cause of liver injury and acute liver failure. MINERVA GASTROENTERO 2020; 65:251-254. [DOI: 10.23736/s1121-421x.19.02596-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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10
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Seetharam A. Intensive Care Management of Acute Liver Failure: Considerations While Awaiting Liver Transplantation. J Clin Transl Hepatol 2019; 7:384-391. [PMID: 31915608 PMCID: PMC6943205 DOI: 10.14218/jcth.2019.00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/06/2019] [Accepted: 10/27/2019] [Indexed: 12/15/2022] Open
Abstract
Acute liver failure is a unique clinical phenomenon characterized by abrupt deterioration in liver function and altered mentation. The development of high-grade encephalopathy and multisystem organ dysfunction herald poor prognosis. Etiologic-specific treatments and supportive measures are routinely employed; however, liver transplantation remains the only chance for cure in those who do not spontaneously recover. The utility of artificial and bioartificial assist therapies as supportive care-to allow time for hepatic recovery or as a bridge to liver transplantation-has been examined but studies have been small, with mixed results. Given the severity of derangements, intensive critical care is needed to successfully bridge patients to transplant, and evaluation of candidates occurs rapidly in parallel with serial reassessments of operative fitness. Psychosocial assessment is often suboptimal and relative contraindications to transplant, such as ventilator-dependence may be overlooked. While often employed to guide evaluation, no single prognostic model discriminates those who will spontaneously recover and those who will require transplant. The purpose of this review will be to summarize approaches in critical care, prognostic modeling, and medical evaluation of the acute liver failure transplant candidate.
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Affiliation(s)
- Anil Seetharam
- Correspondence to: Anil Seetharam, Banner Transplant and Advanced Liver Disease, University of Arizona College of Medicine, 441 N. 12th Street, 2nd Floor, Phoenix, AZ 85006, USA. Tel: +1-602-521-5800; Fax: +1-602-521-5337, E-mail:
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11
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Freeman AF, Yazigi N, Shah NN, Kleiner DE, Parta M, Atkinson P, Heller T, Holland SM, Kaufman SS, Khan KM, Hickstein DD. Tandem Orthotopic Living Donor Liver Transplantation Followed by Same Donor Haploidentical Hematopoietic Stem Cell Transplantation for DOCK8 Deficiency. Transplantation 2019; 103:2144-2149. [PMID: 30720689 PMCID: PMC6667308 DOI: 10.1097/tp.0000000000002649] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND An 11-year-old girl with dedicator of cytokinesis 8 (DOCK8) deficiency was proposed for potentially curative hematopoietic stem cell transplantation (HSCT), the donor being her haploidentical mother. However, end-stage liver disease caused by chronic Cryptosporidium infection required liver transplantation before HSCT. METHODS Consequently, a staged approach of a sequential liver transplant followed by a HSCT was planned with her mother as the donor for both liver and HSCT. RESULTS The patient successfully underwent a left-lobe orthotopic liver transplant; however, she developed a biliary leak delaying the HSCT. Notably, the recipient demonstrated 3% donor lymphocyte chimerism in her peripheral blood immediately before HSCT. Haploidentical-related donor HSCT performed 2 months after liver transplantation was complicated by the development of acyclovir-resistant herpes simplex virus viremia, primary graft failure, and sinusoidal obstruction syndrome. The patient died from sinusoidal obstruction syndrome-associated multiorgan failure with Candida sepsis on day +40 following HSCT. CONCLUSIONS We discuss the many considerations inherent to planning for HSCT preceded by liver transplant in patients with primary immunodeficiencies, including the role of prolonged immunosuppression and the risk of infection before immune reconstitution. We also discuss the implications of potential recipient sensitization against donor stem cells precipitated by exposure of the recipient to the donor lymphocytes from the transplanted organ.
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Affiliation(s)
- Alexandra F. Freeman
- Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases, National Institutes of
Health, Bethesda, MD
| | - Nada Yazigi
- Pediatric Liver Transplantation, Department of Pediatrics,
MedStar Georgetown University Hospital, Washington DC
| | - Nirali N. Shah
- Pediatric Oncology Branch, National Cancer Institute,
National Institutes of Health, Bethesda, MD
| | - David E. Kleiner
- Laboratory of Pathology, National Cancer Institute,
National Institutes of Health, Bethesda, MD
| | - Mark Parta
- Clinical Monitoring Research Program Directorate, Frederick
National Laboratory for Cancer Research sponsored by the National Cancer
Institute
| | - Prescott Atkinson
- Division of Pediatric Allergy, Asthma and Immunology,
University of Alabama at Birmingham, Birmingham, AL
| | - Theo Heller
- Liver Diseases Branch, National Institute of Digestive,
Diabetes, and Kidney Disease Institute, National Institutes of Health, Bethesda,
MD
| | - Steven M. Holland
- Laboratory of Clinical Immunology and Microbiology,
National Institute of Allergy and Infectious Diseases, National Institutes of
Health, Bethesda, MD
| | - Stuart S. Kaufman
- Pediatric Liver Transplantation, Department of Pediatrics,
MedStar Georgetown University Hospital, Washington DC
| | - Khalid M. Khan
- Pediatric Liver Transplantation, Department of Pediatrics,
MedStar Georgetown University Hospital, Washington DC
| | - Dennis D. Hickstein
- Experimental Transplantation and Immunology Branch,
National Cancer Institute, National Institutes of Health, Bethesda, MD
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12
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Abstract
Acute liver failure is a rare and severe consequence of abrupt hepatocyte injury, and can evolve over days or weeks to a lethal outcome. A variety of insults to liver cells result in a consistent pattern of rapid-onset elevation of aminotransferases, altered mentation, and disturbed coagulation. The absence of existing liver disease distinguishes acute liver failure from decompensated cirrhosis or acute-on-chronic liver failure. Causes of acute liver failure include paracetamol toxicity, hepatic ischaemia, viral and autoimmune hepatitis, and drug-induced liver injury from prescription drugs, and herbal and dietary supplements. Diagnosis requires careful review of medications taken, and serological testing for possible viral exposure. Because of its rarity, acute liver failure has not been studied in large, randomised trials, and most treatment recommendations represent expert opinion. Improvements in management have resulted in lower mortality, although liver transplantation, used in nearly 30% of patients with acute liver failure, still provides a life-saving alternative to medical management.
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Affiliation(s)
- R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Digestive and Liver Diseases Division, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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