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Kanda T, Li TC, Takahashi M, Nagashima S, Primadharsini PP, Kunita S, Sasaki-Tanaka R, Inoue J, Tsuchiya A, Nakamoto S, Abe R, Fujiwara K, Yokosuka O, Suzuki R, Ishii K, Yotsuyanagi H, Okamoto H. Recent advances in hepatitis E virus research and the Japanese clinical practice guidelines for hepatitis E virus infection. Hepatol Res 2024; 54:1-30. [PMID: 38874115 DOI: 10.1111/hepr.14062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/22/2024] [Accepted: 05/09/2024] [Indexed: 06/15/2024]
Abstract
Acute hepatitis E was considered rare until reports emerged affirming the existence of hepatitis E virus (HEV) genotypes 3 and 4 infections in Japan in the early 2000s. Extensive studies by Japanese researchers have highlighted the pivotal role of pigs and wild animals, such as wild boars and deer, as reservoirs for HEV, linking them to zoonotic infections in Japan. Currently, when hepatitis occurs subsequent to the consumption of undercooked or grilled pork, wild boar meat, or offal (including pig liver and intestines), HEV infection should be considered. Following the approval of anti-HEV immunoglobulin A antibody as a diagnostic tool for hepatitis E by Japan's Health Insurance System in 2011, the annual number of diagnosed cases of HEV infection has surged. Notably, the occurrence of post-transfusion hepatitis E promoted nationwide screening of blood products for HEV using nucleic acid amplification tests since 2020. Furthermore, chronic hepatitis E has been observed in immunosuppressed individuals. Considering the significance of hepatitis E, heightened preventive measures are essential. The Japan Agency for Medical Research and Development Hepatitis A and E viruses (HAV and HEV) Study Group, which includes special virologists and hepatologists, held a virtual meeting on February 17, 2024. Discussions encompassed pathogenesis, transmission routes, diagnosis, complications, severity factors, and ongoing and prospective vaccination or treatments for hepatitis E. Rigorous assessment of referenced studies culminated in the formulation of recommendations, which are detailed within this review. This comprehensive review presents recent advancements in HEV research and Japanese clinical practice guidelines for HEV infection.
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Affiliation(s)
- Tatsuo Kanda
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minamiuonuma, Japan
- Division of Gastroenterology and Hepatology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Tian-Cheng Li
- Department of Virology II, National Institute of Infectious Diseases, Tokyo, Japan
| | - Masaharu Takahashi
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Shigeo Nagashima
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Putu Prathiwi Primadharsini
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Satoshi Kunita
- Center for Experimental Medicine, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
| | - Reina Sasaki-Tanaka
- Division of Gastroenterology and Hepatology, Department of Medicine, Nihon University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Jun Inoue
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Atsunori Tsuchiya
- Division of Gastroenterology and Hepatology, Graduate School of Medicine and Dental Sciences, Niigata University, Niigata, Japan
| | - Shingo Nakamoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Ryuzo Abe
- Department of Emergency Medicine, Oita University, Oita, Japan
| | - Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chuo-ku, Chiba, Japan
| | - Ryosuke Suzuki
- Department of Virology II, National Institute of Infectious Diseases, Tokyo, Japan
| | - Koji Ishii
- Department of Quality Assurance and Radiological Protection, National Institute of Infectious Diseases, Tokyo, Japan
| | - Hiroshi Yotsuyanagi
- Division of Infectious Diseases, Advanced Clinical Research Center, Institute of Medical Science, University of Tokyo, Tokyo, Japan
- Department of Infectious Diseases and Applied Immunology, Hospital of the Institute of Medical Science, University of Tokyo, Tokyo, Japan
| | - Hiroaki Okamoto
- Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Shimotsuke, Tochigi, Japan
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Sharma B, Bhateja A, Sharma R, Chauhan A, Bodh V. Acute kidney injury in acute liver failure: A narrative review. Indian J Gastroenterol 2024; 43:377-386. [PMID: 38578564 DOI: 10.1007/s12664-024-01559-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024]
Abstract
Acute kidney injury (AKI) is a frequent complication of acute liver failure (ALF) and it worsens the already worse prognoses of ALF. ALF is an uncommon disease, with varying etiologies and varying definitions in different parts of the world. There is limited literature on the impact of AKI on the outcome of ALF with or without transplantation. The multifaceted etiology of AKI in ALF encompasses factors such as hemodynamic instability, systemic inflammation, sepsis and direct nephrotoxicity. Indications of renal replacement therapy (RRT) for AKI in ALF patients extend beyond the conventional criteria for dialysis and continuous renal replacement therapy (CRRT) may have a role in transplant-free survival or bridge to liver transplantation (LT). LT is a life-saving option for ALF, so despite somewhat lower survival rates of LT in ALF patients with AKI, LT is not usually deferred. In this review, we will discuss the guidelines' recommended definition and classification of AKI in ALF, the impact of AKI in ALF, the pathophysiology of AKI and the role of CRRT and LT in ALF patients with AKI.
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Affiliation(s)
- Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Anshul Bhateja
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Rajesh Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Ashish Chauhan
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India.
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Acharya SK. Overview of acute liver failure in India. Indian J Gastroenterol 2024; 43:296-311. [PMID: 38722512 DOI: 10.1007/s12664-024-01589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/08/2024] [Indexed: 05/28/2024]
Abstract
Acute liver failure (ALF) is an infrequent, but serious complication subsequent to severe acute liver injury (sALI) due to various hepatotoxic agents such as hepatotropic virus(es) and drugs such as anti-tubercular medications, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anti-cancer and anti-epileptic therapy and due to metabolic and autoimmune disease flares. ALF after sALI presents with encephalopathy associated with prolonged international normalized ratio (INR). Mortality in ALF is high and ranges between 50% and 80%. Due to severe liver damage, multiple sequels consequent to hepatic dysfunction result in complications such as hyperammonemia that culminates in encephalopathy associated with cerebral edema; innate immune paralysis resulting in increased frequency of infections and endotoxemia causing decrease in systemic vascular resistance (SVR) and tissue hypoperfusion and damage-associated molecular patterns (DAMPs) released from damaged hepatic parenchyma inducing pro-inflammatory cytokine storm, which may cause other organ dysfunctions. Certain etiologies such as hepatitis E virus and hepatitis A virus-related ALF or paracetamol-ALF (hyper-acute presentation) have better survival than remaining causes. In addition, if etiology-specific treatment (antivirals for ALF related to hepatitis B virus (HBV) or Herpes simplex virus (HSV) or N-acetylcysteine for paracetamol) is available, then the outcome with treatment is better. About half of the patients can be salvaged with medical therapy. All patients need intensive care and organ support to provide time for the liver to regenerate. Various prognostic models to predict high probability of mortality have been described, which should be used to select patient early during the disease for liver transplantation, which is associated with high long-term survival in these sick patients. The Indian National Association for Study of the Liver (INASL) recommends the ALF-Early Dynamic (ALFED) model as a preferred prognostic model in the Indian scenario, where hepatitis viruses are a dominant etiology of ALF and occur on a naïve liver with good regenerative capacity.
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Affiliation(s)
- Subrat Kumar Acharya
- Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751 024, India.
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India.
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Devarbhavi H, Asrani SK, Arab JP, Nartey YA, Pose E, Kamath PS. Global burden of Liver Disease: 2023 Update. J Hepatol 2023:S0168-8278(23)00194-0. [PMID: 36990226 DOI: 10.1016/j.jhep.2023.03.017] [Citation(s) in RCA: 244] [Impact Index Per Article: 244.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 03/06/2023] [Accepted: 03/09/2023] [Indexed: 03/31/2023]
Abstract
Liver disease accounts for 2 million deaths and is responsible for 4% of all deaths (1 out of every 25 deaths worldwide); approximately 2/3 of all liver related deaths occur in men. Deaths are largely attributable to complications of cirrhosis and hepatocellular carcinoma, with acute hepatitis accounting for a smaller proportion of deaths. The most common causes of cirrhosis worldwide are related to viral hepatitis, alcohol, and nonalcoholic fatty liver disease (NAFLD). Hepatotropic viruses are the etiological factor in most cases of acute hepatitis, but drug-induced liver injury increasingly accounts for a significant proportion of cases. This iteration of the global burden of liver disease is an update of the 2019 version and focuses mainly on areas where significant new information is available like alcohol-associated liver disease, NAFLD, viral hepatitis, and HCC. We also devote a separate section to the burden of liver disease in Africa, an area of the world typically neglected in such documents.
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Affiliation(s)
- Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, TX, United States.
| | - Juan Pablo Arab
- Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Yvonne Ayerki Nartey
- Department of Internal Medicine, School of Medical Sciences, University of Cape Coast, Cape Coast, Ghana
| | - Elisa Pose
- Liver Unit, Hospital Clinic of Barcelona. Institut D'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS)
| | - Patrick S Kamath
- Mayo Clinic College of Medicine and Science, Rochester, MN, United States
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Sharieff S, Idrees A, Rafai W, Bukhari SUS. Use of Oral N-Acetylcysteine (NAC) in Non-Acetaminophen-Induced Acute Hepatic Failure. Cureus 2023; 15:e35852. [PMID: 37033589 PMCID: PMC10077496 DOI: 10.7759/cureus.35852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2023] [Indexed: 03/09/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a syndrome rather than a specific disease with several possible causes, and viral hepatitis is a major cause. The objective of the study was to assess the benefit of N-acetylcysteine (NAC) in non-acetaminophen-induced acute liver failure (NAI-ALF). METHODS A total of six patients with a diagnosis of acute liver failure (ALF) were included in the study. All six patients received oral NAC for 72 hrs. The parameters evaluated were demographic, clinical, biochemical, outcome, and length of ICU and hospital stay. The primary outcome was a reduction in mortality with the use of NAC in NAI-ALF. The secondary outcomes were to evaluate the safety of NAC and assess factors predicting mortality. RESULTS All patients improved and returned to normal or near-normal liver function with the use of NAC. No side effects were noted, and the use of NAC was associated with a shorter hospital stay. CONCLUSION In patients with non-acetaminophen-related acute liver failure, N-acetyl-L-cysteine (NAC) significantly improves overall survival and also decreases the length of hospital stay.
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Rao A, Rule JA, Cerro-Chiang G, Stravitz RT, McGuire BM, Lee G, Fontana RJ, Lee WM. Role of Hepatitis C Infection in Acute Liver Injury/Acute Liver Failure in North America. Dig Dis Sci 2023; 68:304-311. [PMID: 35546205 PMCID: PMC9094131 DOI: 10.1007/s10620-022-07524-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND While hepatitis A and B are well-known causes of acute liver failure (ALF), few well-documented cases of hepatitis C virus (HCV) infection (absent preexisting liver disease or other liver insults) have been described that result in ALF. We reviewed the Acute Liver Failure Study Group registry for evidence of HCV as a primary or contributing cause to ALF. METHODS From January 1998 to January 2017, 2,332 patients with ALF (INR ≥ 1.5, any degree of hepatic encephalopathy) and 667 with acute liver injury (ALI; INR ≥ 2.0, no hepatic encephalopathy) were enrolled. Anti-HCV testing was done routinely, with confirmatory RT-PCR testing for HCV RNA where necessary. RESULTS A total of 136 patients were anti-HCV-antibody positive, as follows: 56 HCV RNA negative, 65 HCV RNA positive, and 8 with no result nor sera available for testing. Only three subjects with ALI/ALF were determined to represent acute HCV infection. Case 1: 47-year-old female with morbid obesity (BMI 52.4) developed ALF and recovered, experiencing anti-HCV seroconversion. Case 2: 37-year-old female using cocaine presented with ALI and fully recovered. Case 3: 54-year-old female developed ALF requiring transplantation and was anti-HCV negative but viremic prior to transplant experiencing anti-HCV seroconversion thereafter. Among 1636 APAP overdose patients, the 52 with concomitant chronic HCV had higher 3-week mortality than the 1584 without HCV (31% vs 17%, p = 0.01). CONCLUSIONS ALI/ALF solely related to acute hepatitis C infection is very rare. Chronic HCV infection, found in at least 65 (2.2%) of ALI/ALF patients studied, contributed to more severe outcomes in APAP ALI/ALF; ClinicalTrials.gov number, NCT000518440. Trial Registration ClinicalTrials.gov number NCT000518440.
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Affiliation(s)
- Ashwin Rao
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA
| | - Jody A Rule
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA
| | - Giuliana Cerro-Chiang
- Division of Pulmonary Critical Care, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Richard T Stravitz
- Lee-Hume Transplant Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Brendan M McGuire
- Division of Gastroenterology, University of Alabama, Birmingham, AL, USA
| | - Goo Lee
- Division of Anatomic Pathology, University of Alabama, Birmingham, AL, USA
| | - Robert J Fontana
- Division of Gastroenterology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center at Dallas, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, 75390-8887, USA.
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Ye C, Li W, Li L, Zhang K. Glucocorticoid Treatment Strategies in Liver Failure. Front Immunol 2022; 13:846091. [PMID: 35371046 PMCID: PMC8965693 DOI: 10.3389/fimmu.2022.846091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
Abstract
Liver failure is characterized by serious liver decompensation and high mortality. The activation of systemic immune responses and systemic inflammation are widely accepted as the core pathogenesis of liver failure. Glucocorticoids (GCs) are most regularly utilized to suppress excessive inflammatory reactions and immunological responses. GCs have been used in the clinical treatment of liver failure for nearly 60 years. While there has been no unanimity on the feasibility and application of GC treatment in liver failure until recently. The most recent trials have produced conflicting results when it comes to the dose and time for GC therapy of different etiology of liver failure. Our review outlines the issues and options in managing GC treatment in liver failure based on an investigation of the molecular mechanism that GC may give in the treatment.
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Affiliation(s)
- Chao Ye
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Wenyuan Li
- Department of Infectious Diseases, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Lei Li
- Department of Infectious Diseases, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Kaiguang Zhang
- Department of Gastroenterology, The First Affiliated Hospital of University of Science and Technology of China (USTC), Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
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Shrestha DB, Budhathoki P, Sedhai YR, Adhikari A, Poudel A, Aryal B, Baniya R. N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis. Ann Hepatol 2022; 24:100340. [PMID: 33722689 DOI: 10.1016/j.aohep.2021.100340] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 02/04/2023]
Abstract
The role of N-acetylcysteine (NAC) in the treatment of acetaminophen induced acute liver injury (ALI) is well established but its role in non-acetaminophen induced ALI is still elusive. We conducted this meta-analysis to evaluate the role of NAC in non-acetaminophen induced ALI. We searched electronic databases for studies published till Oct 25, 2020. We used RevMan v5.4 software to analyze the data extracted from selected studies by using Covidence systematic review software. Outcome estimation was done using Odds Ratio (OR) with 95% confidence interval (CI). The heterogeneity in various studies was determined using the I2 test. A total of 11 studies were included in quantitative analysis. Use of NAC in non-acetaminophen induced ALI showed 53% reduction in mortality compared to standard of care (OR, 0.47; CI, 0.29-0.75) and reduced mean duration of hospital stay by 6.52 days (95% CI, -12.91 to -0.13). Similarly, the rate of encephalopathy was 59% lower in the treatment group (OR, 0.41; CI, 0.20-0.83). However, the risk of developing nausea and vomiting (OR, 3.99; CI, 1.42-11.19), and the need for mechanical ventilation (OR 3.88; CI, 1.14-13.29) were significantly higher in the treatment group. These findings conclude use of NAC decreases mortality and hepatic encephalopathy compared to standard of care in patients with non-acetaminophen induced ALI. Although there is an increased risk of nausea and vomiting with the use of NAC, the majority of adverse events are transient and minor.
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Affiliation(s)
| | - Pravash Budhathoki
- Department of Emergency Medicine, Dr. Iwamura Memorial Hospital, Bhaktapur 44800, Nepal
| | - Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
| | - Anurag Adhikari
- Department of Emergency Medicine, Nepal National Hospital, Kathmandu, Nepal
| | - Ayusha Poudel
- Department of Emergency Medicine, Alka Hospital, Kathmandu, Nepal
| | - Barun Aryal
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Ramkaji Baniya
- Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
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Kar P, Sengupta A. Hepatitis E virus infection during pregnancy in South Asian countries: why is mortality so high? Future Virol 2022. [DOI: 10.2217/fvl-2021-0261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Affiliation(s)
- Premashis Kar
- Department of Gastroenterology & Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, UP, India
| | - Anando Sengupta
- Department of Gastroenterology & Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, UP, India
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Amatya P, Kapalavai SK, Deep A, Sankaranarayanan S, Krupanandan R, Sadasivam K, Ramachandran B. Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings. Front Pediatr 2022; 10:956699. [PMID: 36120651 PMCID: PMC9478462 DOI: 10.3389/fped.2022.956699] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure. MATERIALS AND METHODS This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled. RESULTS Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation. CONCLUSION Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.
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Affiliation(s)
- Puja Amatya
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Sudeep Kumar Kapalavai
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Akash Deep
- Department of Pediatric Critical Care, King's College Hospital, London, United Kingdom
| | | | - Ravikumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Kalaimaran Sadasivam
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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Khuroo MS. Hepatitis E and Pregnancy: An Unholy Alliance Unmasked from Kashmir, India. Viruses 2021; 13:1329. [PMID: 34372535 PMCID: PMC8310059 DOI: 10.3390/v13071329] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 06/22/2021] [Accepted: 07/05/2021] [Indexed: 12/23/2022] Open
Abstract
The adverse relationship between viral hepatitis and pregnancy in developing countries had been interpreted as a reflection of retrospectively biased hospital-based data collection by the West. However, the discovery of hepatitis E virus (HEV) as the etiological agent of an epidemic of non-A, non-B hepatitis in Kashmir, and the documenting of the increased incidence and severity of hepatitis E in pregnancy via a house-to-house survey, unmasked this unholy alliance. In the Hepeviridae family, HEV-genotype (gt)1 from genus Orthohepevirus A has a unique open reading frame (ORF)4-encoded protein which enhances viral polymerase activity and viral replication. The epidemics caused by HEV-gt1, but not any other Orthohepevirus A genotype, show an adverse relationship with pregnancy in humans. The pathogenesis of the association is complex and at present not well understood. Possibly multiple factors play a role in causing severe liver disease in the pregnant women including infection and damage to the maternal-fetal interface by HEV-gt1; vertical transmission of HEV to fetus causing severe fetal/neonatal hepatitis; and combined viral and hormone related immune dysfunction of diverse nature in the pregnant women, promoting viral replication. Management is multidisciplinary and needs a close watch for the development and management of acute liver failure. (ALF). Preliminary data suggest beneficial maternal outcomes by early termination of pregnancy in patients with lower grades of encephalopathy.
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Affiliation(s)
- Mohammad Sultan Khuroo
- Digestive Diseases Centre, Dr. Khuroo's Medical Clinic, Srinagar, Jammu and Kashmir 190010, India
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Chowdhury D, Mahmood F, Edwards C, Taylor-Robinson SD. Five-day outcome of hepatitis E-induced acute liver failure in the ICU. EGYPTIAN LIVER JOURNAL 2021; 11:39. [PMID: 34804613 PMCID: PMC8591700 DOI: 10.1186/s43066-021-00098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatitis E virus (HEV) is an important cause of acute liver failure (ALF) in Bangladesh with pregnant mothers being more vulnerable. As HEV occurs in epidemics, it limits medical capabilities in this resource-poor country. Cerebral oedema, resulting in raised intracranial pressure (ICP), is an important cause of morbidity and mortality. Practical treatments are currently few. To study the baseline characteristics and clinical outcome of HEV-induced ALF in a recent HEV epidemicTo detect raised ICP clinically and observe response to mannitol infusion.This was a prospective cohort study from June until August 2018 of 20 patients admitted to the intensive care unit (ICU) of a major Bangladeshi Referral Hospital with HEV-induced ALF. We diagnosed HEV infection by detecting serum anti-HEV IgM antibody. All were negative for hepatitis B surface antigen and hepatitis A IgM antibody. Data were collected on 5-day outcome after admission to ICU, monitoring all patients for signs of raised ICP. An intravenous bolus of 20% mannitol was administered at a single time point to patients with raised ICP. RESULTS Twenty patients were included in the study. Ten (50%) patients, seven (70%) females, received mannitol infusion. HE worsened in eight (40%): seven female and three pregnant. Glasgow Coma scores deteriorated in six (30%): all (100%) females and three pregnant. Consciousness status was not significantly different between pregnant and non-pregnant subjects, nor between those who received mannitol and those who did not. Six patients met King's College Criteria for liver transplantation. CONCLUSIONS Female patients had a worse outcome, but pregnancy status was not an additional risk factor in our cohort. Mannitol infusion was also not associated with a significant difference in outcome.
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Affiliation(s)
- Debashis Chowdhury
- Department of Gastroenterology and Hepatology, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Farhana Mahmood
- Department of Medicine, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Cathryn Edwards
- Office of the President, British Society of Gastroenterology, St Andrew’s Place, London, UK
| | - Simon D. Taylor-Robinson
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, UK
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Wang B, Yang R, Zhao W. Construction of a mitochondria-targeted ratiometric fluorescent probe for monitoring hydrazine in soil samples and culture cells. JOURNAL OF HAZARDOUS MATERIALS 2021; 406:124589. [PMID: 33316670 DOI: 10.1016/j.jhazmat.2020.124589] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/30/2020] [Accepted: 11/12/2020] [Indexed: 06/12/2023]
Abstract
Isoniazid and its major metabolite, hydrazine (N2H4), may interfere with mitochondrial function and have negative effects on cells. Consequently, an understanding of the role of N2H4 in mitochondria is highly desirable for protecting human health. Herein, we report a novel mitochondria-targeted ratiometric fluorescent probe (Mitro-N2H4) for N2H4 detection. Mitro-N2H4 exhibited an attenuation of green emission at 521 nm and an enhancement of yellow emission at 590 nm in the presence of N2H4 because of hydrazinolysis, indicating that it can be used as a ratiometric chemosensor for N2H4 with high selectivity and sensitivity. Such on-site monitoring of N2H4 vapour using test strips and N2H4-moistened soil analysis demonstrated its advantages in potential application for the convenient sensing of N2H4. Moreover, the rationally designed probe has many potential applications for imaging N2H4 produced in situ during the metabolism of isoniazid in living cells based on the ratio of the fluorescent signal.
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Affiliation(s)
- Beibei Wang
- State Key Laboratory of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi 214122, China; Jiangsu Key Laboratory of Advanced Food Manufacturing Equipment & Technology, Jiangnan University, Wuxi, Jiangsu, China
| | - Ruijin Yang
- State Key Laboratory of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi 214122, China
| | - Wei Zhao
- State Key Laboratory of Food Science and Technology, School of Food Science and Technology, Jiangnan University, Wuxi 214122, China; Jiangsu Key Laboratory of Advanced Food Manufacturing Equipment & Technology, Jiangnan University, Wuxi, Jiangsu, China.
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14
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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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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.
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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
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16
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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.
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Shalimar, Acharya SK, Kumar R, Bharath G, Rout G, Gunjan D, Nayak B. Acute Liver Failure of Non-A-E Viral Hepatitis Etiology-Profile, Prognosis, and Predictors of Outcome. J Clin Exp Hepatol 2020; 10:453-461. [PMID: 33029054 PMCID: PMC7527854 DOI: 10.1016/j.jceh.2019.12.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 12/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/OBJECTIVES Acute liver failure (ALF) is rare and associated with poor outcomes. The outcomes of ALF and predictors of outcome may vary as per the etiology. There are limited data on the predictors of spontaneous survival among patients with ALF of non-A-E hepatitis or cryptogenic etiology. We aimed to assess clinical course, complications, and outcome of non-A-E etiology ALF. METHODS In this prospective analysis, all consecutive ALF patients (n = 1555; January 1986-June 2018) were analyzed. Non-A-E-ALF was defined as ALF that could not be attributed to known etiologies such as drugs, viral hepatitis, autoimmune hepatitis, and Wilson's disease. Clinical course, complications, and outcomes of non-A-E-ALF patients who did not undergo liver transplantation were analyzed. Unadjusted and adjusted odds ratios (ORs) were calculated. RESULTS Non-A-E-ALF constituted 34.6% (n = 538) of all ALF patients, whereas hepatitis E virus (HEV), hepatitis B virus (HBV), and anti-tuberculosis therapy (ATT) accounted for 29.5% (n = 459), 8.6% (n = 134), and 7.4% (n = 115), respectively. Among non-A-E-ALF patients, mean age was 28.8 ± 12.0 years, 50.9% females, majority (63.1%) had hyperacute presentation, and 79.2% had advanced encephalopathy at presentation. The frequency of cerebral edema in non-A-E-ALF (53.3%) was higher than that in HEV-ALF (41.2%) and ATT-ALF (44.2%), P < 0.001. The survival rate in non-A-E-ALF (37.5%) was poorer than HEV-ALF (54.9%) and was comparable to that in HBV (35.8%) and ATT (29.6%) induced ALF. The baseline prothrombin time prolongation (odds ratio [OR] 1.041; 95% confidence intervals [CI], 1.017-1.065) and infection (OR 2.366; 95%CI, 1.107-5.055) were independent predictors of outcome in non-A-E-ALF. The 3-days acute liver failure early dynamic model had the best value in predicting the outcome. CONCLUSIONS Non-A-E-ALF accounts for one-third of all cases of ALF and is associated with poor spontaneous survival.
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Key Words
- ALF, acute liver failure
- ALFED, acute liver failure early dynamic
- ATT, anti-tuberculosis therapy
- HAV, hepatitis A virus
- HBV, hepatitis B virus
- HEV, hepatitis E virus
- INR, international normalized ratio
- KCH, King’s College Hospital criteria
- LT, liver transplant
- MELD, model for end-stage liver disease
- cerebral edema
- cryptogenic
- liver transplant
- prognosis
- viral hepatitis
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Affiliation(s)
- Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India,Address for correspondence: Shalimar, DM, Room No 127, 1st Floor, Human Nutrition Unit, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, 110029, India. Tel.: +91-11-26546643. Subrat Kumar Acharya, DM, Department of Gastroenterology, Fortis Hospital, Vasant Kunj, New Delhi, India.
| | - Subrat K. Acharya
- Department of Gastroenterology, Fortis Hospital, Vasant Kunj, New Delhi, India,Address for correspondence: Subrat Kumar Acharya, DM, Department of Gastroenterology, Fortis Hospital, Vasant Kunj, New Delhi, India.
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Gangadhar Bharath
- Department of Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Gyanranjan Rout
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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18
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Warrillow S, Bailey M, Pilcher D, Kazemi A, McArthur C, Young P, Bellomo R. Characteristics and outcomes of patients with acute liver failure admitted to Australian and New Zealand intensive care units. Intern Med J 2019; 49:874-885. [DOI: 10.1111/imj.14167] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 11/20/2018] [Accepted: 11/20/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health Melbourne Australia
- School of MedicineUniversity of Melbourne Melbourne Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research CentreMonash University School of Public Health and Preventive Medicine Melbourne Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research CentreMonash University School of Public Health and Preventive Medicine Melbourne Australia
- Department of Intensive Care, Alfred Health Melbourne Australia
| | - Alex Kazemi
- Intensive Care Unit, Middlemore Hospital Auckland New Zealand
| | - Colin McArthur
- Department of Critical Care MedicineAuckland City Hospital Auckland New Zealand
- Medical Research Institute of New Zealand Auckland New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand Auckland New Zealand
- Intensive Care Unit, Wellington Hospital Wellington New Zealand
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health Melbourne Australia
- School of MedicineUniversity of Melbourne Melbourne Australia
- Department of Intensive Care, Alfred Health Melbourne Australia
- Department of Intensive Care Royal Melbourne Hospital Melbourne Australia
- Data Analytics Research and Evaluation (DARE) CentreAustin Hospital and University of Melbourne Melbourne Australia
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19
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Kamar N, Pischke S. Acute and Persistent Hepatitis E Virus Genotype 3 and 4 Infection: Clinical Features, Pathogenesis, and Treatment. Cold Spring Harb Perspect Med 2019; 9:cshperspect.a031872. [PMID: 29735575 DOI: 10.1101/cshperspect.a031872] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Hepatitis E virus (HEV) genotype (gt)3 and 4 infections are prevalent in industrialized and high-income countries. Although most HEV gt3 and gt4 infections are clinically silent, acute infection may be symptomatic in some patients. In persons with underlying liver disease and in elderly men, HEV infections may present as acute or acute-on-chronic liver failure. Chronic hepatitis may develop in immunosuppressed individuals, including transplant recipients, human immunodeficiency virus (HIV)-infected patients, and persons with hematologic malignancy undergoing chemotherapy, and may progress to life-threatening liver cirrhosis. Extrahepatic manifestations of infection may include neurological and renal disease. Although there is no approved specific therapy for the treatment of acute or chronic HEV gt3 or gt4 infection, off-label use of ribavirin appears to be capable of eliminating chronic HEV infection, and may reduce disease severity in patients suffering from acute liver failure.
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Affiliation(s)
- Nassim Kamar
- Department of Nephrology and Organ Transplantation, Université Paul Sabatier, Toulouse 31059, France
| | - Sven Pischke
- Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg 20251, Germany
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20
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Shalimar, Sonika U, Kedia S, Mahapatra SJ, Nayak B, Yadav DP, Gunjan D, Thakur B, Kaur H, Acharya SK. Comparison of Dynamic Changes Among Various Prognostic Scores in Viral Hepatitis-Related Acute Liver Failure. Ann Hepatol 2019; 17:403-412. [PMID: 29735790 DOI: 10.5604/01.3001.0011.7384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Multiple prognostic scores are available for acute liver failure (ALF). Our objective was to compare the dynamicity of model for end stage liver disease (MELD), MELD-sodium, acute liver failure early dynamic model (ALFED), chronic liver failure (CLIF)-consortium ACLF score and King's College Hospital Criteria (KCH) for predicting outcome in ALF. MATERIALS AND METHODS All consecutive patients with ALF at a tertiary care centre in India were included. MELD, MELD-Na, ALFED, CLIF-C ACLF scores and KCH criteria were calculated at admission and day 3 of admission. Area under receiver operator characteristic curves (AUROC) were compared with DeLong method. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and diagnostic accuracy (DA) were reported. RESULTS Of the 115 patients included in the study, 73 (63.5%) died. The discrimination of mortality with baseline values of prognostic scores (MELD, MELD-Na, ALFED, CLIF-C ACLF and KCH) was modest (AUROC: 0.65-0.77). The AUROC increased on day 3 for all scores, except KCH criteria. On day 3 of admission, ALFED score had the highest AUROC 0.95, followed by CLIF-C ACLF 0.88, MELD 0.81, MELD-Na 0.77 and KCH 0.52. The AUROC for ALFED was significantly higher than MELD, MELD-Na and KCH (P < 0.001 for all) and CLIF-C ACLF (P = 0.05). ALFED score ≥ 4 on day 3 had the best sensitivity (87.1%), specificity (89.5%), PPV (93.8%), NPV (79.1%), LR positive (8.3) and DA (87.9%) for predicting mortality. CONCLUSIONS Dynamic assessment of prognostic scores better predicts outcome. ALFED model performs better than MELD, MELD, MELD-Na, CLIF-C ACLF scores and KCH criteria for predicting outcome in viral hepatitis- related ALF.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya J Mahapatra
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Harpreet Kaur
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
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Abstract
Hepatitis E virus (HEV) infection has distinct features, depending upon the genotype and geographical area. HEV genotypes 1 and 2 are endemic to various developing countries causing epidemics of acute viral hepatitis with human to human transmission. On the other hand, HEV genotypes 3 and 4 prevalent in developed countries commonly lead to subclinical infection and are transmitted zoonotically. HEV infection typically causes acute self-limiting illness associated with low morbidity and mortality. Infection with HEV genotype 1 or 2 in pregnancy, especially in the third trimester may lead to severe illness and fulminant liver failure. Poor maternal and fetal outcomes have been reported. Areas covered: This review highlights the various aspects of HEV infection in pregnancy including diagnosis, management, and prevention. Expert commentary: Treatment is mainly supportive with diligent monitoring and intensive care. Therapeutic termination of pregnancy cannot be recommended based to the available literature. Early liver transplantation (LT) should be considered in these patients although the indications and timing of LT are still controversial. Prevention of HEV infection or illness by improved sanitation and active/passive immunization needs further research.
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Affiliation(s)
- Premashis Kar
- a Department of Gastroenterology and Hepatology , Max Super Speciality Hospital , Ghaziabad , India
| | - Anando Sengupta
- a Department of Gastroenterology and Hepatology , Max Super Speciality Hospital , Ghaziabad , India
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Santos Júnior GO, Ferreira Filho RP, Foulon LMDC, Noblat LDACB. Fulminant hepatic failure caused by herbal supplies. BRAZ J PHARM SCI 2018. [DOI: 10.1590/s2175-97902018000317418] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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Rajadhyaksha GC, Meah A. Spectrum of Diseases/conditions Exhibiting Hemostatic Abnormalities in Patients Admitted to a Medical Intensive Care Unit of a Tertiary Care Hospital. Indian J Crit Care Med 2018; 22:711-717. [PMID: 30405281 PMCID: PMC6201640 DOI: 10.4103/ijccm.ijccm_505_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Background and Aims: In a medical intensive care unit (MICU), many patients develop hemostatic abnormalities, ranging from abnormal clotting tests to frank bleeding. The aim of this study was to assess the etiology of diseases that present with bleeding, its common bleeding manifestations, incidence, MICU stay, mortality, and transfusion requirements in an Indian setup and also to assess if the Acute Physiology and Chronic Health Evaluation II (APACHE II) score can be used as a predictor for blood transfusion requirements. Materials and Methods: Between July 2013 and August 2014, 200 patients with clinically significant bleeding admitted in the MICU were prospectively evaluated. Detailed history, examination, laboratory investigations, APACHE II score, and requirement of blood products were also noted. The endpoints were discharge or death. Results: The spectrum of diseases that presented with bleeding was 47 patients with malaria (23.5%) followed by 36 acute undifferentiated febrile illness (18.0%), 33 dengue (16.5%), 30 leptospirosis (15.0%), 31 acute fulminant hepatitis (15.5%), 14 sepsis (7.0%), and the rest nine miscellaneous causes. The most common bleeding manifestation observed was hematuria in 62/200 (31%). Among the patients studied, 126 expired (63%) and 74 survived (37%). Of the 200 patients, 48/200 (24%) received packed cells, 78/200 (39%) fresh frozen plasma, and 82/200 (41%) platelets. Conclusions: Tropical diseases formed the majority of admissions with bleeding manifestations. Thrombocytopenia is an important marker to predict mortality and also has a significant association with MICU stay. APACHE II score was found to be a good predictor of blood transfusion requirements.
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Affiliation(s)
| | - Ameena Meah
- Department of Medicine, Topiwala National Medical College & B.Y.L. Nair Ch Hospital, Mumbai, Maharashtra, India
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Rout G, Jadaun SS, Ranjan G, Kedia S, Gunjan D, Nayak B, Acharya SK, Kumar A, Kapil A. Prevalence, predictors and impact of bacterial infection in acute on chronic liver failure patients. Dig Liver Dis 2018; 50:1225-1231. [PMID: 29910108 DOI: 10.1016/j.dld.2018.05.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/18/2018] [Accepted: 05/20/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute on chronic liver failure (ACLF) is associated with high short term mortality. We aimed to evaluate the prevalence, predictors and impact of bacterial infection in ACLF. METHODS Consecutive hospitalized patients with cirrhosis and acute decompensation (AD), from January 2011-March 2017, were included. Predictors of survival and infection were assessed. RESULTS 572 patients with cirrhosis and AD were classified into 3 groups - no infection (group 1, n = 190, 33.2%), infection at admission/within 48 h (group 2, n = 298, 52.1%) and infection after 48 h (group 3, n = 84, 14.7%). Higher frequency of organ failures - kidney, brain, circulation and respiratory failure - were seen in groups 2 and 3 as compared with group 1 (P < 0.001 for all). Most common site of infection was lungs, followed by spontaneous bacterial peritonitis and urinary tract infection. The frequency of infection increased with higher ACLF grades. Among ACLF patients, on Cox-proportional multivariate analysis, presence of infection was associated with significantly higher mortality [group 2 (HR 2.93; 95%CI, 1.97-4.38, P < 0.001) and group 3 (HR 1.84; 95%CI, 1.16-2.91, P = 0.009)], as compared with group 1. On multivariate logistic regression analysis, advanced hepatic encephalopathy and elevated total leucocyte count were independently associated with development of infection. CONCLUSIONS Infections are common in ACLF, and associated with poor outcome.
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Affiliation(s)
- Gyanranjan Rout
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Shekhar S Jadaun
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Gyan Ranjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Saurabh Kedia
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Deepak Gunjan
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
| | - Ajay Kumar
- Department of Gastroenterology, Govind Ballabh Pant Institute of Postgraduate Medical Education & Research, New Delhi, India, India.
| | - Arti Kapil
- Department of Microbiology, All India Institute of Medical Sciences, New Delhi, India, India.
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Maurya G, Hazam RK, Ruttala R, Karna R, Das BC, Kar P. A study of association between regulatory polymorphism in the IL-10 gene promoter region and acute viral hepatitis, and acute liver failure. Indian J Gastroenterol 2018; 37:293-298. [PMID: 30109600 DOI: 10.1007/s12664-018-0858-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 05/20/2018] [Indexed: 02/04/2023]
Abstract
BACKGROUND The level of inflammatory cytokine Interleukin (IL)-10 is increased in patients infected with hepatitis-related acute liver failure (ALF), and this was thought to be because of the regulatory polymorphism in the IL-10 gene promoter region. The present study was designed to analyze the possible association between IL-10 gene promoter polymorphism and acute viral hepatitis (AVH), and ALF. An attempt was made to quantify IL-10 levels at admission, during the hospital stay, and at the final outcome to study its relationship with liver injury among patients with AVH, ALF, and controls. METHODS The study included 40 patients each with ALF and AVH. IL-10 gene promoter polymorphism was detected by the PCR-RFLP method. Quantification of IL-10 was done using commercially available ELISA kits. RESULTS The individuals with -592 AC, -819 TC, -1082 AA genotypes were found to have a significantly higher risk of ALF whereas those with -592 AA and - 819 CC polymorphism were found to be less susceptible. Individuals with - 819 CC were found to be more susceptible to AVH while those with -592 AA and -819 TT were less susceptible as compared to controls. Mean serum IL-10 at admission was significantly elevated in patients with ALF (38.4±11.3 pg/mL) as compared to patients with AVH (16.7±5.4 pg/mL) and control population (8.3±3.6 pg/mL, p < 0.05). CONCLUSION Regulatory polymorphism in the IL-10 gene promoter has a possible and significant association with severity and outcome in patients with AVH and ALF. Raised levels of IL-10 could be predictive of prognosis in patients with ALF.
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Affiliation(s)
- Gaurav Maurya
- Department of Medicine, Maulana Azad Medical College, University of Delhi, E23 Nivedita Kunj, Sector 10, R.K. Puram, New Delhi, 110 002, India
| | - Rajib Kishore Hazam
- Department of Medicine, Maulana Azad Medical College, University of Delhi, E23 Nivedita Kunj, Sector 10, R.K. Puram, New Delhi, 110 002, India
| | - Rajesh Ruttala
- Department of Medicine, Maulana Azad Medical College, University of Delhi, E23 Nivedita Kunj, Sector 10, R.K. Puram, New Delhi, 110 002, India
| | - Rahul Karna
- Department of Medicine, Maulana Azad Medical College, University of Delhi, E23 Nivedita Kunj, Sector 10, R.K. Puram, New Delhi, 110 002, India
| | - Bhudev C Das
- Center for Biomedical Research, University of Delhi, New Delhi, 110 002, India
| | - Premashis Kar
- Department of Medicine, Maulana Azad Medical College, University of Delhi, E23 Nivedita Kunj, Sector 10, R.K. Puram, New Delhi, 110 002, India.
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Liu L, Xiao D, Yu JH, Shen R, Wang M, Li Q. Clinical course of sporadic acute hepatitis E in a hepatitis B virus endemic region. Int J Infect Dis 2018; 70:107-114. [PMID: 29551632 DOI: 10.1016/j.ijid.2018.03.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 03/03/2018] [Accepted: 03/09/2018] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVES In China, the epidemic pattern of acute hepatitis E virus (HEV) infection has changed from waterborne outbreaks to foodborne sporadic cases. However, the clinical course of sporadic acute hepatitis E (AHE) has not been well defined. METHODS Consecutive patients with AHE who were admitted to the Jinan Infectious Disease Hospital, Jinan, Shandong Province between January 2003 and December 2014 were evaluated and followed. Demographic data, clinical manifestations, results of laboratory tests, and outcomes were recorded. Risk factors for liver failure and death were analyzed. RESULTS A total of 680 patients with AHE were identified during the study period. The incidence was highest in February, March, and April, accounting for about 41% of the cases. The male to female ratio was 5.1:1 (574/106). The average age was 50.9±12.8years. The prevalence rates of prodromal fever, fatigue, loss of appetite, and jaundice were 25.6%, 85.6%, 83.8%, and 92.8%, respectively. The median (range) serum alanine aminotransferase, aspartate aminotransferase, bilirubin, albumin, and platelet levels were 727 (8-6270) U/l, 300 (17-6226) U/l, 196.8 (8.0-1083) μmol/l, 33.0 (15.2-45.8) g/l, and 162 (10-589)×109/l, respectively. The prevalence of hepatitis B surface antigen (HBsAg) was 18.5% (126/680) and of liver cirrhosis was 9.4% (64/680). Thirteen percent (89/680) of the cases progressed to liver failure, including 4.1% (28/680) with acute liver failure (ALF) and 9.0% (61/680) with acute-on-chronic liver failure (ACLF). Among patients with HBsAg positivity or cirrhosis, 28.6% (36/126) and 36.0% (23/64), respectively, progressed to ACLF. Multiple logistic regression analysis indicated that age >53years, prodromal fever, HBsAg positivity, cirrhosis, and thrombocytopenia (platelet count <150×109/l) were independently associated with the development of liver failure, with an odds ratio (95% confidence interval) of 2.5 (1.5-4.3), 1.9 (1.1-3.2), 3.7 (2.0-6.7), 2.1 (1.1-4.2), and 5.9 (3.3-10.4), respectively. The overall mortality was 5.6% (38/680), and the mortality rates in patients with and without underlying liver disease were 9.3% (22/237) and 3.6% (16/443), respectively. Multiple logistic regression analysis indicated that hepatic encephalopathy, bilirubin >500μmol/l, international normalized ratio (INR)>2, and severe thrombocytopenia (platelet count <100×109/l) were independently associated with death, with an odds ratio (95% confidence interval) of 7.2 (2.4-21.8), 5.8 (1.9-17.2), 24.1 (7.9-73.3), and 10.8 (3.6-32.9), respectively. CONCLUSIONS In areas that are dual endemic for hepatitis B virus and HEV, the HEV vaccine for patients with obvious liver diseases is of significance. Thrombocytopenia is an important predictor of liver failure and mortality in sporadic AHE.
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Affiliation(s)
- Li Liu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Di Xiao
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Jin-Hong Yu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Rui Shen
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China
| | - Meng Wang
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China; Division of Infectious Diseases, Jinan Central Hospital, Shandong University, Jinan, China
| | - Qiang Li
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, Jinan, China.
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Shalimar, Kedia S, Sharma H, Vasudevan S, Sonika U, Upadhyaya AD, Acharya SK. Predictors of infection in viral-hepatitis related acute liver failure. Scand J Gastroenterol 2017; 52:1413-1419. [PMID: 28875762 DOI: 10.1080/00365521.2017.1374449] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Infections are common and associated with complications and mortality in acute liver failure (ALF). The temporal relationship between ammonia and infection in ALF patients is unclear. We aimed to evaluate the predictors of infection and its relationship with arterial ammonia levels. MATERIALS AND METHODS Consecutive ALF patients hospitalized between January 2004 and December 2015, without signs of infection at/within 48 h of admission, were included. Occurrence of infection after 48 h was documented and ammonia levels were estimated for five consecutive days. Multivariate logistic regression analysis was used to assess factors associated with development of infection. Generalized estimating equations (GEE) were used to evaluate five-day time trend of ammonia in patients with and without infection. RESULTS Of 540 consecutive patients, 120 were infected at admission/within 48 h and were excluded. Of the rest 420 patients, 144 (34.3%) developed infection after 48 h and 276 (65.7%) remained non-infected. Infected patients had higher mortality than non-infected patients (61.8% vs 40.0%, p < .001). On multivariate analysis, presence of cerebral edema(HR 2.049; 95%CI, 1.30-3.23), ammonia level on day 3 of admission (HR 1.006; 95%CI, 1.003-1.008), and model for end stage liver disease (MELD) score (HR 1.051; 95%CI, 1.026-1.078) were associated with development of infection. GEE showed group difference in serial ammonia values between infected and non-infected patients indicating lack of ammonia decline in infected patients. CONCLUSIONS Cerebral edema, elevated ammonia on day 3, and higher MELD score predict the development of infection in ALF. Ammonia persists at high levels in infected patients, and elevated ammonia on day 3 is associated with complications and death.
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Affiliation(s)
- Shalimar
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kedia
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Hanish Sharma
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Sreejith Vasudevan
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ujjwal Sonika
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ashish Dutt Upadhyaya
- b Department of Biostatistics , All India Institute of Medical Sciences , New Delhi , India
| | - Subrat K Acharya
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
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Severity and Outcome of Acute-on-Chronic Liver Failure is Dependent on the Etiology of Acute Hepatic Insults: Analysis of 368 Patients. J Clin Gastroenterol 2017; 51:734-741. [PMID: 28296656 DOI: 10.1097/mcg.0000000000000823] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) may be precipitated by various hepatic insults. The present study evaluated the outcomes of ACLF with different acute insults. PATIENTS AND METHODS A total of 368 ACLF patients were included. Data collected included etiologies of acute hepatic insult and underlying chronic liver disease, and organ failure. Model for end-stage liver disease (MELD), chronic liver failure consortium (CLIF)-C ACLF, and acute physiology and chronic health evaluation (APACHE) II scores were calculated. Predictors of survival were assessed by the Cox proportional hazard model. RESULTS The most frequent acute insult was active alcohol consumption [150 (40.8%) patients], followed by hepatitis B virus (HBV) [71 (19.3%) patients], hepatitis E virus (HEV) superinfection [45 (12.2%) patients], autoimmune hepatitis flare [17 (4.6%) patients], antituberculosis drugs [16 (4.3%) patients], and hepatitis A virus superinfection [2 (0.5%) patients]; 67 (18.2%) cases were cryptogenic. Alcohol-ACLF and cryptogenic-ACLF were more severe. Median CLIF-C, MELD, and APACHE II scores in alcohol-ACLF and cryptogenic-ACLF were significantly higher than those in HBV-ACLF and HEV-ACLF (CLIF-C: 47.1, 47.4 vs. 42.9, 42.0, P=0.002; MELD: 29, 29.9 vs. 28.9, 25.2, P=0.02; APACHE II: 16.5, 18.0 vs. 12, 14, P<0.001, respectively). Frequencies of kidney and brain failures were also higher in alcohol/cryptogenic-ACLF than in HBV/HEV-ACLF (kidney failure: 35.3%/34.3% vs. 23.9%/11.1%, P=0.009; brain failure: 26.0%/22.4% vs. 15.5%/4.4%, P=0.01, respectively). Mortality in the alcohol-ACLF group was the highest (64.0%), followed by that in the cryptogenic-ACLF (62.7%), HBV-ACLF (45.1%), and HEV-ACLF (17.8%) groups (P<0.001). In multivariable analysis, alcohol-ACLF had significantly higher mortality compared with HEV-ACLF (hazard ratio, 3.06; 95% confidence interval, 1.10-8.49, P=0.03). CONCLUSIONS Alcohol/cryptogenic-ACLF had more severe phenotypic presentation, more incidence of organ failures, and higher mortality compared with HEV/HBV-ACLF. Alcohol-ACLF had the highest mortality, whereas HEV-ACLF had the best survival.
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Nabi T, Nabi S, Rafiq N, Shah A. Role of N-acetylcysteine treatment in non-acetaminophen-induced acute liver failure: A prospective study. Saudi J Gastroenterol 2017; 23:169-175. [PMID: 28611340 PMCID: PMC5470376 DOI: 10.4103/1319-3767.207711] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND/AIMS Acute liver failure (ALF) is a rare but severe medical emergency. To date, there is no established treatment for non-acetaminophen-induced acute liver failure (NAI-ALF) other than liver transplantation, and little is known about the use of N-acetylcysteine (NAC) in NAI-ALF. A randomized case control study was conducted with the aim to determine the effect of NAC on the mortality of NAI-ALF patients, as well as to evaluate the safety and efficacy of NAC use. PATIENTS AND METHODS A total of 80 patients diagnosed with NAI-ALF were included in the study. Forty patients received NAC infusion for 72 h whereas the control group received placebo. The variables evaluated were demographic characteristics, signs and symptoms, biochemical parameters, and clinical course during hospitalization. RESULTS The two groups (NAC and control) were comparable for various baseline characteristics (such as etiology of ALF, INR, alanine aminotransferase, creatinine, albumin, and grade of encephalopathy), except for age. Although majority of patients had undetermined etiology (32.5% in NAC group and 42.5% in control group), the second main cause was acute hepatitis E and drug or toxin-induced ALF. The mortality decreased to 28% with the use of NAC versus 53% in the control group (P = 0.023). The use of NAC was associated with shorter length of hospital stay in survived patients (P = 0.002). Moreover, the survival of patients was improved by NAC (P = 0.025). Also, drug-induced ALF showed improved outcome compared to other etiologies. CONCLUSION The findings of the study recommend the use of NAC along with conventional treatments in patients with NAI-ALF in non-transplant centers while awaiting referrals and conclude the use of NAC as safe.
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Affiliation(s)
- Tauseef Nabi
- Department of Endocrinology, SKIMS, Soura, Srinagar, Jammu and Kashmir, India
| | - Sumaiya Nabi
- Department of Bio-chemistry, University of Kashmir, Srinagar, Jammu and Kashmir, India
| | - Nadeema Rafiq
- Department of Physiology, GMC, Srinagar, Jammu and Kashmir, India
| | - Altaf Shah
- Department of Gastroenterology, SKIMS, Srinagar, Jammu and Kashmir, India
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Acute Liver Failure Due to Hepatitis E Virus Infection Is Associated with Better Survival than Other Etiologies in Indian Patients. Dig Dis Sci 2017; 62:1058-1066. [PMID: 28130708 DOI: 10.1007/s10620-017-4461-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 01/16/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIM Hepatitis E virus (HEV) is a global disease and an important cause of acute liver failure (ALF) in the Indian subcontinent. The aim of this study was to assess the differences in the course of HEV-ALF as compared to other etiologies of ALF. METHODS We compared the clinical course, complications, and outcomes of HEV-ALF with other etiologies. We assessed the prognostic factors and compared existing prognostic scores in HEV-ALF patients. RESULTS One thousand four hundred and sixty-two ALF patients were evaluated between January 1986 and December 2015. HEV was the etiology of ALF in 419 (28.7%) cases, whereas non-A non-E hepatitis, HBV and anti-tuberculosis therapy (ATT) were the etiologies in 527 (36.0%), 128 (8.8%), and 103 (7.0%) cases, respectively. The frequency of cerebral edema in HEV-ALF (41.3%) was lower than that in non-A non-E ALF (52.9%; P < 0.001) and HBV-ALF (52.8%; P = 0.024). Infection and seizures were significantly less in patients with HEV-ALF compared to non-A non-E and HBV-ALF (P = 0.038 and 0.022, respectively). The survival of HEV-ALF patients was significantly better (55.1%, P < 0.001) than patients of other etiologies-including ATT (30.0%), non-A non-E (38.1%) and HBV (35.9%). In HEV-ALF patients, age, female sex, cerebral edema, prothrombin time >60 s, infection, and total bilirubin were observed as independent predictors of outcome on multivariate logistic regression analysis. Model for end-stage liver disease, acute liver failure study group model and King's College Hospital criteria had poor discriminative accuracy for outcome (area under receiver operator characteristic curve 0.63-0.64) in HEV-ALF. CONCLUSIONS Hepatitis E virus-associated ALF has a better outcome than ALF of other etiologies.
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Pérez-Gracia MT, Suay-García B, Mateos-Lindemann ML. Hepatitis E and pregnancy: current state. Rev Med Virol 2017; 27:e1929. [PMID: 28318080 DOI: 10.1002/rmv.1929] [Citation(s) in RCA: 130] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 02/23/2017] [Accepted: 02/24/2017] [Indexed: 12/17/2022]
Abstract
Hepatitis E virus (HEV) is responsible for more than 50% of acute viral hepatitis cases in endemic countries. Approximately 2 billion individuals live in hepatitis E-endemic areas and, therefore, are at risk of infection. According to World Health Organization, HEV causes about 20.1 million infections and 70 000 deaths every year. In developing countries with poor sanitation, this disease is transmitted through contaminated water and is associated with large outbreaks, affecting hundreds or thousands of people. In developed countries, autochthonous cases of HEV have been increasingly recognized in the past several years. Hepatitis E virus typically causes an acute, self-limiting illness similar to other acute viral hepatitis, such as hepatitis A or B, with about 0.2% to 1% mortality rate in the general population. However, the course of hepatitis E in pregnancy is different than the mild self-constraining infection described in other populations. During pregnancy, HEV infection can take a fulminant course, resulting in fulminant hepatic failure, membrane rupture, spontaneous abortions, and stillbirths. Studies from various developing countries have shown a high incidence of HEV infection in pregnancy with a significant proportion of pregnant women progressing to fulminant hepatitis with a fatality rate of up to 30%. The present review will highlight new aspects of the HEV infection and pregnancy.
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Affiliation(s)
- María Teresa Pérez-Gracia
- Área de Microbiología, Departamento de Farmacia, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Moncada, Spain
| | - Beatriz Suay-García
- Área de Microbiología, Departamento de Farmacia, Instituto de Ciencias Biomédicas, Facultad de Ciencias de la Salud, Universidad CEU Cardenal Herrera, Moncada, Spain
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Du WJ, Liu L, Sun C, Yu JH, Xiao D, Li Q. Prodromal fever indicates a high risk of liver failure in acute hepatitis B. Int J Infect Dis 2017; 57:98-103. [PMID: 28223176 DOI: 10.1016/j.ijid.2017.02.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Revised: 01/18/2017] [Accepted: 02/13/2017] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES The role of prodromal fever in the clinical course of acute hepatitis B virus (HBV) infection is still largely unclear. This study was conducted to investigate the factors associated with prodromal fever and its role in the development of acute liver failure (ALF) in patients with acute hepatitis B (AHB). METHODS Inpatients with AHB diagnosed between January 2006 and December 2010 were evaluated and followed. Clinical manifestations, results of laboratory tests, and outcomes were compared between patients with and without prodromal fever. The diagnosis of AHB was based on the discrete onset of symptoms, jaundice, abnormal liver function tests, the detection of high-titer IgM antibody to hepatitis B core antigen (anti-HBc), and a compatible clinical history. RESULTS A total of 618 AHB inpatients were identified during the study period, of whom 102 (16.5%) had prodromal fever and 41 (6.6%) developed ALF. Prodromal fever indicated more severe liver injury and was independently associated with hepatitis B e antigen (HBeAg) negativity. The occurrence of ALF was more common in febrile patients than in non-febrile patients (18.6% vs. 4.3%, p<0.001). Multivariate logistic regression showed prodromal fever and temperature >38.0°C to be independently associated with the risk of ALF, with an odds ratio (95% confidence interval) of 3.5 (1.4-8.6) and 7.1 (2.6-19.7), respectively. CONCLUSIONS AHB patients with prodromal fever, which is associated with a lack of HBeAg due to HBV mutation, are at high risk of ALF. Febrile patients with AHB should be managed with particular care.
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Affiliation(s)
- Wen-Jun Du
- Department of Digestive Diseases, Qianfoshan Hospital, Shandong University, Jinan, China
| | - Li Liu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, 22029 Jingshi Road, Jinan 250021, China
| | - Chao Sun
- Division of Infectious Diseases, Affiliated Hospital of Taishan Medical University, Tai'an, China
| | - Jin-Hong Yu
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, 22029 Jingshi Road, Jinan 250021, China
| | - Di Xiao
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, 22029 Jingshi Road, Jinan 250021, China
| | - Qiang Li
- Division of Liver Diseases, Jinan Infectious Disease Hospital, Shandong University, 22029 Jingshi Road, Jinan 250021, China.
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Das AK, Begum T, Kar P, Dutta A. Profile of Acute Liver Failure from North-east India and Its Differences from other Parts of the Country. Euroasian J Hepatogastroenterol 2016; 6:111-115. [PMID: 29201741 PMCID: PMC5578577 DOI: 10.5005/jp-journals-10018-1181] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Accepted: 06/29/2016] [Indexed: 12/14/2022] Open
Abstract
Background Acute liver failure (ALF) is a critical illness with a large number of viral and nonviral causes. Clinical course and etiologies in the Asian countries are different from those reported from the Western world and mortality is high. There may even be intracountry variations in large countries like India, which have differing culture, ethnicity, and environment. Data from North-east part of India is lacking. Materials and methods Acute liver failure cases (>14 years of age) seen over a period of 8 years (n = 255) were studied at a Government Medical College in Assam for their etiological and other demographic profile. Viral serology was carried out and revalidated at a laboratory in New Delhi. Results Majority of cases were <30 years of age. Commonest etiology was nonviral (non-ABCE). Amongst viral causes, hepatitis A and E were common, while hepatitis B virus (HBV) was rare. Unknown herbal medication use was very frequent in our cases with a significantly higher mortality. Mortality was highest in cases in 3rd decade of life. Statistically, international normalized ratio (INR) was the strongest predictor of death. Conclusion Unlike the rest of India, hepatitis virus is not the major cause of ALF in our part; hepatitis A being commoner than hepatitis E, and B is rare. Unknown herbal medications are major cause of mortality and is important medicosocial issue. Our study highlights the differences in the profile of ALF from other Indian and western studies, possibly due to sociocultural factors prevalent in this part. How to cite this article Das AK, Begum T, Kar P, Dutta A. Profile of Acute Liver Failure from North-east India and Its Differences from other Parts of the Country. Euroasian J Hepato-Gastroenterol 2016;6(2):111-115.
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Affiliation(s)
- Anup K Das
- Department of Medicine, Assam Medical College, Dibrugarh, Assam, India
| | - Tarjina Begum
- Department of Medicine, Assam Medical College, Dibrugarh, Assam, India
| | - Premashish Kar
- Department of Medicine, Maulana Azad Medical College New Delhi, India
| | - Anupam Dutta
- Department of Medicine, Assam Medical College, Dibrugarh, Assam, India
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Hartl J, Wehmeyer MH, Pischke S. Acute Hepatitis E: Two Sides of the Same Coin. Viruses 2016; 8:E299. [PMID: 27827877 PMCID: PMC5127013 DOI: 10.3390/v8110299] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 10/04/2016] [Accepted: 10/17/2016] [Indexed: 12/12/2022] Open
Abstract
The relevance of acute hepatitis E virus (HEV) infections has been underestimated for a long time. In the past, HEV infection had been interpreted falsely as a disease limited to the tropics until the relevance of autochthonous HEV infections in the Western world became overt. Due to increased awareness, the incidence of diagnosed autochthonous HEV infections (predominantly genotype 3) in industrialized countries has risen within the last decade. The main source of infections in industrialized countries seems to be infected swine meat, while infections with the tropical HEV genotypes 1 and 2 usually are mainly transmitted fecal-orally by contaminated drinking water. In the vast majority of healthy individuals, acute HEV infection is either clinically silent or takes a benign self-limited course. In patients who develop a symptomatic HEV infection, a short prodromal phase with unspecific symptoms is followed by liver specific symptoms like jaundice, itching, uncoloured stool and darkened urine. Importantly, tropical HEV infections may lead to acute liver failure, especially in pregnant women, while autochthonous HEV infections may lead to acute-on-chronic liver failure in patients with underlying liver diseases. Immunosuppressed individuals, such as transplant recipients or human immunodeficiency virus (HIV)-infected patients, are at risk for developing chronic hepatitis E, which may lead to liver fibrosis and cirrhosis in the long term. Importantly, specific treatment options for hepatitis E are not approved by the regulation authorities, but off-label ribavirin treatment seems to be effective in the treatment of chronic HEV-infection and may reduce the disease severity in patients suffering from acute liver failure.
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Affiliation(s)
- Johannes Hartl
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246 Hamburg, Germany.
| | - Malte H Wehmeyer
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246 Hamburg, Germany.
| | - Sven Pischke
- First Medical Department, University Medical Center Hamburg-Eppendorf, University Hospital Hamburg Eppendorf (UKE), 20246 Hamburg, Germany.
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Koenig A, Stepanova M, Felix S, Kalwaney S, Clement S, Younossi ZM. Vaccination against hepatitis A and B in patients with chronic liver disease and type 2 diabetes: has anything changed? Liver Int 2016; 36:1096-100. [PMID: 27187614 DOI: 10.1111/liv.13164] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 05/13/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS Given the severity of acute hepatitis in patients with chronic liver diseases (CLD) and patients with type 2 diabetes (DM), most of these patients are recommended to be vaccinated. The aim is to assess the recent changes in HAV and HBV vaccination rates in patients with CLD and DM in the U.S. using the most recent population data. METHODS We used the National Health and Nutrition Examination Surveys (NHANES) cycles 2009-2012 and 2013-2014, and compared those to previous cycles (1999-2004 and 2005-2008). RESULTS In general U.S. population, the rates of quality measure (QM, serologic immunity or history of vaccination) for HBV increased from 31.9% in 1999-2004 to 49.5% in 2013-2014 (P < 0.0001), synchronously with an increase in self-reported HBV vaccination: from 24.4% to 41.3% (P < 0.0001). A similar increase was noted for HAV: 12.0% in 1999-2004 to 33.4% in 2013-2014 in vaccination, 44.0% to 52.4% in HAV QM (all P < 0.0001). Greater recent increases in HBV QM were noted in non-HBV CLD patients: 34.7% to 56.8% in HBV QM and 22.7% to 51.1% in HBV vaccination (all P < 0.0001), while the changes in patients with diabetes were similar to those in general U.S. population despite the recent CDC recommendation (for the age 19-59): 31.0% to 45.1% (P = 0.007) in HBV QM, and 22.3% to 39.0% (P = 0.0004) in HBV vaccination. CONCLUSIONS Despite recommendations, HAV and HBV vaccination rates in patients with CLD and DM remain relatively low. Better vaccination strategies for these high risk patients should be undertaken.
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Affiliation(s)
- Aaron Koenig
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Maria Stepanova
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Sean Felix
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
| | - Shirley Kalwaney
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Stephen Clement
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Zobair M Younossi
- Center for Liver Diseases, Department of Medicine, Inova Fairfax Hospital, Falls Church, VA, USA.,Betty and Guy Beatty Center for Integrated Research, Inova Health System, Falls Church, VA, USA
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Cainelli F, Nardo B, Viderman D, Dzudzor B, Tachi K, Vento S. Treatment of Acute Liver Failure in Resource-Constrained Settings without Transplantation Facilities Can Be Improved. Front Med (Lausanne) 2016; 3:31. [PMID: 27458585 PMCID: PMC4937035 DOI: 10.3389/fmed.2016.00031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 06/30/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- Francesca Cainelli
- Department of Medicine, School of Medicine, Nazarbayev University , Astana , Kazakhstan
| | - Bruno Nardo
- Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, University of Bologna , Bologna , Italy
| | - Dmitriy Viderman
- Department of Biomedical Sciences, School of Medicine, Nazarbayev University , Astana , Kazakhstan
| | - Bartholomew Dzudzor
- Department of Medical Biochemistry, College of Health Sciences, School of Biomedical and Allied Health Sciences, University of Ghana , Accra , Ghana
| | - Kenneth Tachi
- Department of Medicine and Therapeutics, College of Health Sciences, School of Medicine and Dentistry, University of Ghana , Accra , Ghana
| | - Sandro Vento
- Department of Medicine, School of Medicine, Nazarbayev University , Astana , Kazakhstan
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Singla A, Mehta S, Rajaram S, Shree S. Materno-Fetal Outcomes with Viral Hepatitis in Pregnancy. J Obstet Gynaecol India 2016; 66:166-9. [PMID: 27298525 PMCID: PMC4870660 DOI: 10.1007/s13224-014-0666-5] [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: 12/01/2014] [Accepted: 12/28/2014] [Indexed: 10/24/2022] Open
Abstract
OBJECTIVE To evaluate materno-fetal outcomes in pregnant women with jaundice. METHODS A prospective study was conducted over a period of 6 months in a tertiary care hospital of Delhi, India. 82 pregnant women with jaundice were included. The serum was screened for viral markers, liver function tests, and coagulation status. RESULTS The mean age of women was 27.3 ± 4.3 years. 43.9 % (n = 36) women were HEV positive, 36 % (n = 27) HBsAg positive, 4 % (n = 3) HAV positive and 1.3 % (n = 1) HCV positive. Intrahepatic cholestasis was diagnosed in 10.8 % (n = 8) of women. Maternal morbidity was evaluated in terms of chorioamnionitis (5.4 %, n = 3), encephalopathy (26.8 %, n = 15), and coagulopathy (67.9 %, n = 38). There were five maternal deaths, and all were unbooked with HEV-positive status and a bilirubin >15 mg/dl with deranged coagulogram and encephalopathy and IUDs. 79 women delivered vaginally, and three had cesarean section. Of the vaginal deliveries, 59.8 % (n = 49) went into spontaneous labor, and 25.5 % (n = 21) were induced for varied reasons (BPS < 6/10 (38 %, n = 8)) and progressive derangement of LFT (38 %, n = 8). Among the 71 deliveries, 29 (40.8 %) were IUD and 42 (59.1 %) were live born. On analyzing the morbidity data, it was found that HEV-positive women (deranged coagulogram 71.05 %, IUD 75.86 %, encephalopathy 80 %) had a poorer outcome as compared to their HBsAg positive counterparts (deranged coagulogram 10.52 %, IUD 13.79 %, encephalopathy 6.66 %). CONCLUSION Urgent redressal of issues pertaining to sanitation and provision for clean drinking water for citizens of India is the need of the hour as HEV is fecooral in transmission.
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Affiliation(s)
- Anshuja Singla
- Department of Obstetrics & Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, 110095 India
| | - Sumita Mehta
- Department of Obstetrics & Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, 110095 India
| | - Shalini Rajaram
- Department of Obstetrics & Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, 110095 India
| | - Sneha Shree
- Department of Obstetrics & Gynaecology, University College of Medical Sciences and Guru Teg Bahadur Hospital, Dilshad Garden, Delhi, 110095 India
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Shalimar, Kumar D, Vadiraja PK, Nayak B, Thakur B, Das P, Datta Gupta S, Panda SK, Acharya SK. Acute on chronic liver failure because of acute hepatic insults: Etiologies, course, extrahepatic organ failure and predictors of mortality. J Gastroenterol Hepatol 2016; 31:856-64. [PMID: 26519215 DOI: 10.1111/jgh.13213] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 10/02/2015] [Accepted: 10/20/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Acute on chronic liver failure (ACLF) because of precipitating factors (variceal bleed/infections) identifies cirrhotics at risk for high short-term mortality. Information on ACLF because of acute hepatic insults is lacking. The aim of the study was to evaluate acute hepatic insults in ACLF and their effect on the course and outcome. METHODS In a prospective study, 213 consecutive patients of ACLF because of acute hepatic insults were included. Etiology of acute hepatic insult, frequency of silent, and overt chronic liver disease (CLD), organ failure (OF), and outcomes were assessed. Prognostic models such as model for endstage liver disease (MELD), acute physiology and chronic health evaluation (APACHE II), and chronic liver failure-sequential organ failure (CLIF-SOFA) were evaluated. RESULTS Etiologies of acute hepatic insult were hepatitis virus(es)- 81 (38%; HBV-42, HEV-39), continuous alcohol consumption-77 (33.3%), antituberculosis drugs-11 (5.2%), autoimmune hepatitis flare-5(2.3%), cryptogenic-44 (20.7%). The common causes of CLD were alcohol (n = 85/40%), HBV(n = 52/24%), and cryptogenic(n = 50/20%). The MELD, APACHE II, and CLIF-SOFA scores were similar among silent and overt CLD and did not influence outcome. Predominant etiologies of ACLF were hepatitis virus(es) reactivation or superinfection in silent CLD(52/112, 46.4%) and alcohol among overt CLD(43/101, 43%). Independent predictors of mortality included hepatic-encephalopathy (early, HR: 4.01; advanced, HR: 6.10), serum creatinine ≥1.5 mg/dl (HR: 4.53), CLIF-SOFA ≥8(HR: 1.69), and etiology of acute hepatic insult (alcohol, HR: 4.08; cryptogenic, HR: 3.18). HEV-ACLF had lower mortality (12.8% vs. 33-54% in other etiologies;P < 0.001). OF was major determinant of mortality. With increasing number of OF, mortality increased linearly(P = 0.001). CONCLUSIONS Hepatitis virus(es) and continuous alcohol consumption are important causes of ACLF caused by acute hepatic insults. HEV-ACLF has lower mortality. OF is an important prognostic predictor.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Dharmendra Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Baibaswata Nayak
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Prasenjit Das
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Subrat Kumar Panda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat Kumar Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Shiota T, Li TC, Yoshizaki S, Kato T, Wakita T, Ishii K. Establishment of hepatitis E virus infection-permissive and -non-permissive human hepatoma PLC/PRF/5 subclones. Microbiol Immunol 2015; 59:89-94. [PMID: 25495578 DOI: 10.1111/1348-0421.12219] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Revised: 11/20/2014] [Accepted: 11/28/2014] [Indexed: 12/18/2022]
Abstract
PLC/PRF/5 cells show limited permissiveness, meaning that almost all subclones are permissive; however, some subclones do not exhibit permissiveness for hepatitis E virus (HEV) infection. In this study, the single-cell cloning of PLC/PRF/5 was performed and heterogeneous subclones characterized. Notably, the efficiency of intracellular virus replication did not correlate with the permissiveness for HEV infection. However, as well as binding permissive subclones, virus-like particles bound non-permissive subclones on various levels, suggesting that these subclones have some deficiencies in the attachment and entry steps of infection. Our data would be useful for investigating the HEV life cycle.
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Affiliation(s)
- Tomoyuki Shiota
- Department of Virology II, National Institute of Infectious Diseases, Gakuen 4-7-1, Musashi-murayama, Tokyo, 208-0011, Japan
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Kanda T, Yasui S, Nakamura M, Arai M, Sasaki R, Haga Y, Wu S, Nakamoto S, Okamoto H, Yokosuka O. Recent Trend of Hepatitis E Virus Infection in Chiba Area, Japan: 3 of 5 Cases with Rheumatoid Arthritis. Case Rep Gastroenterol 2015; 9:317-26. [PMID: 26600768 PMCID: PMC4649734 DOI: 10.1159/000441387] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Hepatitis E virus (HEV) infection is an emerging health concern in developing and developed countries, such as Japan. Five cases have recently been diagnosed as hepatitis E. Of interest, 3 of them had rheumatoid arthritis (RA), although a previous study demonstrated a lack of association between HEV and RA. One of the other patients developed autoimmune hepatitis and was successfully treated with corticosteroids approximately 150 days after the diagnosis of hepatitis E. In RA patients with liver dysfunction, the presence of HEV infection should be evaluated immediately because these patients are often relatively old. Further investigation of the association between HEV and autoimmune hepatitis is needed.
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Affiliation(s)
- Tatsuo Kanda
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Shin Yasui
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Masato Nakamura
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Makoto Arai
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Reina Sasaki
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Yuki Haga
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Shuang Wu
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
| | - Shingo Nakamoto
- Department of Molecular Virology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Hiroaki Okamoto
- Department of Division of Virology, Department of Infection and Immunity, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology and Nephrology, Chiba University, Chiba, Japan
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Saraf V, Pande S, Gopalakrishnan U, Balakrishnan D, Menon RN, Sudheer OV, Dhar P, Sudhindran S. Acute liver failure due to zinc phosphide containing rodenticide poisoning: Clinical features and prognostic indicators of need for liver transplantation. Indian J Gastroenterol 2015; 34:325-9. [PMID: 26310868 DOI: 10.1007/s12664-015-0583-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/27/2015] [Indexed: 02/04/2023]
Abstract
Zinc phosphide (ZnP) containing rodenticide poisoning is a recognized cause of acute liver failure (ALF) in India. When standard conservative measures fail, the sole option is liver transplantation. Records of 41 patients admitted to a single centre with ZnP-induced ALF were reviewed to identify prognostic indicators for requirement of liver transplantation. Patients were analyzed in two groups: group I (n = 22) consisted of patients who either underwent a liver transplant (n = 14) or died without a transplant (n = 8); group II (n = 19) comprised those who survived without liver transplantation. International normalized ratio (INR) in group I was 9 compared to 3 in group II (p < 0.001). Encephalopathy occurred only in group I. Model for End-Stage Liver Disease (MELD) score in group I was 41 compared to 24 in group II (p < 0.001). MELD score of 36 (sensitivity of 86.7 %, specificity of 90 %) or a combination of INR of 6 and encephalopathy (sensitivity of 100 %, specificity of 83 %) were the best indicators of mortality. Such patients should undergo urgent liver transplantation.
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Affiliation(s)
- Vivek Saraf
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - Supriya Pande
- Sanjay Gandhi Postgraduate Institute of Medical Sciences, Rae Bareli Road, Lucknow, 226 014, India
| | - Unnikrishnan Gopalakrishnan
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - Dinesh Balakrishnan
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - Ramachandran N Menon
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - O V Sudheer
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - Puneet Dhar
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India
| | - S Sudhindran
- Department of Gastro Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponekkara PO, Kochi, 682 041, India.
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Approach to clinical syndrome of jaundice and encephalopathy in tropics. J Clin Exp Hepatol 2015; 5:S116-30. [PMID: 26041951 PMCID: PMC4442860 DOI: 10.1016/j.jceh.2014.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/14/2014] [Indexed: 12/12/2022] Open
Abstract
A large number of patients present with jaundice and encephalopathy in tropical country like India and acute liver failure is the usual cause. Clinical presentation like ALF is also a complication of many tropical infections, and these conditions may mimic ALF but may have subtle differences from ALF. Moreover, what hepatologists see as acute liver failure in tropics is different from what is commonly described in Western Textbooks. Paracetamol overdose, which is possibly the commonest cause of ALF in UK and USA, is hardly ever seen in India. Most common etiology here is viral hepatitis (hepatitis E > hepatitis B> hepatitis A). Apart from ALF, one may also come across subacute hepatic failure (SAHF) as well as acute-on-chronic liver failure (ACLF) due to viral hepatitis. Interestingly, a host of other conditions can mimic ALF because clinical presentation in these conditions can be dominated by jaundice and encephalopathy. Malarial hepatopathy is possibly the best-known condition out of these and is not an uncommon manifestation of severe malaria. A similar presentation can also be seen in other common infections in tropics such as dengue fever, typhoid fever, leptospirosis, scrub typhus, amoebic liver abscesses, tuberculosis and other bacterial and fungal infections with or without human immunodeficiency virus (HIV) related disease. In many of these conditions, liver failure may not be underlying pathophysiology. Some pregnancy related liver diseases could also present with jaundice and encephalopathy. This review summarizes the commonly seen presentations in tropical country like India, where jaundice and encephalopathy dominate the clinical picture.
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Shalimar, Acharya SK. Management in acute liver failure. J Clin Exp Hepatol 2015; 5:S104-15. [PMID: 26041950 PMCID: PMC4442864 DOI: 10.1016/j.jceh.2014.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is a rare, potentially fatal complication of severe hepatic illness resulting from various causes. In a clinical setting, severe hepatic injury is usually recognised by the appearance of jaundice, encephalopathy and coagulopathy. The central and most important clinical event in ALF is occurrence of hepatic encephalopathy (HE) and cerebral edema which is responsible for most of the fatalities in this serious clinical syndrome. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a central role in the pathogenesis. The role of newer ammonia lowering agents is still evolving. Liver transplant is the only effective therapy that has been identified to be of promise in those with poor prognostic factors, whereas in the others, aggressive intensive medical management has been documented to salvage a substantial proportion of patients. A small fraction of patients undergo liver transplant and the remaining are usually treated with medical therapy. Therefore, identification of the complications and causes of death in such patients, and use of appropriate prognostic models to identify those who need liver transplant and those who can be managed with medical treatment is a vital component of therapeutic strategy. In this review, we discuss the various pathogenetic mechanisms and treatment options available.
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Key Words
- AASLD, American Association For the Study of Liver
- ALF, Acute Liver Failure
- ALFED, Acute Liver Failure Early Dynamic Model
- BBB, Blood Brain Barrier
- BCAA, Branched Chain Amino acid
- CBF, Cerebral Blood Flow
- CPP, Cerebral Perfusion Pressure
- CVVHD, Continuous Veno-Venous Hemodialysis
- FFP, Fresh Frozen Plasma
- GM-CSF, Granulocyte Macrophage Colony Stimulating Factor
- HE, Hepatic Encephalopathy
- ICU, Intensive Care Unit
- IEI, Icterus Encephalopathy Interval
- IL-1β, Interleukin-1 beta
- IL6, Interlekin 6
- INR, International Normalized Ratio
- LOLA, l-Ornithine L Aspartate
- LOPA
- LOPA, l-Ornithine Phenyl Acetate
- MAP, Mean Arterial Pressure
- NAC, N-Acetyl Cysteine
- NO, Nitric Oxide
- OLT, Orthotopic Liver Transplantation
- PCWP, Pulmonary Capillary Wedge Pressure
- PEEP, Positive End Expiratory Pressure
- PT, Prothrombin Time
- SIMV, Synchronous Intermittent mandatory Ventilation
- SIRS, Systemic Inflammatory Response Syndrome
- SPEAR, Selective Parenteral and Enteral Antibiotic Regimen
- TNF-α, Tumor Necrosis Factor alfa
- UCD, Urea Cycle Disorder
- USALF, United States Acute liver Failure Study Group
- ammonia
- cerebral edema
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Affiliation(s)
| | - Subrat K. Acharya
- Address for correspondence: Subrat K. Acharya, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India.
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Bagchi A, Kumar S, Ray PC, Das BC, Gumma PK, Kar P. Predictive value of serum actin-free Gc-globulin for complications and outcome in acute liver failure. J Viral Hepat 2015; 22:192-200. [PMID: 24774007 DOI: 10.1111/jvh.12259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 03/09/2014] [Indexed: 12/26/2022]
Abstract
This prospective study was designed to evaluate whether early changes in actin-free Gc-globulin levels were associated with complications and outcomes and to identify factors associated with persistent low actin-free Gc-globulin levels in acute liver failure (ALF). Thirty-two consecutive ALF patients admitted from October 2011 to December 2012 were followed up until death or complete recovery. All had serum actin-free Gc-globulin estimation at admission and at day three or expiry. Logistic regression analysis was performed to identify independent predictors of mortality. A receiver operating characteristic curve analysis was also performed. Nonsurvivors had significantly lower median actin-free Gc-globulin levels than survivors (87.32 vs 180 mg/L; P < 0.001). A receiver operating characteristic curve analysis revealed an area under curve (AUC) of 0.771 and showed that serum actin-free Gc-globulin level of ≤124 mg/L would predict mortality with 92% sensitivity and 71.4% specificity. Patients with lower serum actin-free Gc-globulin levels and decreasing trend in serum actin-free Gc-globulin levels were found to have more mortality and developed more complications. Logistic regression analysis showed that serum actin-free Gc-globulin, total leucocyte count and serum creatinine at admission were independent predictors of mortality. Incorporating these variables, a score predicting mortality risk at admission was derived. The scoring system was compared to MELD score and King's College Criteria as individual predictor of mortality. Serum actin-free Gc-globulin level at presentation is predictive of outcome and can be used for risk stratification. Its persistent low-level predicts mortality and is correlated with various complications.
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Affiliation(s)
- A Bagchi
- General Medicine, Maulana Azad Medical College, University of Delhi, New Delhi, India
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Abstract
BACKGROUND/AIMS Acute liver failure (ALF) in pregnancy is often associated with a poor prognosis. In this single-center observational study we aim to study the incidence, causes, and factors affecting mortality in pregnant women with ALF. PATIENTS AND METHODS Sixty-eight pregnant women reporting with clinical features of liver dysfunction were enrolled as "cases." Their clinical course was followed and laboratory studies were performed. The presence of ALF was defined as the appearance of encephalopathy. The results were compared with a "control" group of 16 nonpregnant women presenting with similar complaints. The cases were further subdivided into two groups of "survivors" and "nonsurvivors" and were compared to find out the factors that contribute to mortality. RESULTS ALF was seen in significantly more number of pregnant women than the controls (P = 0.0019). The mortality rate was also significantly higher (P = 0.0287). Hepatitis E virus (HEV) caused jaundice in a higher number of pregnant women (P < 0.001). It also caused ALF in majority (70.3%) of pregnant women, but HEV infection was comparable between the survivors and nonsurvivors (P = 0.0668), hence could not be correlated with mortality. CONCLUSIONS Pregnant women appear to be more susceptible for HEV infection and development of ALF. The mortality of jaundiced pregnant women increased significantly with appearance of ALF, higher bilirubin, lower platelet count, higher international normalized ratio, and spontaneous delivery.
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Affiliation(s)
- Shweta Sahai
- Department of Medicine, GR Medical College, Gwalior, Madhya Pradesh, India,Address for correspondence: Dr. Shweta Sahai, Department of Medicine, GR Medical College, Gwalior, Madhya Pradesh, India. E-mail:
| | - Ravi Kiran
- Department of Gastroenterology, MS Ramaiah Medical College and Hospitals, Bangalore, Karnataka, India
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Panackel C, Thomas R, Sebastian B, Mathai SK. Recent advances in management of acute liver failure. Indian J Crit Care Med 2015; 19:27-33. [PMID: 25624647 PMCID: PMC4296407 DOI: 10.4103/0972-5229.148636] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Acute liver failure (ALF) is a life-threatening illness, where a previously normal liver fails within days to weeks. Sudden loss of synthetic and detoxification function of liver results in jaundice, encephalopathy, coagulopathy, and multiorgan failure. The etiology of ALF varies demographically. The mortality of ALF is as high as 40-50%. The initial care of patients with ALF depends on prompt recognition of the condition and early detection of etiology. Management includes intensive care support, treatment of specific etiology if present and early detection of candidates for liver transplantation. Liver transplantation remains the only therapeutic intervention with proven survival benefit in patients with irreversible ALF. Living related liver transplantation, auxiliary liver transplantation, and ABO-incompatible liver transplantation are coming up in a big way. Liver assist devices and hepatocyte transplant remain experimental and further advances are required. Public health measures to control hepatitis A, B, E, and drug-induced liver injury will reduce the incidence and mortality of ALF.
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Affiliation(s)
- Charles Panackel
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Rony Thomas
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Benoy Sebastian
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
| | - Sunil K. Mathai
- From: Department of Gastroenterology and Liver Transplantation, Medical Trust Hospital, Cochin, Ernakulam, Kerala, India
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Ramdasi AY, Arya RP, Arankalle VA. Effect of pregnancy on anti-HEV antibody titres, plasma cytokines and the corresponding gene expression levels in the PBMCs of patients presenting with self-recovering clinical and subclinical hepatitis E. PLoS One 2014; 9:e103257. [PMID: 25084004 PMCID: PMC4118861 DOI: 10.1371/journal.pone.0103257] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 06/30/2014] [Indexed: 12/21/2022] Open
Abstract
High mortality in pregnant women (PR) is a characteristic of hepatitis E in developing countries. To understand the pathogenesis of HEV infection in self-limiting disease during pregnancy, we compared clinical (PR-patients) and subclinical-HEV-infections in pregnant women in the first (SC-PR-1) and later (2nd and 3rd, SC-PR-2+3) trimesters with the respective healthy controls and acute non-PR patients. The SC-PR-2+3 exhibited lower ALT, bilirubin levels, anti-HEV-IgM/IgG titres than the acute-PR/non-PR-patients (p<0.05-0.0001). IFNγ/IL4ratios indicated Th2/Th1 bias in non-PR and PR-patients respectively. Raised levels of 10/20 plasma cytokines in the non-PR-patients reflect predominant inflammatory response, unaltered- IFNγ/reduced-IFNα responses and a robust chemokine secretion. On contrary, the acute-PR-patients exhibited drastic reduction in majority of the cytokines relative to in the non-PR-patients. Importantly, diminished or unaltered response was noted in the acute-PR-group when compared to the corresponding controls. The only exception was sIL2RA, increasing in both patient categories. Of the 14 genes evaluated, the expression of IFNγ/IL10/IL1A/IL7/CCL2/CCL3/CXCL8/CXCL10 was higher in the non-PR patients. Of these, the expression of IFNγ/IL10/IL1A/CCL2/CCL3/CXCL8 and, additionally, IL2/IL6/TNF genes was higher in the clinical-PRs. Almost identical pattern was noted in the control-PR-2+3 category indicating no influence of HEV infection. Comparison of patient-categories identified significant elevation of IFNγ(P<0.001), CCL2(p<0.01), CXCL8(P<0.05), IL1B(p<0.05) and IL10(P<0.0001) and decrease in CXCL10(<0.05) in the PR-patients. The results suggest antibody-dependent disease severity and impaired immune response in the PR patients. Higher expression of cytokine-genes in the PBMCs did not correlate with the plasma-cytokine levels in the PR-patients.
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Affiliation(s)
- Ashwini Y. Ramdasi
- Hepatitis Division, National Institute of Virology, Pashan, Pune, Maharashtra, India
| | - Ravi P. Arya
- Hepatitis Division, National Institute of Virology, Pashan, Pune, Maharashtra, India
| | - Vidya A. Arankalle
- Hepatitis Division, National Institute of Virology, Pashan, Pune, Maharashtra, India
- * E-mail:
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Wu ZR, Zhi DJ, Zheng LF, Li JY, Li Y, Xie QJ, Feng N, Bao YF, Gao QY, Song Y, Li HY. Design and applications of bifunctional cinnamide derivatives as potential antimycobacterial agents with few hepatotoxic effects. Med Chem Res 2014. [DOI: 10.1007/s00044-014-1112-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Verghese VP, Robinson JL. A systematic review of hepatitis E virus infection in children. Clin Infect Dis 2014; 59:689-97. [PMID: 24846637 DOI: 10.1093/cid/ciu371] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
A systematic review was conducted, seeking all literature relevant to the epidemiology, clinical and laboratory features, and outcome of hepatitis E virus (HEV) infection in children. Transmission is thought to be primarily from fecal-oral transmission, with the role of transmission from animal reservoirs not being clear in children. Worldwide, seroprevalence is <10% up to 10 years of age, with the exception of 1 of 5 studies from India and the sole study from Egypt. Seroprevalence increases with age, but it is not clear if it is increasing over time. The clinical presentation of HEV infection has broad similarities to hepatitis A virus (HAV) infection, with most cases being subclinical. However, HEV differs from HAV in that infectivity is lower, perinatal transmission can result in neonatal morbidity and even mortality, and a chronic carrier state exists, accounting for chronic hepatitis in some pediatric solid organ transplant recipients.
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Affiliation(s)
| | - Joan L Robinson
- Stollery Children's Hospital and University of Alberta, Edmonton, Canada
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Sato M, Tateishi R, Yasunaga H, Horiguchi H, Yoshida H, Matsuda S, Fushimi K, Koike K. Acute liver disease in Japan: a nationwide analysis of the Japanese Diagnosis Procedure Combination database. J Gastroenterol 2014; 49:547-54. [PMID: 23783841 DOI: 10.1007/s00535-013-0843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 05/23/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Accurate data on the incidence of acute liver disease (ALD) is lacking in most countries. We investigated the incidence of ALD-related admission in Japan using a large sample in a nationwide Japanese database. METHODS Data from the Diagnosis Procedure Combination database were analyzed for 1 July to 31 December 2007-2010. Patient characteristics, in-hospital mortality, and clinical practices, including drugs and procedures during hospitalization, were analyzed. RESULTS We identified 10509 patients with ALD from a total of 11.61 million inpatients in the database. The median age was 53 years and 54.7 % were male. The annual incidence of ALD-related hospital admission was estimated to be 131.1 cases/1 million people. The overall mortality rate was 5.9 % (622 cases). The infant (0-3 years), child (4-18 years), and adult in-hospital mortality rates were 2.7 % (7/261), 1.0 % (5/494), and 6.3 % (610/9754), respectively. The infant and child mortality rates were significantly lower than the adult mortality rate (Chi square test: P = 0.03 and P < 0.001, respectively). Hepatitis A virus- and hepatitis C virus-induced ALD had favorable outcomes, with in-hospital mortality rates of approximately 2 %. Plasma exchange and continuous hemodiafiltration were performed in 5.3 % (556 cases) and 3.4 % (360 cases) of all ALD cases, respectively. CONCLUSIONS In-hospital mortality of ALD in Japan was acceptably low, and was affected by the etiology and patient background characteristics. The present study adds important information on the incidence and prognosis of ALD in Japan. Improvement of public health surveillance systems is necessary for population-based patient monitoring.
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Affiliation(s)
- Masaya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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