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Biswas S, Kumar R, Shalimar, Acharya SK. Viral hepatitis-induced acute liver failure. Indian J Gastroenterol 2024; 43:312-324. [PMID: 38451383 DOI: 10.1007/s12664-024-01538-w] [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: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801 507, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- KIIT University, Bhubaneswar, 751 024, India
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India
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Amer K, Flikshteyn B, Lingiah V, Tafesh Z, Pyrsopoulos NT. Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2023; 27:563-579. [PMID: 37380283 DOI: 10.1016/j.cld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Kamal Amer
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Ben Flikshteyn
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Vivek Lingiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Zaid Tafesh
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 53, Newark, NJ 07101-1709, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 536, Newark, NJ 07101-1709, USA.
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Michel C, Warming S, Neto AS, Abeygunawardana V, Fisher C, Kishore K, Warrillow S, Bellomo R. Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure. J Crit Care 2023; 76:154289. [PMID: 36933387 DOI: 10.1016/j.jcrc.2023.154289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF). MATERIALS AND METHODS Retrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180. RESULTS Of 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84-168) hours, delivering a median 2244 (IQR: 979-4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation. CONCLUSIONS In ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.
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Affiliation(s)
- Claire Michel
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott Warming
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | | | - Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
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El Khiat A, El Hiba O, Tamegart L, Rais H, Fdil N, Sellami S, El Mokhtar MA, Gamrani H. Time dependent alteration of locomotor behavior in rat with acute liver failure induced cerebellar neuroinflammation and neuro-astroglial damage. J Chem Neuroanat 2021; 119:102055. [PMID: 34863855 DOI: 10.1016/j.jchemneu.2021.102055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 11/27/2021] [Accepted: 11/27/2021] [Indexed: 11/26/2022]
Abstract
Hepatic encephalopathy (HE) is a neurophysiological syndrome secondary to acute or chronic liver failure. Studies showed that HE patients exhibit a deficit in motor coordination, which may result from cerebellar functional impairment. The aim of this study is to assess the time-dependent alteration of locomotor behavior and the glial and neuronal alteration in rat with acute HE induced chemically. The study was carried out in male Sprague-Dawley rats with thioacetamide (TAA) induced acute liver failure at different stages 12 h, 24 h and 36 h. Hepatic and renal functions were assessed via various biochemical and histopathological examinations, while the cerebellum and the midbrain were examined using histology and immunohistochemistry for tyrosine hydroxylase (TH), cyclooxygenase-2 (COX-2) and glial fibrillary acidic protein (GFAP). We used as well, the open field test and the Rotarod test for assessing the locomotor activity and coordination. Our data showed a progressive loss of liver function and a progressive alteration in locomotor behavior and motor coordination in acute HE rats. In the cerebellum, we noted an increase in the degeneration of cerebellar Purkinje neurons parallel to increased COX-2 immunoreactivity together with astrocytic morphology and density changes. Likewise, in substantia nigra pars compacta, TH levels were reduced. We showed through the current study, a progressive deterioration in locomotor behavior in acute HE rats, as a result of Purkinje neurons death and a deficient dopaminergic neurotransmission, together with the morpho-functional astroglial modifications involving the oxidative stress and neuroinflammation.
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Affiliation(s)
- Abdelaati El Khiat
- Laboratory of Clinical and Experimental Neurosciences and Environment, faculty of Medicine and Pharmacy, Cadi Ayyad University, 4000 Marrakech, Morocco; Higher Institute of Nursing Professions and Health Techniques, Ouarzazate, Morocco.
| | - Omar El Hiba
- Nutritional Physiopathologies and Toxicology Team, faculty of Sciences, Chouaib Doukkali University, El Jadida, Morocco.
| | - Lahcen Tamegart
- Laboratory of Clinical and Experimental Neurosciences and Environment, faculty of Medicine and Pharmacy, Cadi Ayyad University, 4000 Marrakech, Morocco; Department of Biology, Faculty of Science, Abdelmalek Essaadi University, Tetouan, Morocco
| | - Hanane Rais
- Laboratory of Morphosciences, Faculty of Medicine and Pharmacy, Cadi Ayyad University, Morocco; Mohammed VI University Hospital, Marrakech, Morocco
| | - Naima Fdil
- Metabolics platform, Biochemistry Laboratory, Faculty of Medicine, Cadi Ayyad University, Sidi Abbad, BP 40000 Marrakech, Morocco
| | | | - Mohamed Ait El Mokhtar
- Laboratory of Biochemistry, Environment &Agri-food URAC 36, Department of Biology, Faculty of Sciences and Techniques, Mohmmedia, Hassan II University of Casablanca, Morocco
| | - Halima Gamrani
- Laboratory of Clinical and Experimental Neurosciences and Environment, faculty of Medicine and Pharmacy, Cadi Ayyad University, 4000 Marrakech, Morocco.
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Zoica BS, Deep A. Extracorporeal renal and liver support in pediatric acute liver failure. Pediatr Nephrol 2021; 36:1119-1128. [PMID: 32500250 DOI: 10.1007/s00467-020-04613-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 05/07/2020] [Accepted: 05/12/2020] [Indexed: 12/28/2022]
Abstract
The liver is the only organ which can regenerate and, thus, potentially negate the need for transplantation in acute liver failure (ALF). Cerebral edema and sepsis are leading causes of mortality in ALF. Both water-soluble and protein-bound toxins have been implicated in pathogenesis of various ALF complications. Ammonia is a surrogate marker of water-soluble toxin accumulation in ALF and high levels are associated with higher grades of hepatic encephalopathy, raised intracranial pressure, and mortality. Therefore, extracorporeal therapies aim to lower ammonia and maintain fluid balance and cytokine homeostasis. The most common and easily available modality is continuous kidney replacement therapy (CKRT). Early initiation of high-volume CKRT utilizing an anticoagulation regimen minimizing treatment downtime and delivering the prescribed dose is highly desirable. Ideally, extracorporeal liver-assist devices (ECLAD) should perform both synthetic and detoxification functions of the liver. ECLAD may temporarily replace lost liver function and serve as a bridge, either to spontaneous recovery or liver transplantation. Various bioartificial and biologic liver-assist devices are described in specialty literature, including molecular adsorbent recirculating system (MARS), single pass albumin dialysis (SPAD), and total plasma exchange (TPE); however, clinicians commonly use modalities easily available in intensive care units. There is a lack of standardization of indications for ECLAD, availability of different extracorporeal devices with varied technical approaches, and, of note, the differences in doses of ECLAD provided in clinical practice. We review the practicalities and evidence regarding these four artificial liver support devices in pediatric ALF.
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Affiliation(s)
- Bogdana Sabina Zoica
- Pediatric Intensive Care Unit, King's College Hospital, 3rd Floor Cheyne Wing, London, SE5 9RS, UK
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, 3rd Floor Cheyne Wing, London, SE5 9RS, UK.
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Guazzelli PA, Cittolin-Santos GF, Meira-Martins LA, Grings M, Nonose Y, Lazzarotto GS, Nogara D, da Silva JS, Fontella FU, Wajner M, Leipnitz G, Souza DO, de Assis AM. Acute Liver Failure Induces Glial Reactivity, Oxidative Stress and Impairs Brain Energy Metabolism in Rats. Front Mol Neurosci 2020; 12:327. [PMID: 31998076 PMCID: PMC6968792 DOI: 10.3389/fnmol.2019.00327] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Accepted: 12/18/2019] [Indexed: 01/02/2023] Open
Abstract
Acute liver failure (ALF) implies a severe and rapid liver dysfunction that leads to impaired liver metabolism and hepatic encephalopathy (HE). Recent studies have suggested that several brain alterations such as astrocytic dysfunction and energy metabolism impairment may synergistically interact, playing a role in the development of HE. The purpose of the present study is to investigate early alterations in redox status, energy metabolism and astrocytic reactivity of rats submitted to ALF. Adult male Wistar rats were submitted either to subtotal hepatectomy (92% of liver mass) or sham operation to induce ALF. Twenty-four hours after the surgery, animals with ALF presented higher plasmatic levels of ammonia, lactate, ALT and AST and lower levels of glucose than the animals in the sham group. Animals with ALF presented several astrocytic morphological alterations indicating astrocytic reactivity. The ALF group also presented higher mitochondrial oxygen consumption, higher enzymatic activity and higher ATP levels in the brain (frontoparietal cortex). Moreover, ALF induced an increase in glutamate oxidation concomitant with a decrease in glucose and lactate oxidation. The increase in brain energy metabolism caused by astrocytic reactivity resulted in augmented levels of reactive oxygen species (ROS) and Poly [ADP-ribose] polymerase 1 (PARP1) and a decreased activity of the enzymes superoxide dismutase and glutathione peroxidase (GSH-Px). These findings suggest that in the early stages of ALF the brain presents a hypermetabolic state, oxidative stress and astrocytic reactivity, which could be in part sustained by an increase in mitochondrial oxidation of glutamate.
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Affiliation(s)
- Pedro Arend Guazzelli
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil.,Department of Biochemistry, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Giordano Fabricio Cittolin-Santos
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil.,Department of Biochemistry, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Leo Anderson Meira-Martins
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Mateus Grings
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Yasmine Nonose
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Gabriel S Lazzarotto
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Daniela Nogara
- Department of Biochemistry, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Jussemara S da Silva
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Fernanda U Fontella
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Moacir Wajner
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil.,Department of Biochemistry, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Guilhian Leipnitz
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Diogo O Souza
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil.,Department of Biochemistry, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil
| | - Adriano Martimbianco de Assis
- Post-graduate Program in Biological Sciences: Biochemistry, ICBS, Universidade Federal do Rio Grande do Sul-UFRGS, Porto Alegre, Brazil.,Post-graduate Program in Health and Behavior, Health Sciences Centre, Universidade Católica de Pelotas-UCPel, Pelotas, Brazil
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Saunders JM, González-Maeso J, Bajaj JS. The Toll of Hyperammonemia on the Brain. Cell Mol Gastroenterol Hepatol 2019; 8:649-650. [PMID: 31536718 PMCID: PMC6889707 DOI: 10.1016/j.jcmgh.2019.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 08/23/2019] [Indexed: 12/10/2022]
Affiliation(s)
| | | | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia.
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8
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Cittolin-Santos G, Guazzelli P, Nonose Y, Almeida R, Fontella F, Pasquetti M, Ferreira-Lima F, Lazzaroto G, Berlezi R, Osvaldt A, Calcagnotto M, de Assis A, Souza D. Behavioral, Neurochemical and Brain Oscillation Abnormalities in an Experimental Model of Acute Liver Failure. Neuroscience 2019; 401:117-129. [DOI: 10.1016/j.neuroscience.2018.12.032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Revised: 12/14/2018] [Accepted: 12/18/2018] [Indexed: 01/17/2023]
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9
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Escorsell À, Castellote J, Sánchez-Delgado J, Charco R, Crespo G, Fernández J. Manejo de la insuficiencia hepática aguda grave. Documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:51-64. [DOI: 10.1016/j.gastrohep.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/19/2018] [Accepted: 07/27/2018] [Indexed: 02/08/2023]
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10
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Krawitz S, Lingiah V, Pyrsopoulos NT. Acute Liver Failure: Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2018; 22:243-256. [PMID: 29605064 DOI: 10.1016/j.cld.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute liver failure is accompanied by a pathologic syndrome common to numerous different etiologies of liver injury. This acute liver failure syndrome leads to potentially widespread devastating end-organ consequences. Systemic dysregulation and dysfunction is likely propagated via inflammation as well as underlying hepatic failure itself. Decoding the mechanisms of the disease process and multisystemic involvement of acute liver failure offers potential for targeted treatment opportunities and improved clinical outcomes in this sick population.
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Affiliation(s)
- Steven Krawitz
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-534, Newark, NJ 07103, USA.
| | - Vivek Lingiah
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-530, Newark, NJ 07103, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-536, Newark, NJ 07103, USA
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Singh SA, Singh A, Pamecha V, Pandey CK, Sarin SK. Living Donor Liver Transplantation for Acute Liver Failure With Fixed Pupils: Are We Fixed? J Clin Exp Hepatol 2017; 7:155-157. [PMID: 28663681 PMCID: PMC5478968 DOI: 10.1016/j.jceh.2016.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Accepted: 09/28/2016] [Indexed: 12/12/2022] Open
Abstract
Living donor liver transplantation (LDLT) is fraught with the social and ethical dilemma of excising a part of the liver from a healthy first-degree relative. When LDLT is to be done for an acute liver failure (ALF), identification of a suitable donor is a race against time. Herein, we describe a unique challenge faced by the transplant team of whether to proceed with donor hepatectomy from a son, when the recipient (HBV-related ALF) developed non-reactive fully dilated pupils on the table, prior to beginning the surgery. The patient ultimately underwent a LDLT despite fixed dilated pupils by virtue of further workup, which suggested that cerebral blood flow was maintained despite clinical evidence of brainstem herniation.
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Affiliation(s)
- Shweta A. Singh
- Additional Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Science, New Delhi 110070, India,Address for correspondence: Shweta A. Singh, Anaesthesiology &Crititcal Care, Institute of Liver and Biliary Sciences, D1, Vasant Kunj, New Delhi 110070, India. Tel.: +91 9810625177.Shweta A. Singh, Anaesthesiology &Crititcal Care, Institute of Liver and Biliary SciencesD1, Vasant KunjNew Delhi110070India
| | - Anshuman Singh
- Assistant Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Viniyendra Pamecha
- Additional Professor – HPB Surgery & Head Liver Transplantation Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Chandra Kant Pandey
- Professor – Anaesthesiology & Critical Care Institute of Liver and Biliary Sciences, New Delhi 110070, India
| | - Shiv Kumar Sarin
- Senior Professor & Head of Department, Hepatology, Institute of Liver and Biliary Sciences, New Delhi 110070, India
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Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 517] [Impact Index Per Article: 73.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
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Palenzuela L, Oria M, Romero-Giménez J, Garcia-Lezana T, Chavarria L, Cordoba J. Gene expression profiling of brain cortex microvessels may support brain vasodilation in acute liver failure rat models. Metab Brain Dis 2016; 31:1405-1417. [PMID: 27406245 DOI: 10.1007/s11011-016-9863-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Accepted: 06/19/2016] [Indexed: 12/13/2022]
Abstract
Development of brain edema in acute liver failure can increase intracranial pressure, which is a severe complication of the disease. However, brain edema is neither entirely cytotoxic nor vasogenic and the specific action of the brain microvasculature is still unknown. We aimed to analyze gene expression of brain cortex microvessels in two rat models of acute liver failure. In order to identify global gene expression changes we performed a broad transcriptomic approach in isolated brain cortex microvessels from portacaval shunted rats after hepatic artery ligation (HAL), hepatectomy (HEP), or sham by array hybridization and confirmed changes in selected genes by RT-PCR. We found 157 and 270 up-regulated genes and 143 and 149 down-regulated genes in HAL and HEP rats respectively. Western blot and immunohistochemical assays were performed in cortex and ELISA assays to quantify prostaglandin E metabolites were performed in blood of the sagittal superior sinus. We Identified clusters of differentially expressed genes involving inflammatory response, transporters-channels, and homeostasis. Up-regulated genes at the transcriptional level were associated with vasodilation (prostaglandin-E synthetase, prostaglandin-E receptor, adrenomedullin, bradykinin receptor, adenosine transporter), oxidative stress (hemoxygenase, superoxide dismutase), energy metabolism (lactate transporter) and inflammation (haptoglobin). The only down-regulated tight junction protein was occludin but slightly. Prostaglandins levels were increased in cerebral blood with progression of liver failure. In conclusion, in acute liver failure, up-regulation of several genes at the level of microvessels might suggest an involvement of energy metabolism accompanied by cerebral vasodilation in the cerebral edema at early stages.
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Affiliation(s)
- Lluis Palenzuela
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Marc Oria
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain.
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain.
- Center for Fetal, Cellular and Mollecular Therapy, Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center (CCHMC), Cincinnati, OH, USA.
| | - Jordi Romero-Giménez
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Teresa Garcia-Lezana
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Laia Chavarria
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Cordoba
- Servei de Medicina Interna-Hepatologia, Valld'Hebron Institut de Recerca (VH-IR), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
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Bittencourt PL, Terra C, Parise ER, Farias AQ, Arroyo V, Fernandez J, Pereira G, Maubouisson LM, Andrade GM, Costa FGDB, Codes L, Andrade AR, Mattos AAD, Torres A, Couto F, Zyngier I. Intensive care management of patients with liver disease: proceedings of a single-topic conference sponsored by the Brazilian Society of Hepatology. ARQUIVOS DE GASTROENTEROLOGIA 2016; 52 Suppl 1:55-72. [PMID: 26959806 DOI: 10.1590/s0004-28032015000500004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Survival rates of critically ill patients with liver disease has sharply increased in recent years due to several improvements in the management of decompensated cirrhosis and acute liver failure. This is ascribed to the incorporation of evidence-based strategies from clinical trials aiming to reduce mortality. In order to discuss the cutting-edge evidence regarding critical care of patients with liver disease, a joint single topic conference was recently sponsored by the Brazilian Society of Hepatology in cooperation with the Brazilian Society of Intensive Care Medicine and the Brazilian Association for Organ Transplantation. This paper summarizes the proceedings of the aforementioned meeting and it is intended to guide intensive care physicians, gastroenterologists and hepatologists in the care management of patients with liver disease.
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Affiliation(s)
- Paulo Lisboa Bittencourt
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Carlos Terra
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, RJ, Brazil
| | | | - Alberto Queiroz Farias
- Departamento de Gastroenterologia, Faculdade de Medicina, Universidade de São Paulo, SP, Brazil
| | | | | | - Gustavo Pereira
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
| | | | | | | | - Liana Codes
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | - Antônio Ricardo Andrade
- Hospital Português, Salvador, Brazil.,Hospital Universitário Professor Edgard Santos, Universidade Federal da Bahia, Salvador, BA, Brasil
| | | | - André Torres
- Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro, RJ, Brazil
| | - Fernanda Couto
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
| | - Ivan Zyngier
- Departamento de Gastroenterologia, Hospital Federal do Bonsucesso, Rio de Janeiro, RJ, Brasil
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16
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Olin P, Hausken J, Foss A, Karlsen TH, Melum E, Haugaa H. Continuous molecular adsorbent recirculating system treatment in 69 patients listed for liver transplantation. Scand J Gastroenterol 2015; 50:1127-34. [PMID: 25865318 PMCID: PMC4673540 DOI: 10.3109/00365521.2015.1027262] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The molecular adsorbent recirculating system (MARS) is used to purify blood from albumin-bound toxins in patients with liver failure. However, the application of MARS has not demonstrated improved survival in randomized clinical trials and the clinical utility has not been finally established. In our department, the use of MARS is now restricted to the most critically ill patients with acute or acute on chronic liver failure. MATERIAL AND METHODS Since 2005, we have treated 69 patients (30 males/39 females with median age of 49 years ranging from 1 months to 70 years) listed for liver transplantation (LT) with MARS. Median model of end-stage liver disease score in patients older than 12 years of age (n = 56) was 33 (interquartile range 26-39). The flow rate was 35-40 mL/kg/h and treatment kits were changed every 8-12 h. The patients were treated for a median of 27 h (range 1-144 h). RESULTS Fifty-six patients (81%) were transplanted. Nine died before they could be transplanted, and four patients recovered without transplantation. Forty-six (82%) of the transplanted patients were alive 30 days after transplantation. Ammonium decreased modestly from a median of 148 to 124 µM (p = 0.03) during MARS treatment. We detected worsening of coagulopathy with significant decreases in platelet count and fibrinogen concentrations, and increase in International Normalized Ratio. Phosphate and magnesium decreased significantly during MARS treatment. CONCLUSION Continuous MARS therapy may bridge liver failure patients to LT under close observation and treatment of coagulopathy and electrolyte disturbances.
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Affiliation(s)
- Per Olin
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway,Correspondence: Per Olin, Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway. +47 23 07 00 00.
| | - John Hausken
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Aksel Foss
- Section for Transplantation Surgery, Department of Transplantation Medicine, Oslo University Hospital, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tom Hemming Karlsen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway,Department of Transplantation Medicine, Section for Gastroenterology, Oslo University Hospital, Oslo, Norway
| | - Espen Melum
- Department of Transplantation Medicine, Section for Gastroenterology, Oslo University Hospital, Oslo, Norway,Norwegian PSC Research Center, Division of Cancer, Surgery and Transplantation, Oslo University Hospital, Rikshospitalet, Oslo, Norway,K.G. Jebsen Inflammation Research Centre, Research Institute of Internal Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Håkon Haugaa
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway,Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Amieva-Balmori M, Mejia-Loza SMI, Ramos-González R, Zamarripa-Dorsey F, García-Ruiz E, Pérez y López N, Juárez-Valdés EI, López-Luria A, Remes-Troche JM. Model for end-stage liver disease-Na score or Maddrey discrimination function index, which score is best? World J Hepatol 2015; 7:2119-2126. [PMID: 26301054 PMCID: PMC4539405 DOI: 10.4254/wjh.v7.i17.2119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 01/16/2015] [Accepted: 07/17/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the ability of model for end-stage liver disease (MELD)-Na and Maddrey discrimination function index (DFI) to predict mortality at 30 and 90 d in patients with alcoholic hepatitis (AH).
METHODS: We prospectively assessed 52 patients with AH. Demographic, clinical and laboratory parameters were obtained. MELD-Na and Maddrey DFI were calculated on admission. Short-term mortality was assessed at 30 and 90 d. Receiver operating characteristic curve analysis was performed.
RESULTS: Thirty-day and 90-d mortality was 44% and 58%, respectively. In the univariate analysis, sodium levels was associated with mortality at 30 and 90 d (P = 0.001 and P = 0.03). Child stage, encephalopathy, ascites, or types of treatment were not associated with mortality. MELD-Na was the only predictive factor for mortality at 90 d. For 30-d mortality area under the curve (AUC) was 0.763 (95%CI: 0.63-0.89) for Maddrey DFI and 0.784 for MELD-Na (95%CI: 0.65-0.91, P = 0.82). For 90-d mortality AUC was 0.685 (95%CI: 0.54-0.83) for Maddrey DFI and 0.8710 for MELD-Na (95%CI: 0.76-0.97, P = 0.041).
CONCLUSION: AH is associated with high short-term mortality. Our results show that MELD-Na is a more valuable model than DFI to predict short-term mortality.
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Pathogenesis of brain edema and investigation into anti-edema drugs. Int J Mol Sci 2015; 16:9949-75. [PMID: 25941935 PMCID: PMC4463627 DOI: 10.3390/ijms16059949] [Citation(s) in RCA: 194] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Revised: 04/15/2015] [Accepted: 04/27/2015] [Indexed: 12/18/2022] Open
Abstract
Brain edema is a potentially fatal pathological state that occurs after brain injuries such as stroke and head trauma. In the edematous brain, excess accumulation of extracellular fluid results in elevation of intracranial pressure, leading to impaired nerve function. Despite the seriousness of brain edema, only symptomatic treatments to remove edema fluid are currently available. Thus, the development of novel anti-edema drugs is required. The pathogenesis of brain edema is classified as vasogenic or cytotoxic edema. Vasogenic edema is defined as extracellular accumulation of fluid resulting from disruption of the blood-brain barrier (BBB) and extravasations of serum proteins, while cytotoxic edema is characterized by cell swelling caused by intracellular accumulation of fluid. Various experimental animal models are often used to investigate mechanisms underlying brain edema. Many soluble factors and functional molecules have been confirmed to induce BBB disruption or cell swelling and drugs targeted to these factors are expected to have anti-edema effects. In this review, we discuss the mechanisms and involvement of factors that induce brain edema formation, and the possibility of anti-edema drugs targeting them.
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Rama Rao KV, Jayakumar AR, Norenberg MD. Brain edema in acute liver failure: mechanisms and concepts. Metab Brain Dis 2014; 29:927-36. [PMID: 24567229 DOI: 10.1007/s11011-014-9502-y] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2014] [Accepted: 02/05/2014] [Indexed: 12/18/2022]
Abstract
Brain edema and associated increase in intracranial pressure continue to be lethal complications of acute liver failure (ALF). Abundant evidence suggests that the edema in ALF is largely cytotoxic brought about by swelling of astrocytes. Elevated blood and brain ammonia levels have been strongly implicated in the development of the brain edema. Additionally, inflammation and sepsis have been shown to contribute to the astrocyte swelling/brain edema in the setting of ALF. We posit that ammonia initiates a number of signaling events, including oxidative/nitrative stress (ONS), the mitochondrial permeability transition (mPT), activation of the transcription factor (NF-κB) and signaling kinases, all of which have been shown to contribute to the mechanism of astrocyte swelling. All of these factors also impact ion-transporters, including Na(+), K(+), Cl(-) cotransporter and the sulfonylurea receptor 1, as well as the water channel protein aquaporin-4 resulting in a perturbation of cellular ion and water homeostasis, ultimately resulting in astrocyte swelling/brain edema. All of these events are also potentiated by inflammation. This article reviews contemporary knowledge regarding mechanisms of astrocyte swelling/brain edema formation which hopefully will facilitate the identification of therapeutic targets capable of mitigating the brain edema associated with ALF.
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Affiliation(s)
- Kakulavarapu V Rama Rao
- Department of Pathology, University of Miami Miller School of Medicine, PO Box 016960, Miami, FL, 33101, USA,
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20
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Sørensen H, Grocott HP, Niemann M, Rasmussen A, Hillingsø JG, Frederiksen HJ, Secher NH. Ventilatory strategy during liver transplantation: implications for near-infrared spectroscopy-determined frontal lobe oxygenation. Front Physiol 2014; 5:321. [PMID: 25202281 PMCID: PMC4142416 DOI: 10.3389/fphys.2014.00321] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Accepted: 08/04/2014] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND As measured by near infrared spectroscopy (NIRS), cerebral oxygenation (ScO2) may be reduced by hyperventilation in the anhepatic phase of liver transplantation surgery (LTx). Conversely, the brain may be subjected to hyperperfusion during reperfusion of the grafted liver. We investigated the relationship between ScO2 and end-tidal CO2 tension (EtCO2) during the various phases of LTx. METHODS In this retrospective study, 49 patients undergoing LTx were studied. Forehead ScO2, EtCO2, minute ventilation (VE), and hemodynamic variables were recorded from the beginning of surgery through to the anhepatic and reperfusion phases during LTx. RESULTS In the anhepatic phase, ScO2 was reduced by 4.3% (95% confidence interval: 2.5-6.0%; P < 0.0001), EtCO2 by 0.3 kPa (0.2-0.4 kPa; P < 0.0001), and VE by 0.4 L/min (0.1-0.7 L/min; P = 0.0018). Conversely, during reperfusion of the donated liver, ScO2 increased by 5.5% (3.8-7.3%), EtCO2 by 0.7 kPa (0.5-0.8 kPa), and VE by 0.6 L/min (0.3-0.9 L/min; all P < 0.0001). Changes in ScO2 were correlated to those in EtCO2 (Pearson r = 0.74; P < 0.0001). CONCLUSION During LTx, changes in ScO2 are closely correlated to those of EtCO2. Thus, this retrospective analysis suggests that attention to maintain a targeted EtCO2 would result in a more stable ScO2 during the operation.
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Affiliation(s)
- Henrik Sørensen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hilary P. Grocott
- Department of Anesthesia and Perioperative Medicine, St. Boniface Hospital, University of ManitobaWinnipeg, MB, Canada
| | - Mads Niemann
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Allan Rasmussen
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Jens G. Hillingsø
- Department of Surgery and Transplantation, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Hans J. Frederiksen
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
| | - Niels H. Secher
- Department of Anesthesia, Rigshospitalet, University of CopenhagenCopenhagen, Denmark
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21
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Castello H, Schoch L, Grogan TA. Acute liver failure in an obstetric patient: challenge of critical care for 1 patient with 2 subspecialty needs. Crit Care Nurse 2013; 33:48-56. [PMID: 23377157 DOI: 10.4037/ccn2013631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Acute fatty liver of pregnancy is a rare and life-threatening disease associated with a defect in fatty acid metabolism in the fetus that causes liver disease in the mother. Prompt diagnosis and management are critical to the outcome of both the mother and the fetus and require involvement of several medical specialties, including hepatology, obstetrics, and, possibly, critical care. The included case study describes a woman with acute fatty liver of pregnancy decompensating to acute liver failure complicated by encephalopathy, cerebral edema, and intracranial hypertension. Subsequent management of these conditions, including the woman's progression to liver transplant, is provided.
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Affiliation(s)
- Holly Castello
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
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22
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Serum sodium based modification of the MELD does not improve prediction of outcome in acute liver failure. BMC Gastroenterol 2013; 13:58. [PMID: 23551795 PMCID: PMC3637827 DOI: 10.1186/1471-230x-13-58] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 03/21/2013] [Indexed: 12/25/2022] Open
Abstract
Background Acute liver failure (ALF) is a devastating clinical syndrome with a high mortality rate. The MELD score has been implied as a prognostic tool in ALF. Hyponatremia is associated with lethal outcome in ALF. Inclusion of serum sodium (Na) into the MELD score was found to improve its predictive value in cirrhotic patients. Therefore the aim of this study was to determine whether inclusion of serum Na improves the predictive value of MELD in ALF compared to established criteria. Methods In a prospective single center study (11/2006–12/2010), we recruited 108 consecutive ALF patients (64% females / 36% males), who met the criteria defined by the “Acute Liver Failure Study Group Germany”. Upon admission, clinical and laboratory data were collected, King’s College Criteria (KCC), Model of End Stage Liver Disease score (MELD), and serum sodium based modifications like the MELD-Na score and the United Kingdom Model of End Stage Liver Disease score (UKELD) were calculated and area under the receiver operating characteristic curve analyses were performed regarding the prediction of spontaneous recovery (SR) or non-spontaneous recovery (NSR; death or transplantation). Results Serum bilirubin was of no prognostic value in ALF, and Na also failed to predict NSR in ALF. The classical MELD score was superior to sodium-based modifications and KCC. Conclusions We validated the prognostic value of MELD-Na and UKELD in ALF. Classic MELD score calculations performed superior to KCC in the prediction of NSR. Serum Na and Na-based modifications of MELD did not further improve its prognostic value.
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Staufer K, Trauner M, Fuhrmann V. Akutes Leberversagen. WIENER KLINISCHE WOCHENSCHRIFT. EDUCATION 2012; 7:59-76. [PMID: 32288850 PMCID: PMC7101669 DOI: 10.1007/s11812-012-0051-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Katharina Staufer
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Michael Trauner
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
| | - Valentin Fuhrmann
- Klinische Abteilung für Gastroenterologie und Hepatologie, Intensivstation 13h1, Universitätsklinik für Innere Medizin III, Medizinische Universität Wien, Wien, Österreich
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Pretransplant Neurological Presentation and Severe Posttransplant Brain Injury in Patients With Acute Liver Failure. Transplantation 2012; 94:768-74. [DOI: 10.1097/tp.0b013e3182620596] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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D'Agostino D, Diaz S, Sanchez MC, Boldrini G. Management and prognosis of acute liver failure in children. Curr Gastroenterol Rep 2012; 14:262-269. [PMID: 22528660 DOI: 10.1007/s11894-012-0260-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Although the etiologies of pediatric acute liver failure (ALF) are diverse, ultimate pathophysiologic pathways and management challenges for these disorders, usually lethal in the pre-transplant era, are similar. This review considers particularly the mechanisms of, and monitoring for, intracranial hypertension and coagulopathy; summarizes detailed advice for management of the ALF-associated failures of multiple body systems; and reviews the variety of prognostic scores available to guide management and assist in choosing the patients most apt to benefit from liver transplantation and the optimal timing for such transplantation.
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Affiliation(s)
- Daniel D'Agostino
- Gastroenterology-Hepatology Division, Liver-Intestinal Transplantation Center, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Vaquero J. Therapeutic hypothermia in the management of acute liver failure. Neurochem Int 2012; 60:723-35. [DOI: 10.1016/j.neuint.2011.09.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2011] [Revised: 09/13/2011] [Accepted: 09/13/2011] [Indexed: 02/07/2023]
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Lee WM. Recent developments in acute liver failure. Best Pract Res Clin Gastroenterol 2012; 26:3-16. [PMID: 22482521 PMCID: PMC3551290 DOI: 10.1016/j.bpg.2012.01.014] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2011] [Accepted: 01/24/2012] [Indexed: 02/08/2023]
Abstract
Acute liver failure is a remarkably rare syndrome, the result of rapid hepatocyte injury occurring over days or a few weeks, and encompassing multiple etiologies, but all with a remarkably similar clinical picture. The clinical features of coagulopathy and encephalopathy characterize this severe and often fatal condition. To date, transplantation has been the only reliable form of rescue for many patients. Recent developments have included a clearer understanding of the different contributing etiologies, how to build a diagnosis and prognosis based on initial laboratory findings, a more aggressive approach to intensive care management and more detailed understanding of the role of transplantation in this setting. This review will provide an overview of standard practices and new research initiatives and findings for this interesting but vexing orphan disease. Particular attention will be paid to practical matters for clinicians to consider in approaching the ALF patient. Few controlled clinical trials have been possible because of the condition's rarity. Critical care of these rare patients is key to their survival and decisions must be made decisively, sometimes with inadequate information. Experience is helpful but experienced clinician managers are even rarer than the disease: few hepatologists or intensivists have in-depth experience with ALF patients.
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Mpabanzi L, Jalan R. Neurological complications of acute liver failure: pathophysiological basis of current management and emerging therapies. Neurochem Int 2011; 60:736-42. [PMID: 22100567 DOI: 10.1016/j.neuint.2011.10.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 10/17/2011] [Accepted: 10/26/2011] [Indexed: 12/11/2022]
Abstract
One of the major causes of mortality in patients with acute liver failure (ALF) is the development of hepatic encephalopathy (HE) which is associated with increased intracranial pressure (ICP). High ammonia levels, increased cerebral blood flow and increased inflammatory response have been identified as major contributors to the development of HE and the related brain swelling. The general principles of the management of patients with ALF are straightforward. They include identifying the insult causing hepatic injury, providing organ systems support to optimize the patient's physical condition, anticipation and prevention of development of complications. Increasing insights into the pathophysiological mechanisms of ALF are contributing to better therapies. For instance, the evident role of cerebral hyperemia in the pathogenesis of increased ICP has led to a re-evaluation of established therapies such as hyperventilation, N-acetylcysteine, thiopentone sodium and propofol. The role of systemic inflammatory response in the pathogenesis of increased ICP has also gained importance supporting the concept that antibiotics given prophylactically reduce the risk of developing sepsis during the course of illness. Moderate hypothermia has also been established as a therapy able to reduce ICP in patients with uncontrolled intracranial hypertension and to prevent increases in ICP during orthopic liver transplantation. Ornithine phenylacetate, a new drug in the treatment of liver failure, and liver replacement therapies are still being investigated both experimentally and clinically. Despite many advances in the understanding of the pathophysiological basis and the management of intracranial hypertension in ALF, more clinical trials should be conducted to determine the best therapeutic management for this difficult clinical event.
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Affiliation(s)
- Liliane Mpabanzi
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 5800, Maastricht, The Netherlands
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Abstract
PURPOSE OF REVIEW Acute liver failure (ALF) results in a multitude of serious complications that often lead to multi-organ failure. This brief review focuses on the pathophysiological processes in ALF and how to manage these. RECENT FINDINGS The clinical presentation in ALF ranges from slightly altered conscious level with profound coagulopathy to coma with a catastrophic failure of multiple organs, including uncontrollable cerebral edema and brain death, which is rarely seen in decompensated cirrhosis. Interestingly, ALF patients who recover as the liver is regenerating, usually do not suffer from hepatic or extrahepatic sequelae. In contrast patients surviving acute-on-chronic liver failure will return to a state with incompensated cirrhosis, and eventually need transplantation for survival.In the management of ALF, the use of noradrenalin in combination with continuous high-dose renal replacement therapy, terlipressin, hypertonic sodium chloride, and mannitol can ameliorate systemic vasodilation and attenuate brain edema. Furthermore, liver assist devices seem to improve extrahepatic organ dysfunction and survival. SUMMARY Insight into the of pathopysiological mechanisms of ALF that lead to cardiovascular instability, brain edema and development of multiorgan failure has advanced and resulted in improved survival. The role of liver assisting is still unknown but preliminary results indicate a positive effect on survival.
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Abstract
OPINION STATEMENT Cerebral edema is very common in patients with acute liver failure and encephalopathy. In severe cases, it produces brain tissue shift and potentially fatal herniation. Brain swelling in acute liver failure is produced by a combination of cytotoxic (cellular) and vasogenic edema. Accumulation of ammonia and glutamine leads to disturbances in the regulation of cerebral osmolytes, increased free radical production and calcium-mediated mitochondrial injury, and alterations in glucose metabolism (inducing high levels of brain lactate), resulting in astrocyte swelling. Activation of inflammatory cytokines can cause increased blood-brain barrier permeability leading to vasogenic edema, although the relative contribution of vasogenic edema is probably minor compared with cellular swelling. Cerebral blood flow is disturbed and generally increased in patients with acute liver failure; persistent vasodilatation and loss of autoregulation may generate hyperemia, and the consequent augmentation in cerebral blood volume may exacerbate brain edema.Adequate management of intracranial hypertension demands continuous monitoring of intracranial pressure and cerebral perfusion pressure. Coagulation status should be assessed and bleeding diathesis should be treated prior to insertion of the intracranial pressure monitor. Standard treatment measures such as hyperventilation and osmotic agents (e.g., mannitol, hypertonic saline) remain useful first-line interventions. Although hypertonic saline may be preferred in patients with coexistent hyponatremia, the rate of correction of hyponatremia must be gradual to avoid the risk of osmotic demyelination. Barbiturate coma and intravenous indomethacin are available options in refractory cases. The most promising novel therapeutic alternative is the induction of moderate hypothermia (aiming for a core temperature of 32-34°C). However, the safety and efficacy of therapeutic hypothermia for brain swelling caused by liver failure still needs to be proven in randomized, controlled clinical trials. Management of intracranial pressure in patients with acute liver failure should be guided by well-defined treatment protocols.
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Affiliation(s)
- Alejandro A Rabinstein
- Department of Neurology, W8B, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA,
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32
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Tang XN, Yenari MA. Hypothermia as a cytoprotective strategy in ischemic tissue injury. Ageing Res Rev 2010; 9:61-8. [PMID: 19833233 DOI: 10.1016/j.arr.2009.10.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Revised: 10/02/2009] [Accepted: 10/06/2009] [Indexed: 12/19/2022]
Abstract
Hypothermia is a well established cytoprotectant, with remarkable and consistent effects demonstrated across multiple laboratories. At the clinical level, it has recently been shown to improve neurological outcome following cardiac arrest and neonatal hypoxia-ischemia. It is increasingly being embraced by the medical community, and could be considered an effective neuroprotectant. Conditions such as brain injury, hepatic encephalopathy and cardiopulmonary bypass seem to benefit from this intervention. It's role in direct myocardial protection is also being explored. A review of the literature has demonstrated that in order to appreciate the maximum benefits of hypothermia, cooling needs to begin soon after the insult, and maintained for relatively long period periods of time. In the case of ischemic stroke, cooling should ideally be applied in conjunction with the re-establishment of cerebral perfusion. Translating this to the clinical arena can be challenging, given the technical challenges of rapidly and stably cooling patients. This review will discuss the application of hypothermia especially as it pertains to its effects neurological outcome, cooling methods, and important parameters in optimizing hypothermic protection.
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Affiliation(s)
- Xian N Tang
- Department of Neurology, University of California, San Francisco, CA 94121, USA
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Abstract
Cerebral edema is a potentially life-threatening complication of acute liver failure, the syndrome of abrupt loss of liver function in a patient with a previously healthy liver. Although the prevalence of cerebral edema appears to be decreasing, patients with rapidly progressive (hyperacute) liver failure, such as after acetaminophen overdose, remain at highest risk. In severe cases of cerebral edema, intracranial hypertension develops and leads to brain death after brainstem herniation or to anoxic brain injury and permanent neurologic impairment. Intracranial hypertension in patients with acute liver failure often can be temporarily controlled by manipulating body position, increasing the degree of sedation, and increasing blood osmolarity through pharmacologic means. However, these maneuvers often postpone, but do not eliminate, the risk of brainstem herniation unless orthotopic liver transplantation or spontaneous liver regeneration follows in short order. To buy time, the induction of therapeutic hypothermia (core temperature 32 degrees C-35 degrees C) has been shown to effectively bridge patients to transplant. Similar to the experience in patients with cerebral edema after other neurologic insults, hypothermia reduces cerebral edema and intracranial hypertension in patients with acute liver failure by decreasing splanchnic ammonia production, restoring normal regulation of cerebral hemodynamics, and lowering oxidative metabolism within the brain. Hypothermia may also ameliorate the degree of liver injury. Hypothermia has not been adequately studied for its safety and theoretically may increase the risk of infection, cardiac dysrhythmias, and bleeding, all complications independently associated with acute liver failure. Therefore, although an ample body of experimental and human data provides a rationale for the use of therapeutic hypothermia in patients with acute liver failure, multicenter, randomized, controlled clinical trials are needed to confirm that hypothermia secures brain viability and improves survival without causing harm.
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Metselaar H, van Hoek B. 7 Leverfalen. LEVERZIEKTEN 2009. [PMCID: PMC7120829 DOI: 10.1007/978-90-313-7437-3_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
De lever vervult tal van essentiële functies in het menselijk lichaam, waaronder ontgifting van het bloed en aanmaak van diverse eiwitten en hormonen. Tevens speelt de lever een rol in het afweersysteem. Leverfalen kan omschreven worden als een situatie van onvoldoende werking van de lever bij deze processen. Dit beeld ontstaat wanneer door het verlies van functionele cellen het totale effectieve levervolume beneden een kritische grens komt. In dit hoofdstuk wordt ingegaan op diverse vormen van leverfalen en twee specifieke bij leverfalen voorkomende problemen, namelijk hepatische encefalopathie en verhoogde bloedingsneiging.
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