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Maiwall R, Kulkarni AV, Arab JP, Piano S. Acute liver failure. Lancet 2024; 404:789-802. [PMID: 39098320 DOI: 10.1016/s0140-6736(24)00693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
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2
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Kulkarni AV, Gustot T, Reddy KR. Liver transplantation for acute liver failure and acute-on-chronic liver failure. Am J Transplant 2024:S1600-6135(24)00435-0. [PMID: 39094950 DOI: 10.1016/j.ajt.2024.07.012] [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: 03/12/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver (ACLF) are distinct phenotypes of liver failure and, thus, need to be compared and contrasted for appropriate management. There has been a significant improvement in the outcomes of these patients undergoing liver transplantation (LT). Survival post-LT for ALF and ACLF ranges between 90% and 95% and 80% and 90% at 1 year, futility criteria have been described in both ALF and ACLF where organ failures define survival. Plasma exchange and continuous renal replacement therapy may serve as bridging therapies. Identifying the futility of LT is as necessary as the utility of LT in patients with ALF and ACLF. The role of regenerative therapies such as granulocyte colony-stimulating factors in ACLF and hepatocyte and xenotransplantation in both conditions remains uncertain. Measures to increase the donor pool through increasing deceased donor transplants in Asian countries, living donations in Western countries, auxiliary liver transplants, and ABO-incompatible liver transplants are necessary to improve the survival of these patients. In this review, we discuss the similarities and differences in clinical characteristics and the timing and outcomes of LT for ALF and ACLF, briefly highlighting the role of bridging therapies and providing an overview of recent advances in the management of ALF and ACLF.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, HUB Hôpital Erasme, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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3
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Complementary Roles of Cadaveric and Living Donor Liver Transplantation in Acute Liver Failure. J Gastrointest Surg 2021; 25:2516-2523. [PMID: 33565013 DOI: 10.1007/s11605-021-04932-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 01/16/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Living donor liver transplantation may complement cadaveric transplantation in acute liver failure (ALF) patients. METHODS Between 2008 and 2017, 89 patients were treated for ALF; 15 patients (17%) recovered with intensive care treatment; 31 (35%) died without transplant. The records of the remaining 43 patients (median (range) age: 14 (1-62)) who underwent transplantation were evaluated. RESULTS The etiologic factors were toxic agents (10; mushrooms: 8; herbs: 2), hepatitis viruses (7; A: 1; B: 6), Wilson's disease (7), autoimmune hepatitis (4), and Budd-Chiari syndrome (2); 13 cases were idiopathic. Cadaveric organs (whole, split, reduced) were transplanted to 32 patients; 11 patients underwent living donor transplantation. One patient (2%) died of septic shock on the second postoperative day. Bacterial infection was the most common early (< 3 months) complication in the remaining patients (31/42; 74%), followed by delirium (5/42; 12%) and acute rejection requiring steroid pulse (5/42; 12%). Seven other patients died during median (range) follow-up of 94 (14-142) months: various infections (5), leukemia (1), and acute myocardial infarction (1). The 1-, 5-, and 10-year survival rates were 100%, 96%, and 92% in children and 94%, 82%, and 65% in adults respectively. CONCLUSIONS Cadaveric organ sharing and transplantation from living donors when appropriate yield a high survival rate, despite high early morbidity, in ALF patients whose conditions deteriorate despite intensive care treatment. Efforts to eliminate preventable causes of acute liver failure will lead to more efficient use of health care resources.
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4
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Tsien C, Tan H, Sharma S, Palaniyappan N, Wijayasiri P, Leung K, Hayre J, Mowlem E, Kang R, Eddowes PJ, Wilkes E, Venkatachalapathy SV, Guha IN, Antonova L, Cheung AC, Griffiths WJ, Butler AJ, Ryder SD, James MW, Aithal GP, Aravinthan AD. Long-term outcomes of liver transplant recipients followed up in non-transplant centres: Care closer to home. Clin Med (Lond) 2021; 21:e32-e38. [PMID: 33479081 DOI: 10.7861/clinmed.2020-0609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Increasing rates of liver transplantation and improved outcomes have led to greater numbers of transplant recipients followed up in non-transplant centres. Our aim was to document long-term clinical outcomes of liver transplant recipients managed in this 'hub-and-spoke' healthcare model. METHODS A retrospective analysis of all adult patients who underwent liver transplantation between 1987 and 2016, with post-transplant follow-up in two non-transplant centres in the UK (Nottingham) and Canada (Ottawa), was performed. RESULTS The 1-, 5-, 10- and 20-year patient survival rates were 98%, 95%, 87% and 62%, and 100%, 96%, 88% and 62% in the Nottingham and Ottawa groups, respectively (p=0.87). There were no significant differences between the two centres in 1-, 5-, 10- and 20-year cumulative incidence of death-censored graft-survival (p=0.10), end-stage renal disease (p=0.29) or de novo cancer (p=0.22). Nottingham had a lower incidence of major cardiovascular events (p=0.008). CONCLUSION Adopting a new model of healthcare provides a means of delivering post-transplant patient care close to home without compromising patient survival and long-term clinical outcomes.
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Affiliation(s)
- Cynthia Tsien
- The Ottawa Hospital, Ottawa, Canada, University of Ottawa, Ottawa, Canada and Ottawa Hospital Research Institute, Ottawa, Canada
| | - Huey Tan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | - Naaventhan Palaniyappan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Pramudi Wijayasiri
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | | | | | | | - Peter J Eddowes
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Emilie Wilkes
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Suresh V Venkatachalapathy
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Indra N Guha
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | | | - Angela C Cheung
- The Ottawa Hospital, Ottawa, Canada, University of Ottawa, Ottawa, Canada and Ottawa Hospital Research Institute, Ottawa, Canada
| | | | | | - Stephen D Ryder
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Martin W James
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Guruprasad P Aithal
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
| | - Aloysious D Aravinthan
- NIHR Nottingham Biomedical Research Centre, Nottingham, UK, Nottingham University Hospitals NHS Trust, Nottingham, UK and the University of Nottingham, Nottingham, UK
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5
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Avni D, Harikumar KB, Sanyal AJ, Spiegel S. Deletion or inhibition of SphK1 mitigates fulminant hepatic failure by suppressing TNFα-dependent inflammation and apoptosis. FASEB J 2021; 35:e21415. [PMID: 33566377 PMCID: PMC8491138 DOI: 10.1096/fj.202002540r] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/15/2021] [Accepted: 01/20/2021] [Indexed: 12/13/2022]
Abstract
Acute liver failure (ALF) causes severe liver dysfunction that can lead to multi-organ failure and death. Previous studies suggest that sphingosine kinase 1 (SphK1) protects against hepatocyte injury, yet not much is still known about its involvement in ALF. This study examines the role of SphK1 in D-galactosamine (GalN)/lipopolysaccharide (LPS)-induced ALF, which is a well-established experimental mouse model that mimics the fulminant hepatitis. Here we report that deletion of SphK1, but not SphK2, dramatically decreased GalN/LPS-induced liver damage, hepatic apoptosis, serum alanine aminotransferase levels, and mortality rate compared to wild-type mice. Whereas GalN/LPS treatment-induced hepatic activation of NF-κB and JNK in wild-type and SphK2-/- mice, these signaling pathways were reduced in SphK1-/- mice. Moreover, repression of ALF in SphK1-/- mice correlated with decreased expression of the pro-inflammatory cytokine TNFα. Adoptive transfer experiments indicated that SphK1 in bone marrow-derived infiltrating immune cells but not in host liver-resident cells, contribute to the development of ALF. Interestingly, LPS-induced TNFα production was drastically suppressed in SphK1-deleted macrophages, whereas IL-10 expression was markedly enhanced, suggesting a switch to the anti-inflammatory phenotype. Finally, treatment with a specific SphK1 inhibitor ameliorated inflammation and protected mice from ALF. Our findings suggest that SphK1 regulates TNFα secretion from macrophages and inhibition or deletion of SphK1 mitigated ALF. Thus, a potent inhibitor of SphK1 could potentially be a therapeutic agent for fulminant hepatitis.
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Affiliation(s)
- Dorit Avni
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Kuzhuvelil B. Harikumar
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Arun J. Sanyal
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
| | - Sarah Spiegel
- Department of Biochemistry and Molecular Biology, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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6
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Kumar S, Lin S, Schold JD. Impact of donation after circulatory death donor allografts on outcomes following liver transplantation for fulminant hepatic failure in the United States. Am J Transplant 2021; 21:382-390. [PMID: 32865321 DOI: 10.1111/ajt.16286] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Revised: 08/18/2020] [Accepted: 08/19/2020] [Indexed: 01/25/2023]
Abstract
Limited data exist regarding the impact of donation after circulatory death (DCD) allografts on outcomes following liver transplantation in fulminant hepatic failure (FHF). Utilizing the Scientific Registry of Transplant Recipients (SRTR), we compared outcomes after DCD in FHF to donation after brain death (DBD) in FHF and DCD in non-FHF over a 15-year period. Primary outcome measures were graft and patient survival. A total of 117, 3437, and 4379 recipients underwent DCD-FHF, DBD-FHF and DCD-non-FHF, respectively. One-year graft survival in DCD-FHF was inferior to DBD-FHF (72.9% vs. 83.8%, p = .002), but comparable to DCD-non-FHF (72.9% vs. 82.7%, p = .23). However, 3- and 5-year graft survival in DCD-FHF were comparable to DBD-FHF (67.9 vs. 77.6%, p = .63; 57.8% vs. 73.2%, p = .27) and DCD-non-FHF (67.9% vs. 72.9%, p = .44; 57.8% vs. 66.6%, p = .06). One-, 3-, and 5-year patient survival were also comparable among the three groups. Graft and patient survival in DCD-FHF improved over the study period. Multivariable analysis identified recipient age, male gender, African American ethnicity, donor age, and cold ischemia time as predictors of graft and patient survival in FHF, while DCD status was only predictive of graft survival. Long-term graft survival and patient survival in DCD-FHF are comparable to DBD-FHF and DCD-non-FHF. Consideration of DCD in FHF could help expand the donor pool in this subset of critically ill patients.
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Affiliation(s)
- Shiva Kumar
- Department of Gastroenterology & Hepatology, Digestive Disease Institute, Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates
| | - Songhua Lin
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Jesse D Schold
- Department of Quantitative Health Sciences, Cleveland Clinic Foundation, Cleveland, Ohio, USA.,Center for Populations Health Research, Cleveland Clinic Foundation, Cleveland, Ohio, USA
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7
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Abstract
Neurologic disturbances including encephalopathy, seizures, and focal deficits complicate the course 10-30% of patients undergoing organ or stem cell transplantation. While much or this morbidity is multifactorial and often associated with extra-cerebral dysfunction (e.g., graft dysfunction, metabolic derangements), immunosuppressive drugs also contribute significantly. This can either be through direct toxicity (e.g., posterior reversible encephalopathy syndrome from calcineurin inhibitors such as tacrolimus in the acute postoperative period) or by facilitating opportunistic infections in the months after transplantation. Other neurologic syndromes such as akinetic mutism and osmotic demyelination may also occur. While much of this neurologic dysfunction may be reversible if related to metabolic factors or drug toxicity (and the etiology is recognized and reversed), cases of multifocal cerebral infarction, hemorrhage, or infection may have poor outcomes. As transplant patients survive longer, delayed infections (such as progressive multifocal leukoencephalopathy) and post-transplant malignancies are increasingly reported.
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8
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Pamecha V, Vagadiya A, Sinha PK, Sandhyav R, Parthasarathy K, Sasturkar S, Mohapatra N, Choudhury A, Maiwal R, Khanna R, Alam S, Pandey CK, Sarin SK. Living Donor Liver Transplantation for Acute Liver Failure: Donor Safety and Recipient Outcome. Liver Transpl 2019; 25:1408-1421. [PMID: 30861306 DOI: 10.1002/lt.25445] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Accepted: 03/01/2019] [Indexed: 12/12/2022]
Abstract
In countries where deceased organ donation is sparse, emergency living donor liver transplantation (LDLT) is the only lifesaving option in select patients with acute liver failure (ALF). The aim of the current study is living liver donor safety and recipient outcomes following LDLT for ALF. A total of 410 patients underwent LDLT between March 2011 and February 2018, out of which 61 (14.9%) were for ALF. All satisfied the King's College criteria (KCC). Median admission to transplant time was 48 hours (range, 24-80.5 hours), and median living donor evaluation time was 18 hours (14-20 hours). Median Model for End-Stage Liver Disease score was 37 (32-40) with more than two-thirds having grade 3 or 4 encephalopathy and 70% being on mechanical ventilation. The most common etiology was viral (37%). Median jaundice-to-encephalopathy time was 15 (9-29) days. Preoperative culture was positive in 47.5%. There was no difference in the complication rate among emergency and elective living liver donors (13.1% versus 21.2%; P = 0.19). There was no donor mortality. For patients who met the KCC but did not undergo LT, survival was 22.8% (29/127). The 5-year post-LT actuarial survival was 65.57% with a median follow-up of 35 months. On multivariate analysis, postoperative worsening of cerebral edema (CE; hazard ratio [HR], 2.53; 95% confidence interval [CI], 1.01-6.31), systemic inflammatory response syndrome (SIRS; HR, 16.7; 95% CI, 2.05-136.7), preoperative culture positivity (HR, 6.54; 95% CI, 2.24-19.07), and a longer anhepatic phase duration (HR, 1.01; 95% CI, 1.00-1.02) predicted poor outcomes. In conclusion, emergency LDLT is lifesaving in selected patients with ALF. Outcomes of emergency living liver donation were comparable to that of elective donors. Postoperative worsening of CE, preoperative SIRS, and sepsis predicted outcome after LDLT for ALF.
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Affiliation(s)
- Viniyendra Pamecha
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Vagadiya
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Kumar Sinha
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rommel Sandhyav
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kumaraswamy Parthasarathy
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shridhar Sasturkar
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nihar Mohapatra
- Department of Liver Transplant and Hepato-Pancreato-Biliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Chandra Kant Pandey
- Department of Anaesthesiology and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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9
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Cardim D, Robba C, Schmidt E, Schmidt B, Donnelly J, Klinck J, Czosnyka M. Transcranial Doppler Non-invasive Assessment of Intracranial Pressure, Autoregulation of Cerebral Blood Flow and Critical Closing Pressure during Orthotopic Liver Transplant. ULTRASOUND IN MEDICINE & BIOLOGY 2019; 45:1435-1445. [PMID: 30952467 DOI: 10.1016/j.ultrasmedbio.2019.02.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/15/2019] [Accepted: 02/05/2019] [Indexed: 06/09/2023]
Abstract
Transcranial Doppler (TCD) ultrasonography allows continuous non-invasive monitoring of cerebral blood flow velocity in a variety of clinical conditions. Recently, signal processing of TCD signals has provided several comprehensive parameters for the assessment of cerebral haemodynamics. In this work, we applied a TCD multimodal approach in patients with acute liver failure undergoing orthotopic liver transplant (OLT) to assess the clinical feasibility of using TCD for cerebral haemodynamics assessment in this setting. We retrospectively studied six patients undergoing OLT with continuous monitoring of arterial blood pressure and blood flow velocity in the middle cerebral artery. The main cerebral haemodynamic parameters assessed were non-invasive intracranial pressure, cerebral perfusion pressure, cerebral autoregulation, pulsatility index, critical closing pressure and diastolic closing margin. TCD monitoring revealed marked alterations of these parameters in the OLT setting, which could provide relevant clinical information when there is imminent risk of neurologic impairment.
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Affiliation(s)
- Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom; Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Chiara Robba
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom; Policlinico San Martino IRCCS, Genoa, Italy.
| | - Eric Schmidt
- Service de Neurochirurgie, Hôpital Universitaire Toulouse-Purpan, Toulouse, France
| | - Bernhard Schmidt
- Department of Neurology, University Hospital Chemnitz, Chemnitz, Germany
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom; Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - John Klinck
- Department of Anaesthesia, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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10
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Blackford SJ, Ng SS, Segal JM, King AJ, Austin AL, Kent D, Moore J, Sheldon M, Ilic D, Dhawan A, Mitry RR, Rashid ST. Validation of Current Good Manufacturing Practice Compliant Human Pluripotent Stem Cell-Derived Hepatocytes for Cell-Based Therapy. Stem Cells Transl Med 2019; 8:124-137. [PMID: 30456803 PMCID: PMC6344902 DOI: 10.1002/sctm.18-0084] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 08/22/2018] [Accepted: 09/25/2018] [Indexed: 01/04/2023] Open
Abstract
Recent advancements in the production of hepatocytes from human pluripotent stem cells (hPSC-Heps) afford tremendous possibilities for treatment of patients with liver disease. Validated current good manufacturing practice (cGMP) lines are an essential prerequisite for such applications but have only recently been established. Whether such cGMP lines are capable of hepatic differentiation is not known. To address this knowledge gap, we examined the proficiency of three recently derived cGMP lines (two hiPSC and one hESC) to differentiate into hepatocytes and their suitability for therapy. hPSC-Heps generated using a chemically defined four-step hepatic differentiation protocol uniformly demonstrated highly reproducible phenotypes and functionality. Seeding into a 3D poly(ethylene glycol)-diacrylate fabricated inverted colloid crystal scaffold converted these immature progenitors into more advanced hepatic tissue structures. Hepatic constructs could also be successfully encapsulated into the immune-privileged material alginate and remained viable as well as functional upon transplantation into immune competent mice. This is the first report we are aware of demonstrating cGMP-compliant hPSCs can generate cells with advanced hepatic function potentially suitable for future therapeutic applications. Stem Cells Translational Medicine 2019;8:124&14.
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Affiliation(s)
- Samuel J.I. Blackford
- Centre for Stem Cells and Regenerative MedicineKing's College LondonLondonUnited Kingdom
| | - Soon Seng Ng
- Centre for Stem Cells and Regenerative MedicineKing's College LondonLondonUnited Kingdom
| | - Joe M. Segal
- Centre for Stem Cells and Regenerative MedicineKing's College LondonLondonUnited Kingdom
| | - Aileen J.F. King
- Diabetes Research GroupFaculty of Life Sciences & Medicine, King's College LondonLondonUnited Kingdom
| | - Amazon L. Austin
- Diabetes Research GroupFaculty of Life Sciences & Medicine, King's College LondonLondonUnited Kingdom
| | - Deniz Kent
- Centre for Stem Cells and Regenerative MedicineKing's College LondonLondonUnited Kingdom
| | - Jennifer Moore
- RUCDR Infinite BiologicsRutgers UniversityNew BrunswickNew JerseyUSA
| | - Michael Sheldon
- RUCDR Infinite BiologicsRutgers UniversityNew BrunswickNew JerseyUSA
| | - Dusko Ilic
- Stem Cell Laboratory, Department of Women and Children's HealthFaculty of Life Sciences and Medicine, King's College LondonLondonUnited Kingdom
| | - Anil Dhawan
- Institute for Liver StudiesKing's College Hospital, King's College LondonLondonUnited Kingdom
| | - Ragai R. Mitry
- Institute for Liver StudiesKing's College Hospital, King's College LondonLondonUnited Kingdom
| | - S. Tamir Rashid
- Centre for Stem Cells and Regenerative MedicineKing's College LondonLondonUnited Kingdom
- Institute for Liver StudiesKing's College Hospital, King's College LondonLondonUnited Kingdom
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11
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Vishwakarma SK, Bardia A, Lakkireddy C, Raju N, Paspala SAB, Habeeb MA, Khan AA. Intraperitoneal transplantation of bioengineered humanized liver grafts supports failing liver in acute condition. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 98:861-873. [PMID: 30813092 DOI: 10.1016/j.msec.2019.01.045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Revised: 11/16/2018] [Accepted: 01/10/2019] [Indexed: 01/18/2023]
Abstract
Acute liver failure (ALF) is one of the most devastating fatal conditions which have posed crucial challenges to the clinicians and researchers for identifying permanent cure. Currently liver transplantation has been considered as the only managerial option. However it's wider applicability has been limited owing to non-availability of quality donor organs, cost-intensiveness, surgical hitches, life-long use of immunosuppressive drugs and long-term complications. Since last decades, several liver support systems have been developed for the management of failing liver in acute condition. However, the major limitation has been the lack of natural biological support and long-term survival of the grafts post-transplantation. Repopulation of decellularized xenogeneic organs is one of the emerging technologies for development of humanized neo-organs for demanding regenerative application. However, the earlier reported studies do not fulfil the insistence to provide immunologically tolerable humanized liver grafts for clinical applications. Here we demonstrate an efficient approach to generate transplantable humanized liver grafts which provides long-term support to the failing liver in Acute Liver Failure (ALF) animal models. These bioengineered humanized liver tissue grafts expresses several liver specific transcripts and performed crucial synthetic (albumin production) and detoxification (urea synthesis) functions at comparative level to normal liver. Intraperitoneal transplantation of these humanized liver grafts offered favourable microenvironment to exchange toxic substances across the barrier during ALF condition and provided long-term survival and function of the graft. In summary, the results of present study provide a first proof of concept in pre-clinical ALF animal model for the applicability of these bioengineered humanized livers in the management of failing liver on demand and may be considered as potential bridge to liver transplantation.
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Affiliation(s)
- Sandeep Kumar Vishwakarma
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Avinash Bardia
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Chandrakala Lakkireddy
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Nagarapu Raju
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Syed Ameer Basha Paspala
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Md Aejaz Habeeb
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India
| | - Aleem Ahmed Khan
- Central Laboratory for Stem Cell Research and Translational Medicine, Centre for Liver Research and Diagnostics, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad 500058, Telangana, India; Dr. Habeebullah Life Sciences, Attapur, Hyderabad 500048, Telangana, India.
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12
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Anand AC, Singh P. Neurological Recovery After Recovery From Acute Liver Failure: Is it Complete? J Clin Exp Hepatol 2019; 9:99-108. [PMID: 30765942 PMCID: PMC6363962 DOI: 10.1016/j.jceh.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
Neurologic dysfunction characterised by Hepatic Encephalopathy (HE) and cerebral oedema are the most dramatic presentations of Acute Liver Failure (ALF) and signify poor outcome. Improved critical care and wider availability of emergency Liver Transplantation (LT) has improved survivability in ALF. In most cases absence of clinically overt encephalopathy after spontaneous recovery from ALF or after LT is thought to indicate complete neurologic recovery. Recent data suggests that neurologic recovery may not always be complete. Instances of persistent neurologic dysfunction as well as neuropsychiatric abnormalities are now being recognised and warrant active follow up of these patients. Although evidences irreversible neurologic damage is uncommon after ALF, neuropsychiatric disturbances are not uncommon. Complex pathogenesis is involved in neurocognitive disorders seen after many other conditions including LT that require critical care. Structural damage and persistent neurological abnormalities seen after ALF are more likely to be related to cerebral edema, raised intracranial tension and cerebral hypoxemia, while neurocognitive dysfunctions may be a part of a wider spectrum of disorders commonly seen among those who recover from any critical illness.
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Key Words
- ALF, Acute Liver Failure
- APAP, Acetaminophen
- BBB, Blood Brain Barrier
- CARS, Compensatory Anti-Inflammatory Response Syndrome
- CVVH, Continuous Veno-Venous Hemodialysis
- DAMPS, Damage Associated Molecular Pattern
- DWI, Diffusion-Weighted Imaging
- EEG, Electroencephalography
- FLAIR, Fluid-Attenuated Inversion Recovery
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MPT, Mitochondrial Permeability Transition
- PET, Positron Emission Tomography
- SIRS, Systemic Inflammatory Response Syndrome
- acute liver failure
- cerebral oedema
- hepatic encephalopathy
- neurological dysfunction
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Affiliation(s)
- Anil C. Anand
- Address for correspondence: Anil C. Anand, Senior Consultant, Gastroenterology & Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India.
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13
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Putignano A, Figorilli F, Alabsawy E, Agarwal B, Jalan R. Long-term outcome in patients with acute liver failure. Liver Int 2018; 38:2228-2238. [PMID: 29927051 DOI: 10.1111/liv.13914] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Accepted: 06/09/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Acute liver failure patients who meet poor prognostic criteria have high early mortality without emergency liver transplantation. A recent study however, reported that patients that survive spontaneously have a poorer outcome compared with patients undergoing transplantation. In this single centre study, we aimed to confirm or refute this observation. METHODS Early survivors (acute liver failure patients who survived 90 days after the ICU admission) were assessed for long-term outcomes in four distinctive cohorts, incorporating aetiology (Acetaminophen overdose or non-Acetaminophen overdose), and management strategy (conservative or liver transplantation). Chi Squared or Fisher test were used to compare outcomes among the four cohorts (P < 0.05) and Kaplan-Meier curve (Log Rank test) to represent cumulative survival. RESULTS Two hundred consecutive acute liver failure patients between 1990 and 2014 were included; mean age 38.3, ±12.8, male 70, 35%. 124/200 (62%) early survivors were identified; 13/124 (10.5%) acetaminophen patients underwent transplantation and 48/124 (38.7%) survived spontaneously; 36/124 (29.0%) non-acetaminophen underwent transplantation and 27/124 (21.8%) survived spontaneously. A total of 11/124 (8.9%) died subsequently (median survival 5.3± IQR 9.1), three spontaneous survivors and eight transplanted patients (P = 0.025); of the eight transplanted patients, six died of transplant related complications and two of suicide. CONCLUSION The results of this study suggest that although liver transplantation is a life-saving procedure for acute liver failure patients, they have a worse long-term outcome compared with spontaneous survivors. Novel therapies to increase the percentage of spontaneous survivors are urgently needed.
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Affiliation(s)
- Antonella Putignano
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK.,Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Francesco Figorilli
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Eman Alabsawy
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
| | - Banwari Agarwal
- Intensive Care Unit, Royal Free Hospital, Royal Free London NHS Foundation Trust, London, UK
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, London, UK
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14
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Ugamura A, Chu PS, Nakamoto N, Taniki N, Ojiro K, Hibi T, Shinoda M, Obara H, Masugi Y, Yamaguchi A, Shiba S, Morikawa R, Usui S, Ebinuma H, Kitagawa Y, Saito H, Kanai T. Liver Fibrosis Markers Improve Prediction of Outcome in Non-Acetaminophen-Associated Acute Liver Failure. Hepatol Commun 2018; 2:1331-1343. [PMID: 30411080 PMCID: PMC6211334 DOI: 10.1002/hep4.1233] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 06/20/2018] [Indexed: 12/17/2022] Open
Abstract
A prognostic system for acute liver failure (ALF) with a higher predictive value is urgently needed. The role of extracellular matrix (ECM) remodeling in ALF has not been fully elucidated. We hypothesized that serologic fibrosis markers, which reflect ECM remodeling, are predictive of ALF outcome at first presentation. This observational study included 110 patients with acute liver dysfunction, of which 73 had non-acetaminophen-associated ALF (NAA-ALF). We evaluated serum levels of hyaluronic acid, 7S domain of type IV collagen (4COL7S), and Wisteria floribunda agglutinin-positive Mac-2-binding protein at first presentation to a tertiary center. Serologic fibrosis markers were significantly higher in NAA-ALF compared with acute hepatitis. Elevated hyaluronic acid and 4COL7S levels at first presentation correlated significantly with worse clinical outcomes. 4COL7S, along with age, ammonia, and the Model for End-Stage Liver Disease (MELD) score, was a significant prognostic factor in multivariate analysis; 4COL7S correlated significantly with coagulopathy, decreased hepatic synthetic functions, advanced hepatic encephalopathy, and liver atrophy and also predicted 180-day transplant-free survival. Cox regression models incorporating 4COL7S with the MELD system had profoundly improved predictive values that significantly surpassed the MELD system alone. Conclusion: Elevation of serologic fibrosis markers reflecting ECM remodeling in NAA-ALF predicted a worse clinical outcome. Incorporation of 4COL7S at first presentation to a transplant center improves the specificity while retaining the sensitivity of the MELD system. External validation of a fibrosis marker as part of a clinical prediction tool in ALF warrants further investigation.
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Affiliation(s)
- Aya Ugamura
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Po-Sung Chu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Nobuhiro Nakamoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Nobuhito Taniki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Keisuke Ojiro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Department of Gastroenterology and Hepatology Tokyo Dental College Ichikawa General Hospital Ichikawa City Japan
| | - Taizo Hibi
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Masahiro Shinoda
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Hideaki Obara
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Yohei Masugi
- Department of Pathology Keio University School of Medicine Tokyo Japan
| | - Akihiro Yamaguchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Shunsuke Shiba
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Rei Morikawa
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
| | - Shingo Usui
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Department of Gastroenterology and Hepatology National Hospital Organization Saitama Hospital Wako City Japan
| | - Hirotoshi Ebinuma
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,International University of Health and Welfare Mita Hospital Tokyo Japan
| | - Yuko Kitagawa
- Department of Surgery Keio University School of Medicine Tokyo Japan
| | - Hidetsugu Saito
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan.,Division of Pharmacotherapeutics Keio University School of Pharmacy Tokyo Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine Keio University School of Medicine Tokyo Japan
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15
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Noor A, Panwala A, Forouhar F, Wu GY. Hepatitis caused by herpes viruses: A review. J Dig Dis 2018; 19:446-455. [PMID: 29923691 DOI: 10.1111/1751-2980.12640] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 05/30/2018] [Accepted: 06/17/2018] [Indexed: 12/11/2022]
Abstract
Herpes virus hepatitis varies in presentation, ranging from asymptomatic to acute liver failure, in both immunocompetent and immunocompromised individuals. Hepatitis caused by the Herpesviridae family is uncommon and usually results in mild disease. It is also often self-limiting, although in certain populations especially immunosuppressed patients, it can cause severe infections, leading to acute to fulminant hepatic failure. In addition, some isolated cases of fulminant disease in immunocompetent individuals have been reported. As the presentation is frequently non-specific, it is important to maintain a high level of suspicion for these viral etiologies and start empiric therapy with antiviral agents as soon as possible. Liver transplantation is the last resort. Mortality remains high in fulminant hepatic failure caused by Herpesviridae without liver transplantation. Here we review the literatures on hepatitis caused by three members of the Herpesviridae family, cytomegalovirus, Epstein-Barr virus and herpes simplex virus to discuss the epidemiology, diagnostic methods, clinical features and current management, and also to determine which aspects need to be investigated in further detail. Herpesviridae-mediated acute liver failure is rare but is associated with a poor prognosis, even after early treatment.
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Affiliation(s)
- Arish Noor
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Amruta Panwala
- Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - Faripour Forouhar
- Department of Pathology, University of Connecticut Health Center, Farmington, Connecticut, USA
| | - George Y Wu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Connecticut Health Center, Farmington, Connecticut, USA
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16
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Live donor liver transplantation for acute liver failure: A single center experience. Indian J Gastroenterol 2018; 37:25-30. [PMID: 29455437 DOI: 10.1007/s12664-017-0812-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 12/22/2017] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Acute liver failure (ALF) is an indication for emergency liver transplantation (LT). Although centers performing only deceased donor liver transplants (DDLT) have shown improved outcomes in this situation, they still have relatively long waiting lists. An alternative would be living donor liver transplantation (LDLT), which has shown equivalent outcomes in the elective situation but there is limited evidence of its results in ALF. AIM The purpose of this study was to assess the outcomes in patients with ALF undergoing emergency LDLT in our center in Delhi, India. METHODS We prospectively collected data on 479 patients who underwent LT in our hospital between January 2009 and December 2015 to evaluate the outcomes of those with ALF. The ALF patients were listed for transplantation after they met the Kings' College criteria and rapid evaluation was done following a protocol consisting of three phases. Patients with grade III/IV encephalopathy were put on mechanical ventilation. Data regarding their postoperative course, morbidity, and mortality were analyzed. RESULTS Thirty-six (7.5%) out of the 479 patients underwent emergency LT for ALF. Their mean age was 27.5 years (range 4-59 years) and the male to female ratio of 2:3. Preoperative intubation was required in 15 of 25 patients who had encephalopathy. Wilson's disease was the most common cause of ALF in children while in adults, it was acute viral hepatitis. The time interval between listing and transplantation was a mean of 36 ± 12.4 h. The mean graft to recipient weight ratio (GRWR) was 1.06 ± 0.3. The recipients were extubated postoperatively after a mean period of 2.6 days and their mean ICU stay was 6.3 days. Postoperative infection was the most common complication and required upgradation of antifungal and antibiotic treatments. Neurological complications occurred in five patients. Thirty-one of 36 (86.1%) patients survived and progressive cerebral edema and sepsis were the most common causes of mortality. Patients who died had higher model for end-stage liver disease scores, longer cold ischemia time (CIT), and higher grades of encephalopathy (though 80% patients with encephalopathy survived). There was no donor mortality. At long-term follow up of a median of 56 months, 29 (80.5%) of 36 patients were still alive. CONCLUSIONS In our experience, LDLT is an alternative procedure to DDLT in patients with ALF and is associated with good outcomes even in patients with high grades of encephalopathy.
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17
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Jung DH, Hwang S, Lim YS, Kim KH, Ahn CS, Moon DB, Ha TY, Song GW, Park GC, Lee SG. Outcome comparison of liver transplantation for hepatitis A-related versus hepatitis B-related acute liver failure in adult recipients. Clin Transplant 2017; 32. [PMID: 29044729 DOI: 10.1111/ctr.13140] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2017] [Indexed: 01/13/2023]
Abstract
Hepatitis A virus (HAV) can cause acute liver failure (ALF). This study compares outcomes between liver transplantation (LT) for HAV-related ALF (HAV-ALF) and LT for hepatitis B virus (HBV)-related ALF (HBV-ALF). Of 3616 adult LTs performed between January 2005 and December 2014, we performed LT for HAV-ALF recipients (n = 29) and LT for HBV-ALF recipients (n = 34). HAV-ALF group included 18 males and 11 females with mean age of 33.1 years. Graft survival rates in HAV-ALF and HBV-ALF were 65.5% and 88.0% (1 year) and 65.5% and 84.0% (5 years) (P = .048). Patient survival rates in HAV-ALF and HBV-ALF were 69.0% and 88.0% (1 year) and 69.0% and 84.0% (5 years) (P = .09). Multivariate analyses demonstrated that acute pancreatitis and HAV recurrence were independent risk factors of graft and patient survival. Post-transplant outcome was poorer in patients with HAV-ALF than in those with HBV-ALF. This weakens LT's appropriateness in HAV-ALF patients with pancreatitis. HAV recurrence after LT for HAV-ALF is common and often fatal; thus, HAV recurrence should be monitored vigilantly, beginning early post-transplant.
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Affiliation(s)
- Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-Suk Lim
- Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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18
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Sheriff SA, Shaik Ibrahim S, Devaki T, Chakraborty S, Agarwal S, Pérez-Sánchez H. Lycopene Prevents Mitochondrial Dysfunction during d-Galactosamine/Lipopolysaccharide-Induced Fulminant Hepatic Failure in Albino Rats. J Proteome Res 2017; 16:3190-3199. [PMID: 28758404 DOI: 10.1021/acs.jproteome.7b00176] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Functional perturbation of mitochondria is associated with fulminant hepatic failure (FHF). d-Galactosamine/lipopolysaccharide (d-GalN/LPS)-induced FHF is a renowned model to evaluate the efficacy of hepatoprotective agents. Lycopene is an antioxidant and phytonutrient from the carotenoid family. The health benefits of lycopene are prominent against cancer and cardiovascular, lung, liver, and skin problems. Recent studies have demonstrated the hepatoprotective, antidyslipidemic, and antioxidant roles of lycopene. The current study was designed to appraise the ability of lycopene to prevent mitochondrial dysfunction during the d-GalN/LPS-induced FHF. The administration of d-GalN/LPS (300 mg and 30 μg/kg body weight, respectively) to the experimental rats induced several disturbances in mitochondrial function. The lipid peroxide and hydrogen peroxide levels were increased (p < 0.05). The activities of mitochondrial antioxidants, tricarboxylic acid (TCA) cycle, and electron transport chain enzymes and the cellular adenosine triphosphate (ATP) content were decreased (p < 0.05). Lycopene (10 mg/kg body weight for 6 days) pretreatment attenuated lipid peroxidation and prohibited the excessive synthesis of hydrogen peroxide. The d-GalN/LPS-induced impairment in ATP production and increased enzyme activities were effectively prevented by the lycopene administration. The lycopene-mediated mitochondrial protection was mainly ascribed to the strong antioxidant potential of this phytonutrient. Molecular modeling results obtained show evidence that lycopene inhibits several lipoxygenases and provides rationale for the observed prevention of lipid peroxidation in the mitochondrial membrane. The carotenoid lycopene combatted oxidative stress, scavenged free radicals, prevented ROS generation, and inhibited the toxic effects of d-GalN/LPS during FHF.
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Affiliation(s)
- Sheik Abdulazeez Sheriff
- Department of Biochemistry, University of Madras , Guindy Campus, Chennai, Tamilnadu 600 025, India
| | - Shaikhussain Shaik Ibrahim
- Department of Computer Science and Engineering, Government College of Engineering , Salem, Tamilnadu 627 007, India
| | - Thiruvengadam Devaki
- Department of Biochemistry, University of Madras , Guindy Campus, Chennai, Tamilnadu 600 025, India
| | - Sandipan Chakraborty
- Department of Microbiology, University of Calcutta , 35 Ballygunge Circular Road, Kolkata, West Bengal 700 019, India
| | - Subhash Agarwal
- Bioinformatics Division, National Institute of Cancer Prevention and Research (NICPR-ICMR) , I-7, Sector-39, Noida, Uttar Pradesh 201301, India
| | - Horacio Pérez-Sánchez
- Bioinformatics and High Performance Computing Research Group (BIO-HPC), Computer Engineering Department, Universidad Católica San Antonio de Murcia (UCAM) , Guadalupe, 30107 Murcia, Spain
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19
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Rajajee V, Fontana RJ, Courey AJ, Patil PG. Protocol based invasive intracranial pressure monitoring in acute liver failure: feasibility, safety and impact on management. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:178. [PMID: 28693567 PMCID: PMC5504795 DOI: 10.1186/s13054-017-1762-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 06/19/2017] [Indexed: 01/20/2023]
Abstract
Background Acute liver failure (ALF) may result in elevated intracranial pressure (ICP). While invasive ICP monitoring (IICPM) may have a role in ALF management, these patients are typically coagulopathic and at risk for intracranial hemorrhage (ICH). Contemporary ICP monitoring techniques and coagulopathy reversal strategies may be associated with a lower risk of hemorrhage. Our objective was to evaluate the safety, feasibility, impact on clinical management and outcomes associated with protocol-directed use of IICPM in ALF. Methods Adult patients admitted between June 2011 and October 2016, with ALF and grade-4 encephalopathy with a reasonable likelihood of survival, were eligible for IICPM. The coagulopathy reversal protocol included administration of recombinant Factor VIIa (rFVIIa) and desmopressin, a goal platelet count >50,000/mm3 and fibrinogen >100 mg/dL. Monitor insertion was performed within an hour of the rFVIIa dose. Only intraparenchymal monitors were used. Computed tomography of the brain was performed prior to and within 24 hours of monitor placement. Outcomes of interest included ICH, sustained intracranial hypertension, therapeutic intensity level (TIL) for ICP management, mortality and functional outcome on the Glasgow Outcome Scale (GOS) at discharge and 6 months. Results A total of 24/37 patients (65%) with ALF underwent IICPM. The most common reason for exclusion was encephalopathy grade <4. Four patients underwent liver transplantation. There was one asymptomatic ICH following IICPM, in a patient who had an excellent outcome. Sustained intracranial hypertension occurred in 13/24 monitored patients (54%), 5/24 (21%) required extreme measures (TIL-4) for ICP control, which were successful in 4 patients: 12/24 patients (50%) died but only 4 deaths (17%) were attributed to intracranial hypertension. Six of the 8 survivors with 6-month follow up had good functional outcome (GOS >3). Conclusions Protocol-directed use of IICPM in ALF is feasible, associated with a low incidence of serious complications and has a significant impact on clinical management.
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Affiliation(s)
- Venkatakrishna Rajajee
- Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center, 1500 East Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109-5338, USA.
| | - Robert J Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Anthony J Courey
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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20
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Zhang W, Chen B, Chen Y, Chamberland R, Fider-Whyte A, Craig J, Varma C, Befeler AS, Bisceglie AMD, Horton P, Lai JP. Epstein-Barr Virus-Associated Acute Liver Failure Present in a 67-Year-Old Immunocompetent Female. Gastroenterology Res 2016; 9:74-78. [PMID: 27785330 PMCID: PMC5040549 DOI: 10.14740/gr718e] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/09/2016] [Indexed: 02/07/2023] Open
Abstract
Acute liver failure (ALF) is a rare illness with a high mortality rate. The only favorable management is emergent liver transplantation. About 13% of ALF cases have no clear etiology. Epstein-Barr virus (EBV)-associated ALF accounts for less than 1% of all ALF cases, and is seen mostly in adults younger than 40 years. There are only a few cases of EBV-associated ALF in elderly immunocompromised adults. We report a case of ALF in an immunocompetent 67-year-old woman caused by EBV infection that was treated by orthotopic liver transplantation (OLT). The diagnosis of EBV-associated ALF was established by EBV-DNA polymerase chain reaction (PCR) and EBV-encoded RNA (EBER-RNA) in situ hybridization (EBER-RISH). The patient is currently doing well 6 months after transplantation without any evidence of clinical EBV infection. This case illustrates the importance of early recognition and diagnosis of EBV-associated ALF by detection of EBV from liver biopsy, especially when patients are immunocompetent and other causes are excluded. To the best of our knowledge, this is the first case of EBV-associated ALF present in an immunocompetent elderly female.
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Affiliation(s)
- Wei Zhang
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA; Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Betty Chen
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Yongxin Chen
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Robin Chamberland
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Alexa Fider-Whyte
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Julia Craig
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Chintalapati Varma
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Alex S Befeler
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Adrian M Di Bisceglie
- Department of Internal Medicine, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Peter Horton
- Department of Surgery, Saint Louis University School of Medicine, St Louis, MO 63104, USA
| | - Jin-Ping Lai
- Department of Pathology, Saint Louis University School of Medicine, St Louis, MO 63104, USA
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21
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Porcher R, Vaquero J. Hypothermia in acute liver failure: What got lost in translation? J Hepatol 2016; 65:240-2. [PMID: 27184532 DOI: 10.1016/j.jhep.2016.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 05/04/2016] [Indexed: 01/06/2023]
Affiliation(s)
- Raphaël Porcher
- Centre de Recherche Épidémiologie et Statistique Sorbonne Paris Cité (CRESS-UMR1153), Hôtel-Dieu, Paris, France.
| | - Javier Vaquero
- Laboratorio de Investigación en Hepatología y Gastroenterología, HGU Gregorio Marañón - IiSGM - CIBERehd, Madrid, Spain.
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Abstract
Acute liver failure is life threatening liver injury with coagulopathy and hepatic encephalopathy within 26 weeks and generally, in the absence of preexisting liver disease. Fulminant liver failure occurs when hepatic encephalopathy occurs within 8 weeks of jaundice. The majority of patients with ALF are women with the median age of 38 years. In the United States, drug induced liver injury including acetaminophen causes the majority of ALF cases. The etiology of ALF should be determined, if possible, because many causes have a specific treatment. The mainstay for ALF is supportive care and liver transplantation, if necessary. There are multiple prognostic criteria available. Prognosis can be poor and patients should be referred to a liver transplantation center as soon as possible.
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Affiliation(s)
- Carmi S Punzalan
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Curtis T Barry
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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Application of the Liver Maximum Function Capacity Test in Acute Liver Failure: A Helpful Tool for Decision-Making in Liver Transplantation? Case Rep Transplant 2016; 2016:7074636. [PMID: 27274881 PMCID: PMC4870360 DOI: 10.1155/2016/7074636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2015] [Accepted: 04/10/2016] [Indexed: 01/15/2023] Open
Abstract
Background. Despite aggressive intensive medical management acute liver failure (ALF) may require high-urgency liver transplantation (LTx). Available prognostic scores do not apply for all patients; reliable tools to identify individuals in need of LTx are highly required. The liver maximum function capacity test (LiMAx) might represent an appropriate option. Referring to a case of ALF after Amanita phalloides-intoxication the potential of the LiMAx-test in this setting is discussed. Presentation of Case. LiMAx was performed in a 27-year-old patient prior to and after high-urgency LTx. In accordance with clinical appearance of hepatic encephalopathy, coagulopathy, and acute kidney failure, the LiMAx-test constituted a fulminant course of ALF with hardly any detectable metabolic activity. Following LTx with a marginal donor organ (95% hepatosteatosis), uptake of liver function was demonstrated by postoperative increase of the LiMAx-value. The patient was discharged from hospital on postoperative day 26. Discussion. ALF often is associated with a critical state of the patient that requires almost immediate decision-making regarding further therapy. Application of a noninvasive liver function test might help to determine the prognosis of ALF and support decision-making for or against LTx as well as acceptance of a critical donor organ in case of a critically ill patient.
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Tamaoki S, Suzuki H, Okada M, Fukui N, Isobe M, Saito T. Development of an experimental rat model of hyperammonemic encephalopathy and evaluation of the effects of rifaximin. Eur J Pharmacol 2016; 779:168-76. [DOI: 10.1016/j.ejphar.2016.03.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Revised: 03/10/2016] [Accepted: 03/11/2016] [Indexed: 02/07/2023]
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Duan WD, Wang XT, Wang HG, Ji WB, Li H, Dong JH. Auxiliary partial liver transplantation for acute liver failure using "high risk" grafts: Case report. World J Gastroenterol 2016; 22:1919-1924. [PMID: 26855552 PMCID: PMC4724624 DOI: 10.3748/wjg.v22.i5.1919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/11/2015] [Accepted: 11/09/2015] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure (ALF) is a reversible disorder that is associated with an abrupt loss of hepatic mass, rapidly progressive encephalopathy and devastating complications. Despite its high mortality, an emergency liver transplantation nowadays forms an integral part in ALF management and has substantially improved the outcomes of ALF. Here, we report the case of a 32-year-old female patient who was admitted with grade IV hepatic encephalopathy (coma) following drug-induced ALF. We performed an emergency auxiliary partial orthotopic liver transplantation with a “high risk” graft (liver macrovesicular steatosis approximately 40%) from a living donor. The patient was discharged on postoperative day 57 with normal liver function. Weaning from immunosuppression was achieved 9 mo after transplantation. A follow-up using CT scan showed a remarkable increase in native liver volume and gradual loss of the graft. More than 6 years after the transplantation, the female now has a 4-year-old child and has returned to work full-time without any neurological sequelae.
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Yan BZ, Yang BS, Li H, Zhang YF, Pei FH, Zhu AC, Wang XR, Liu BR. The therapeutic effect of CORM-3 on acute liver failure induced by lipopolysaccharide/D-galactosamine in mice. Hepatobiliary Pancreat Dis Int 2016; 15:73-80. [PMID: 26818546 DOI: 10.1016/s1499-3872(15)60044-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute liver failure (ALF) is a severe and life-threatening clinical syndrome resulting in a high mortality and extremely poor prognosis. Recently, a water-soluble CO-releasing molecule (CORM-3) has been shown to have anti-inflammatory effect. The present study was to investigate the effect of CORM-3 on ALF and elucidate its underlying mechanism. METHODS ALF was induced by a combination of LPS/D-GalN in mice which were treated with CORM-3 or inactive CORM-3 (iCORM-3). The efficacy of CORM-3 was evaluated based on survival, liver histopathology, serum aminotransferase activities (ALT and AST) and total bilirubin (TBiL). Serum levels of inflammatory cytokines (TNF-alpha, IL-6, IL-1beta and IL-10) and liver immunohistochemistry of NF-kappaB-p65 were determined; the expression of inflammatory mediators such as iNOS, COX-2 and TLR4 was measured using Western blotting. RESULTS The pretreatment with CORM-3 significantly improved the liver histology and the survival rate of mice compared with the controls; CORM-3 also decreased the levels of ALT, AST and TBiL. Furthermore, CORM-3 significantly inhibited the increased concentration of pro-inflammatory cytokines (TNF-alpha, IL-6 and IL-1beta) and increased the anti-inflammatory cytokine (IL-10) productions in ALF mice. Moreover, CORM-3 significantly reduced the increased expression of iNOS and TLR4 in liver tissues and inhibited the nuclear expression of NF-kappaB-p65. CORM-3 had no effect on the increased expression of COX-2 in the ALF mice. An iCORM-3 failed to prevent acute liver damage induced by LPS/D-GalN. CONCLUSION These findings provided evidence that CORM-3 may offer a novel alternative approach for the management of ALF through anti-inflammatory functions.
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Affiliation(s)
- Bing-Zhu Yan
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, China.
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Wang K, Chen X, Ren J. Autologous bone marrow stem cell transplantation in patients with liver failure: a meta-analytic review. Stem Cells Dev 2015; 24:147-59. [PMID: 25356526 DOI: 10.1089/scd.2014.0337] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Autologous bone marrow stem cell (ABMSC) transplantation has been utilized in clinical practice to treat patients with liver failure, but the therapeutic effect remains to be defined. A meta-analysis is essential to assess clinical advantages of ABMSC transplantation in patients with liver failure. A systematic search of published works [eg, PubMed, Medline, Embase, Chin J Clinicians (Electronic edition), and Science Citation Index] was conducted to compare clinical outcomes of ABMSC transplantation in patients with liver failure. Meta-analytic results were tested by fixed-effects model or random-effects model, dependent on the characteristics of variables. A total of 534 patients from seven studies were included in final meta-analysis. Subsequent to ABMSC transplantation, there was no significant improvement in general symptom and signs such as loss of appetite, fatigue, and ascites. Activities of serum ALT were not significantly decreased with weighted mean difference (WMD) of -19.36 and 95% confidence interval (CI) -57.53 to 18.80 (P=0.32). Postoperative level of albumin (ALB) was expectedly enhanced by stem cell transplantation (WMD 2.97, 95% CI 0.52 to 5.43, P<0.05, I(2)=84%). Coagulation function was improved as demonstrated by a short prothrombin time (PT) (WMD -1.18, 95% CI -2.32 to -0.03, P<0.05, I(2)=6%), but was not reflected by prothrombin activity (PTA) (P=0.39). Total bilirubin (TBIL) was drastically diminished after ABMSC therapy (WMD -14.85, 95% CI -20.39 to -9.32, P<0.01, I(2)=73%). Model for end-stage liver disease (MELD) scores were dramatically reduced (WMD -2.27, 95% CI -3.53 to -1.02, P<0.01, I(2)=0%). The advantage of ABMSC transplantation could be maintained more than 24 weeks as displayed by time-courses of ALB, TBIL, and MELD score. ABMSC transplantation does provide beneficial effects for patients with liver failure. Therapeutic effects can last for 6 months. However, long-term effects need to be determined.
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Affiliation(s)
- Kewei Wang
- 1 Department of Surgery, University of Illinois College of Medicine , Peoria, Illinois
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Adam R, Karam V, Delvart V, Trunečka P, Samuel D, Bechstein WO, Němec P, Tisone G, Klempnauer J, Rossi M, Rummo OO, Dokmak S, Krawczyk M, Pratschke J, Kollmar O, Boudjema K, Colledan M, Ericzon BG, Mantion G, Baccarani U, Neuhaus P, Paul A, Bachellier P, Zamboni F, Hanvesakul R, Muiesan P. Improved survival in liver transplant recipients receiving prolonged-release tacrolimus in the European Liver Transplant Registry. Am J Transplant 2015; 15:1267-82. [PMID: 25703527 DOI: 10.1111/ajt.13171] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Revised: 11/28/2014] [Accepted: 12/09/2014] [Indexed: 01/25/2023]
Abstract
This study was a retrospective analysis of the European Liver Transplant Registry (ELTR) performed to compare long-term outcomes with prolonged-release tacrolimus versus tacrolimus BD in liver transplantation (January 2008-December 2012). Clinical efficacy measures included univariate and multivariate analyses of risk factors influencing graft and patient survival at 3 years posttransplant. Efficacy measures were repeated using propensity score-matching for baseline demographics. Patients with <1 month of follow-up were excluded from the analyses. In total, 4367 patients (prolonged-release tacrolimus: n = 528; BD: n = 3839) from 21 European centers were included. Tacrolimus BD treatment was significantly associated with inferior graft (risk ratio: 1.81; p = 0.001) and patient survival (risk ratio: 1.72; p = 0.004) in multivariate analyses. Similar analyses performed on the propensity score-matched patients confirmed the significant survival advantages observed in the prolonged-release tacrolimus- versus tacrolimus BD-treated group. This large retrospective analysis from the ELTR identified significant improvements in long-term graft and patient survival in patients treated with prolonged-release tacrolimus versus tacrolimus BD in primary liver transplant recipients over 3 years of treatment. However, as with any retrospective registry evaluation, there are a number of limitations that should be considered when interpreting these data.
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Affiliation(s)
- R Adam
- Hepato-Biliary Center, AP-HP Paul Brousse Hospital, University of Paris-Sud, Inserm U 776, Villejuif, France
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Fontana RJ, Ellerbe C, Durkalski VE, Rangnekar A, Reddy KR, Stravitz T, McGuire B, Davern T, Reuben A, Liou I, Fix O, Ganger DR, Chung RT, Schilsky M, Han S, Hynan LS, Sanders C, Lee WM. Two-year outcomes in initial survivors with acute liver failure: results from a prospective, multicentre study. Liver Int 2015; 35:370-80. [PMID: 25039930 PMCID: PMC4291312 DOI: 10.1111/liv.12632] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/01/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS The long-term clinical outcomes in initial survivors with acute liver failure (ALF) are not well known. The aim of this study was to provide an overview of the 2-year clinical outcomes among initial survivors and liver transplant (LT) recipients that were alive 3 weeks after enrolment in the Acute Liver Failure Study Group (ALFSG). METHODS Outcomes in adult ALFSG patients that were enrolled between 1998 and 2010 were reviewed. RESULTS Two-year patient survival was significantly higher in the 262 LT recipients (92.4%) compared to the 306 acetaminophen (APAP) spontaneous survivors (SS) (89.5%) and 200 non-APAP SS (75.5%) (P < 0.0001). The causes of death were similar in the three groups but the time to death was significantly longer in the LT recipients (P < 0.0001). Independent predictors of 2-year mortality in the APAP group were a high serum phosphate level and patient age (c-statistic = 0.65 (0.54, 0.76)), patient age and days from jaundice to ALF onset in the non-APAP group (c-statistic = 0.69 (0.60, 0.78)), and patient age, days from jaundice, and higher coma grade in the LT recipients (c-statistic = 0.74 (0.61, 0.87)). The LT recipients were significantly more likely to be employed and have a higher educational level (P < 0.05). CONCLUSIONS Two-year outcomes in initial survivors of ALF are generally good but non-APAP patients have a significantly lower survival which may relate to pre-existing medical comorbidities. Spontaneous survivors with APAP overdose experience substantial morbidity during follow-up from ongoing psychiatric and substance abuse issues.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109–0362
| | - Caitlyn Ellerbe
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Valerie E. Durkalski
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Amol Rangnekar
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109–0362
| | - K. Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Todd Stravitz
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Brendan McGuire
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Adrian Reuben
- Medical University of South Carolina, Charleston, SC
| | - Iris Liou
- University of Washington, Seattle, WA
| | - Oren Fix
- University of California San Francisco, San Francisco, CA
| | - Daniel R Ganger
- Division of Gastroenterology, Northwestern University, Chicago, Il
| | | | - Mike Schilsky
- Section of Transplantation and Immunology, Yale University, New Haven, CT
| | - Steven Han
- University of California, Los Angeles, CA
| | - Linda S. Hynan
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Corron Sanders
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - William M. Lee
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
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Abstract
BACKGROUND We sought to compare liver transplant waiting list access by demographics and geography relative to the pool of potential liver transplant candidates across the United States using a novel metric of access to care, termed a liver wait-listing ratio (LWR). METHODS We calculated LWRs from national liver transplant registration data and liver mortality data from the Scientific Registry of Transplant Recipients and the National Center for Healthcare Statistics from 1999 to 2006 to identify variation by diagnosis, demographics, geography, and era. RESULTS Among patients with ALF and CLF, African Americans had significantly lower access to the waiting list compared with whites (acute: 0.201 versus 0.280; pre-MELD 0.201 versus 0.290; MELD era: 0.201 versus 0.274; all, P<0.0001) (chronic: 0.084 versus 0.163; pre-MELD 0.085 versus 0.179; MELD 0.084 versus 0.154; all, P<0.0001). Hispanics and whites had similar LWR in both eras (both P>0.05). In the MELD era, female subjects had greater access to the waiting list compared with male subjects (acute: 0.428 versus 0.154; chronic: 0.158 versus 0.140; all, P<0.0001). LWRs varied by three-fold by state (pre-MELD acute: 0.122-0.418, chronic: 0.092-0.247; MELD acute: 0.121-0.428, chronic: 0.092-0.243). CONCLUSIONS The marked inequity in early access to liver transplantation underscores the need for local and national policy initiatives to affect this disparity.
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ABO-incompatible liver transplantation in acute liver failure: a single Portuguese center study. Transplant Proc 2013; 45:1110-5. [PMID: 23622639 DOI: 10.1016/j.transproceed.2013.02.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION ABO-incompatible liver transplantation (ABOi LT) is considered to be a rescue option in emergency transplantation. Herein, we have reported our experience with ABOi LT including long-term survival and major complications in these situations. PATIENT AND METHODS ABOi LT was performed in cases of severe hepatic failure with imminent death. The standard immunosuppression consisted of basiliximab, corticosteroids, tacrolimus, and mycophenolate mofetil. Pretransplantation patients with anti-ABO titers above 16 underwent plasmapheresis. If the titer was above 128, intravenous immunoglobulin (IVIG) was added at the end of plasmapheresis. The therapeutic approach was based on the clinical situation, hepatic function, and titer evolution. A rapid increase in titer required five consecutive plasmapheresis sessions followed by administration of IVIG, and at the end of the fifth session, rituximab. RESULTS From January 2009 to July 2012, 10 patients, including 4 men and 6 women of mean age 47.8 years (range, 29 to 64 years), underwent ABOi LT. At a mean follow-up of 19.6 months (range, 2 days to 39 months), 5 patients are alive including 4 with their original grafts. One patient was retransplanted at 9 months. Major complications were infections, which were responsible for 3 deaths due to multiorgan septic failure (2 during the first month); rejection episodes (4 biopsy-proven of humoral rejections in 3 patients and 1 cellular rejection) and biliary. CONCLUSION The use of ABOi LT as a life-saving procedure is justifiable in emergencies when no other donor is available. With careful recipient selection close monitoring of hemagglutinins and specific immunosuppression we have obtained acceptable outcomes.
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Rangnekar AS, Ellerbe C, Durkalski V, McGuire B, Lee WM, Fontana RJ. Quality of life is significantly impaired in long-term survivors of acute liver failure and particularly in acetaminophen-overdose patients. Liver Transpl 2013; 19:991-1000. [PMID: 23780824 PMCID: PMC3775983 DOI: 10.1002/lt.23688] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
Functional outcomes for long-term survivors of acute liver failure (ALF) are not well characterized. The aim of this prospective study was to determine health-related quality of life in long-term adult ALF survivors. Acute Liver Failure Study Group registry participants completed the Centers for Disease Control and Prevention Health-Related Quality of Life 14 and Short Form 36 (SF-36) questionnaires at 1- and/or 2-year follow-up study visits. Responses were compared among ALF subgroups and to those for available general US population controls. Among the 282 adult ALF patients, 125 had undergone liver transplantation (LT), whereas 157, including 95 acetaminophen overdose (APAP) patients and 62 non-APAP patients, were spontaneous survivors (SSs). APAP SS patients reported significantly lower general health scores and more days of impaired mental and physical health, activity limitations due to poor health, pain, depression, and anxiety in comparison with the other groups (P ≤ 0.001). There were no significant differences in coma grade or in the use of mechanical ventilation or intracranial pressure monitoring among the patient groups during their ALF hospitalization, but APAP SSs had significantly higher rates of psychiatric disease and substance abuse (P < 0.001). In comparison with the general US population, a greater proportion of the combined SS patients reported fair or poor health and ≥14 days of impaired physical/mental health and activity limitations due to poor health. In addition, a greater proportion of LT recipients reported ≥14 days of impaired physical/mental health. Similar results were observed with the SF-36 across the 3 ALF subgroups and in comparison with population controls. In conclusion, long-term adult survivors of ALF reported significantly lower quality of life scores than US population controls. Furthermore, APAP SS patients reported the lowest quality of life scores, possibly because of higher rates of premorbid psychiatric and substance abuse disorders.
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Affiliation(s)
- Amol S. Rangnekar
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109-0362
| | - Caitlyn Ellerbe
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Valerie Durkalski
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Brendan McGuire
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - William M. Lee
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Robert J. Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109-0362
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Akamatsu N, Sugawara Y, Kokudo N. Acute liver failure and liver transplantation. Intractable Rare Dis Res 2013; 2:77-87. [PMID: 25343108 PMCID: PMC4204547 DOI: 10.5582/irdr.2013.v2.3.77] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Accepted: 07/18/2013] [Indexed: 12/19/2022] Open
Abstract
Acute liver failure (ALF) is defined by the presence of coagulopathy (International Normalized Ratio ≥ 1.5) and hepatic encephalopathy due to severe liver damage in patients without pre-existing liver disease. Although the mortality due to ALF without liver transplantation is over 80%, the survival rates of patients have considerably improved with the advent of liver transplantation, up to 60% to 90% in the last two decades. Recent large studies in Western countries reported 1, 5, and 10-year patient survival rates after liver transplantation for ALF of approximately 80%, 70%, and 65%, respectively. Living donor liver transplantation (LDLT), which has mainly evolved in Asian countries where organ availability from deceased donors is extremely scarce, has also improved the survival rate of ALF patients in these regions. According to recent reports, the overall survival rate of adult ALF patients who underwent LDLT ranges from 60% to 90%. Although there is still controversy regarding the graft type, optimal graft volume, and ethical issues, LDLT has become an established treatment option for ALF in areas where the use of deceased donor organs is severely restricted.
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Affiliation(s)
- Nobuhisa Akamatsu
- Department of Hepato-biliary-pancreatic Surgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Yasuhiko Sugawara
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
- Address correspondence to: Dr. Yasuhiko Sugawara, Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan. E-mail:
| | - Norihiro Kokudo
- Artificial Organ and Transplantation Division, Department of Surgery, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Rodriguez Lopez M, Perez Saborido B, Pacheco Sanchez D, Asensio Diaz E, Labarga Rodriguez F, Martinez Diaz R, Gonzalo Martin M, Velasco Lopez R, Pinto Fuentes P, Barrera Rebollo A. Transplantation for acute liver failure: report of results in the region of Castilla y Leon (Spain) after 10 years of activity. Transplant Proc 2013; 44:2625-6. [PMID: 23146476 DOI: 10.1016/j.transproceed.2012.09.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Acute liver failure is an uncommon disease but its overall mortality rate is still high without liver transplantation, which is the treatment of choice for patients achieving certain criteria. We have reported herein the experience and retrospectively analyzed results of liver transplantation for acute liver failure since the beginning of activity of our group, which is the only one in the region of "Castilla y Leon" (Spain). In 10 years, 14 patients underwent emergency transplantation among an overall series of 325 subjects. The patients were generally young men and women; the average wait list time was 2.14 days. The most common etiology was toxic exposure (no cases were related to acetaminophen overdose), followed by viral infection (all because of acute hepatitis B). Our posttransplant outcomes were: perioperative mortality, 0%; posttransplant in-hospital mortality, 14%; and 1-y, 3-y, and 5-year survival rates of 77.1%, 64.3%, and 64.3% respectively. Retransplantation rate was 7%. A major morbidity occurred in four patients: one primary dysfunction, one hyperacute rejection due to ABO blood group-incompatibility requiring retransplantation, two arterial complications, and two biliary leakages. Our outcomes of emergency transplantation were similar to those reported by both the European and Spanish Liver Transplantation Registries, despite the small number of patients.
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Affiliation(s)
- M Rodriguez Lopez
- General and Digestive Surgery Department (Liver Transplantation Unit), "Rio Hortega" University Hospital, Valladolid, Spain.
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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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Germani G, Theocharidou E, Adam R, Karam V, Wendon J, O'Grady J, Burra P, Senzolo M, Mirza D, Castaing D, Klempnauer J, Pollard S, Paul A, Belghiti J, Tsochatzis E, Burroughs AK. Liver transplantation for acute liver failure in Europe: outcomes over 20 years from the ELTR database. J Hepatol 2012; 57:288-96. [PMID: 22521347 DOI: 10.1016/j.jhep.2012.03.017] [Citation(s) in RCA: 163] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2011] [Revised: 02/01/2012] [Accepted: 03/08/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Liver transplantation for acute liver failure (ALF) still has a high early mortality. We evaluated changes during 20 years, and identified risk factors for poor outcome. METHODS Donor, graft, and recipient variables from the European Liver Transplant Registry database (January 1988-June 2009), were analysed. Aetiologies and time periods were compared. Three and 12-month survival models were generated from separate training data sets, which were validated. A sub-analysis was performed for recipient older than 50 years. RESULTS Four thousand nine hundred and three patients were evaluated. One, 5- and 10-year patient, and graft survival rates were 74%, 68%, 63%, and 63%, 57%, 50%, respectively. Survival was better in 2004-2009 compared to previous quinquennia (p<0.001), despite donors >60 years increased from 1.8% to 21%. A higher incidence of suicide or non-adherence occurred in paracetamol-related ALF (p<0.001). Death or graft loss were independently associated with male recipients (adjusted OR 1.25), recipient >50 years (1.26), incompatible ABO matching (1.93), donors >60 years (1.21), and reduced size graft (1.54). For both 3- and 12-month models, incompatible ABO matching, non-viral aetiology, reduced size graft, and non-UW preservation fluid were associated with increased mortality/graft loss, whereas male recipients and age >50 years were associated only at 12 months. Both models had reasonable discriminative ability with good calibration at 3 months. Recipients >50 years, combined with donors >60 years resulted in 57% mortality/graft loss within the first year. CONCLUSIONS Survival after liver transplantation has improved despite increases in donor/recipient age. Recipients >50 years paired with donors >60 years had a very high mortality/graft loss within the first year.
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Affiliation(s)
- Giacomo Germani
- The Royal Free Sheila Sherlock Liver Centre, University Department of Surgery, Royal Free Hospital and UCL, London UK
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Nguyen JH. Blood-brain barrier in acute liver failure. Neurochem Int 2011; 60:676-83. [PMID: 22100566 DOI: 10.1016/j.neuint.2011.10.012] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/20/2011] [Accepted: 10/26/2011] [Indexed: 12/16/2022]
Abstract
Brain edema remains a challenging obstacle in the management of acute liver failure (ALF). Cytotoxic mechanisms associated with brain edema have been well recognized, but evidence for vasogenic mechanisms in the pathogenesis of brain edema in ALF has been lacking. Recent reports have not only shown a role of matrix metalloproteinase-9 in the pathogenesis of brain edema in experimental ALF but have also found significant alterations in the tight junction elements including occludin and claudin-5, suggesting a vasogenic injury in the blood-brain barrier (BBB) integrity. This article reviews and explores the role of the paracellular tight junction proteins in the increased selective BBB permeability that leads to brain edema in ALF.
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Affiliation(s)
- Justin H Nguyen
- Division of Transplant Surgery, Department of Transplantation, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States.
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Is there a role for extracorporeal liver support as a bridge to liver transplantation in acute liver failure? Transplantation 2011; 92:e44-5. [PMID: 21989274 DOI: 10.1097/tp.0b013e318230c0f1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Clinical investigations in acute liver failure (ALF) continue to advance our understanding and capacity to diagnose and treat afflicted children and adults. The purpose of this review is to summarize the advances in clinical research in ALF during 2009-2010 that are pertinent to hepatologists and transplant surgeons caring for these critically ill patients. RECENT FINDINGS Principal advances occurred in the characterization of cause and epidemiology, genetic susceptibility, assessment of prognosis for survival with medical therapy, clarification of long-term outcomes of transplantation for ALF, and publication of the final results of large randomized, placebo-controlled therapeutic trials. SUMMARY Despite advances in our understanding, ALF remains a cause of significant mortality in children and adults because of the absence of curative medical therapy. Hence, only emergency liver transplantation is reliably life-saving. There is an urgent need for better understanding of the pathogenesis of ALF caused by different causes, of genetic susceptibility, development of validated prognostic indicators and application of this knowledge to devise new therapeutic strategies for testing in appropriately powered, randomized controlled trials.
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LEKIĆ N, ČERNÝ D, HOŘÍNEK A, PROVAZNÍK Z, MARTÍNEK J, FARGHALI H. Differential Oxidative Stress Responses to D-Galactosamine-Lipopolysaccharide Hepatotoxicity Based on Real Time PCR Analysis of Selected Oxidant/Antioxidant and Apoptotic Gene Expressions in Rat. Physiol Res 2011; 60:549-58. [DOI: 10.33549/physiolres.932041] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Oxidative stress and apoptosis are proposed mechanisms of cellular injury in studies of xenobiotic hepatotoxicity. This study is focused on addressing the mutual relationship and early signals of these mechanisms in the D-galactosamine and lipopolysaccharide (D-GalN/LPS) hepatotoxicity model, with the help of standard liver function and biochemistry tests, histology, and measurement of gene expression by RT-PCR. Intraperitoneal injection of 400 mg/kg D-GalN and 50 μg/kg LPS was able to induce hepatotoxicity in rats, as evidenced by significant increases in liver enzymes (ALT, AST) and raised bilirubin levels in plasma. Heme oxygenase-1 and nitric oxide synthase-2 gene expressions were significantly increased, along with levels of their products, bilirubin and nitrite. The gene expression of glutathione peroxidase 1 remained unchanged, whereas a decrease in superoxide dismutase 1 gene expression was noted. Furthermore, the significant increase in the gene expression of apoptotic genes Bid, Bax and caspase-3 indicate early activation of apoptotic pathways, which was confirmed by histological evaluation. In contrast, the measured caspase-3 activity remained unchanged. Overall, the results have revealed differential oxidative stress and apoptotic responses, which deserves further investigations in this hepatotoxicity model.
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Affiliation(s)
- N. LEKIĆ
- Institute of Pharmacology, First Faculty of Medicine, Charles University in Prague, Prague, Czech Republic
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Chen F, Hori T, Ohashi N, Baine AM, Eckman CB, Nguyen JH. Occludin is regulated by epidermal growth factor receptor activation in brain endothelial cells and brains of mice with acute liver failure. Hepatology 2011; 53:1294-305. [PMID: 21480332 PMCID: PMC3079316 DOI: 10.1002/hep.24161] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
UNLABELLED Mechanisms of brain edema in acute liver failure (ALF) are not completely understood. We recently demonstrated that matrix metalloproteinase 9 (MMP-9) induces significant alterations to occludin in brain endothelial cells in vitro and in brains of mice with experimental ALF (Hepatology 2009;50:1914). In this study we show that MMP-9-induced transactivation of epidermal growth factor receptor (EGFR) and p38 MAPK/NFκB (mitogen-activated protein kinase/nuclear factor-kappa B) signals participate in regulating brain endothelial occludin level. Mouse brain endothelial bEnd3 cells were exposed to MMP-9 or p38 MAPK up-regulation in the presence and absence of EGFR inhibitor, p38 MAPK inhibitor, NFκB inhibitor, and/or appropriate small interfering RNA. Reverse-transcription polymerase chain reaction (RT-PCR) and western blotting were used for messenger RNA and protein expression analyses. Immunohistochemical staining and confocal microscopy were used to demonstrate cellular EGFR activation. Intraperitoneal azoxymethane was use to induce ALF in mice. Brains of comatose ALF mice were processed for histological and biochemical analyses. When bEnd3 cells were exposed to MMP-9, EGFR was significantly transactivated, followed by p38 MAPK activation, I-kappa B alpha (IκBα) degradation, NFκB activation, and suppression of occludin synthesis and expression. Similar EGFR activation and p38 MAPK/NFκB activation were found in the brains of ALF mice, and these changes were attenuated with GM6001 treatment. CONCLUSION EGFR activation with p38 MAPK/NFκB signaling contributes to the regulation of tight junction integrity in ALF. EGFR activation may thus play an important role in vasogenic brain edema in ALF.
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Affiliation(s)
- Feng Chen
- Department of Neuroscience Mayo Clinic, Jacksonville, FL
| | - Tomohide Hori
- Department of Neuroscience Mayo Clinic, Jacksonville, FL
| | | | | | | | - Justin H. Nguyen
- Division of Transplant Surgery, Department of Transplantation, Mayo Clinic, Jacksonville, FL
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Long-term patient outcome and quality of life after liver transplantation: analysis of 20-year survivors. Ann Surg 2010; 252:652-61. [PMID: 20881772 DOI: 10.1097/sla.0b013e3181f5f23a] [Citation(s) in RCA: 191] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate patient survival and allograft function and health-related quality of life (HRQOL) 20 years after orthotopic liver transplantation (LT). SUMMARY OF BACKGROUND DATA Although LT is the established treatment of choice for acute and chronic liver failure, allograft function and recipient HRQOL 20 years after LT remain undefined. METHODS We performed a prospective, cross-sectional study of LT recipients surviving 20 years or more. Clinical data were reviewed to identify factors associated with 20-year survival. Survivors were directly contacted and offered a survey to assess HRQOL (SF-36; Liver Disease Quality of Life), social support, and cognition (Neuropsychological Impairment Scale). Logistic regression analysis was performed to identify clinical factors influencing HRQOL 20 years after LT. RESULTS Between February 1, 1984 and December 31, 1988, a total of 293 patients (179 adults, 114 children) received 348 LTs. Of the 293 patients, 168 (56%) survived for 20 years or more. Actuarial 20-year survival was 52% (patient) and 42% (graft). Factors associated with 20-year survival included recipient age <18 (P = 0.01), nonurgent LT (P = 0.01), no retransplantation (0.02), female gender (0.03), absence of biliary complications (P = 0.04), and short total ischemia time (P = 0.05). Rejection episodes were seen in a greater proportion of 20-year survivors than in nonsurvivors (35% vs. 27%; P = 0.3). Of the 168 survivors, 87 were contacted, and 68 (78%) completed the HRQOL surveys. Compared with the general population, survivors had lower physical scores (P < 0.01) but comparable mental scores on the SF-36. Overall HRQOL was significantly better in 20-year survivors than in patients with chronic liver disease, congestive heart failure, or diabetes. Clinical factors associated with improved post-LT HRQOL were younger age at LT, allograft longevity, and strong social support. More than 90% of pediatric survivors completed high school. After LT, 34% of pediatric recipients married, and 79% remained married at 20 years' follow-up. CONCLUSIONS More than 50% of LT recipients survive 20 years, achieve important socioeconomic milestones, and report quality of life superior to patients with liver disease or other chronic conditions. LT is a durable surgery that restores both long-term physiologic and psychologic well-being in patients with end-stage liver disease.
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