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Weinberg EM, Wong F, Vargas HE, Curry MP, Jamil K, Pappas SC, Sharma P, Reddy KR. Decreased need for RRT in liver transplant recipients after pretransplant treatment of hepatorenal syndrome-type 1 with terlipressin. Liver Transpl 2024; 30:347-355. [PMID: 37801553 DOI: 10.1097/lvt.0000000000000277] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/25/2023] [Indexed: 10/08/2023]
Abstract
Hepatorenal syndrome-acute kidney injury (HRS-AKI), a serious complication of decompensated cirrhosis, has limited therapeutic options and significant morbidity and mortality. Terlipressin improves renal function in some patients with HRS-1, while liver transplantation (LT) is a curative treatment for advanced chronic liver disease. Renal failure post-LT requiring renal replacement therapy (RRT) is a major risk factor for graft and patient survival. A post hoc analysis with a 12-month follow-up of LT recipients from a placebo-controlled trial of terlipressin (CONFIRM; NCT02770716) was conducted to evaluate the need for RRT and overall survival. Patients with HRS-1 were treated with terlipressin plus albumin or placebo plus albumin for up to 14 days. RRT was defined as any type of procedure that replaced kidney function. Outcomes compared between groups included the incidence of HRS-1 reversal, the need for RRT (pretransplant and posttransplant), and overall survival. Of the 300 patients in CONFIRM (terlipressin n = 199; placebo, n = 101), 70 (23%) underwent LT alone (terlipressin, n = 43; placebo, n = 27) and 5 had simultaneous liver-kidney transplant (terlipressin, n = 3, placebo, n = 2). The rate of HRS reversal was significantly higher in the terlipressin group compared with the placebo group (37%, n = 16 vs. 15%, n = 4; p = 0.033). The pretransplant need for RRT was significantly lower among those who received terlipressin ( p = 0.007). The posttransplant need for RRT, at 12 months, was significantly lower among those patients who received terlipressin and were alive at Day 365, compared to placebo ( p = 0.009). Pretransplant treatment with terlipressin plus albumin in patients with HRS-1 decreased the need for RRT pretransplant and posttransplant.
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Affiliation(s)
| | | | | | - Michael P Curry
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Khurram Jamil
- Mallinckrodt Pharmaceuticals, Bridgewater, New Jersey, USA
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Tulla KA, Tinney FJ, Cameron AM. Outcomes of Living Donor Liver Transplantation Compared with Deceased Donor Liver Transplantation. Surg Clin North Am 2024; 104:79-88. [PMID: 37953042 DOI: 10.1016/j.suc.2023.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2023]
Abstract
Improved surgical techniques and revolutionary immunosuppressive agents have enhanced the long-term outcomes for liver transplantation, with more patients seeking the benefits of liver transplantation, and demand is high. In this review, we hope to delineate where the current data supporting favorable outcomes in using live donation to expand the donor pool compared with the outcomes seen in deceased donor liver transplants. Advances in surgery, transplant and center comfort has made live donor transplantation an asset with favorable patient outcomes in comparison to decease donor data.
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Affiliation(s)
- Kiara A Tulla
- Department of Surgery, Division of Transplant Surgery, John Hopkins Medicine
| | - Francis J Tinney
- Department of Surgery, Division of Transplant Surgery, John Hopkins Medicine
| | - Andrew M Cameron
- Department of Surgery, Johns Hopkins University School of Medicine, John Hopkins Medicine, 720 Rutland Avenue, Ross 765, Baltimore, MD 21205, USA.
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Kulkarni AV, Reddy R, Arab JP, Sharma M, Shaik S, Iyengar S, Kumar N, Gupta R, Premkumar GV, Menon BP, Reddy DN, Rao PN, Reddy KR. Early Living Donor Liver Transplantation for Alcohol-Associated Hepatitis. Ann Hepatol 2023; 28:101098. [PMID: 37028597 DOI: 10.1016/j.aohep.2023.101098] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 01/15/2023] [Accepted: 03/02/2023] [Indexed: 04/09/2023]
Abstract
INTRODUCTION AND OBJECTIVES Lately, there has been a steady increase in early liver transplantation for alcohol-associated hepatitis (AAH). Although several studies have reported favorable outcomes with cadaveric early liver transplantation, the experiences with early living donor liver transplantation (eLDLT) are limited. The primary objective was to assess one-year survival in patients with AAH who underwent eLDLT. The secondary objectives were to describe the donor characteristics, assess the complications following eLDLT, and the rate of alcohol relapse. MATERIALS AND METHODS This single-center retrospective study was conducted at AIG Hospitals, Hyderabad, India, between April 1, 2020, and December 31, 2021. RESULTS Twenty-five patients underwent eLDLT. The mean time from abstinence to eLDLT was 92.4±42.94 days. The mean model for end-stage liver disease and discriminant function score at eLDLT were 28.16±2.89 and 104±34.56, respectively. The mean graft-to-recipient weight ratio was 0.85±0.12. Survival was 72% (95%CI, 50.61-88) after a median follow-up of 551 (23-932) days post-LT. Of the 18 women donors,11 were the wives of the recipient. Six of the nine infected recipients died: three of fungal sepsis, two of bacterial sepsis, and one of COVID-19. One patient developed hepatic artery thrombosis and died of early graft dysfunction. Twenty percent had alcohol relapse. CONCLUSIONS eLDLT is a reasonable treatment option for patients with AAH, with a survival of 72% in our experience. Infections early on post-LT accounted for mortality, and thus a high index of suspicion of infections and vigorous surveillance, in a condition prone to infections, are needed to improve outcomes.
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Affiliation(s)
| | - Raghuram Reddy
- Department of Liver transplantation, AIG Hospitals, Hyderabad, India
| | - Juan Pablo Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sameer Shaik
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sowmya Iyengar
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Naveen Kumar
- Department of Psychiatry, AIG Hospitals, Hyderabad, India
| | - Rajesh Gupta
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | | | | | | | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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Tseng HY, Lin YH, Lin CC, Chen CL, Yong CC, Lin LM, Wang CC, Chan YC. Long-term renal outcomes comparison between patients with chronic kidney disease and hepatorenal syndrome after living donor liver transplantation. Front Surg 2023; 10:1116728. [PMID: 37077866 PMCID: PMC10106629 DOI: 10.3389/fsurg.2023.1116728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/27/2023] [Indexed: 04/05/2023] Open
Abstract
Background and aimsHepatorenal syndrome (HRS) is a disastrous renal complication of advanced liver disease with a poor prognosis. Restoring normal liver function through liver transplantation (LT) is a standardized treatment with favorable short-term survival. However, the long-term renal outcomes in patients with HRS receiving living donor LT (LDLT) are controversial. This study aimed to investigate the prognostic impact of LDLT in patients with HRS.MethodsWe reviewed adult patients who underwent LDLT between July 2008 and September 2017. Recipients were classified into 1) HRS type 1 (HRS1, N = 11), 2) HRS type 2 (HRS2, N = 19), 3) non-HRS recipients with pre-existing chronic kidney disease (CKD, N = 43), and 4) matched normal renal function (N = 67).ResultsPostoperative complications and 30-day surgical mortality were comparable among the HRS1, HRS2, CKD, and normal renal function groups. The 5-year survival rate was >90% and estimated glomerular filtration rate (eGFR) transiently improved and peaked at 4 weeks post-transplantation in patients with HRS. However, renal function deteriorated and resulted in CKD stage ≥ III in 72.7% of HRS1 and 78.9% of HRS2 patients (eGFR <60 ml/min/1.73 m2). The incidence of developing CKD and end-stage renal disease (ESRD) was similar between the HRS1, HRS2, and CKD groups, but significantly higher than that in the normal renal function group (both P < 0.001). In multivariate logistic regression, pre-LDLT eGFR <46.4 ml/min/1.73 m2 predicted the development of post-LDLT CKD stage ≥ III in patients with HRS (AUC = 0.807, 95% CI = 0.617–0.997, P = 0.011).ConclusionsLDLT provides a significant survival benefit for patients with HRS. However, the risk of CKD stage ≥ III and ESRD among patients with HRS was similar to that in pre-transplant CKD recipients. An early preventative renal-sparing strategy in patients with HRS is recommended.
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Affiliation(s)
- Hsiang-Yu Tseng
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yu-Hung Lin
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chih-Che Lin
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chao-Long Chen
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Chee-Chien Yong
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Li-Man Lin
- Department of Early Childhood Care and Education, Cheng Shiu University, Kaohsiung, Taiwan
| | - Chih-Chi Wang
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
| | - Yi-Chia Chan
- Liver Transplantation Center, and Department of Surgery, Kaohsiung Chang Gung Memorial Hospital, and Chang Gung University College of Medicine, Kaohsiung, Taiwan
- Correspondence: Yi-Chia Chan
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Takahashi R, Akamatsu N, Nakazawa A, Nagata R, Ichida A, Kawaguchi Y, Ishizawa T, Kaneko J, Arita J, Hasegawa K. Effect of the response to preoperative treatment for hepatorenal syndrome on the outcome of recipients of living-donor liver transplantation. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2022; 29:798-809. [PMID: 35332705 DOI: 10.1002/jhbp.1143] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2021] [Revised: 01/22/2022] [Accepted: 01/26/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND The effect of pretransplant hepatorenal syndrome (HRS) on the outcomes of living-donor liver transplantation (LDLT) recipients with special reference to the recovery of HRS before LDLT was investigated. METHODS The rate of HRS was 43.9% (125/285) among the cohort, and the subjects were divided into 3 groups: those without HRS (No-HRS group, n=160), those with HRS but recovered following pretransplant renal function restoration treatment (Responders group, n=55), and those with persistent HRS (Non-responders group, n=70). RESULTS While the 1-, 3-, and 5-year patient survival rates were comparable between those with and without HRS (89.6%, 84.7%, and 84.7% vs. 95.6%, 92.2%, and 87.5%), the cumulative incidence of the development of posttransplant chronic kidney disease (CKD) was significantly higher in those with HRS (p<0.001). In addition, there was a significant difference between Responders and Non-responders in the development of CKD (p=0.01). In the Cox regression model, Non-responders (p=0.032, HR 1.79 [95% C.I. 1.05-3.03]) and recipient age (p=0.014, HR 1.62 [95% C.I. 1.10-2.37]) were independent predictors for the development of CKD after LDLT. CONCLUSION LDLT is safe and effective for patients with HRS, and CKD progression could be reduced among those with HRS who responded to renal restoration treatment.
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Affiliation(s)
- Ryugen Takahashi
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Nobuhisa Akamatsu
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Akiko Nakazawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Rihito Nagata
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Akihiko Ichida
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Yoshikuni Kawaguchi
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Takeaki Ishizawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Kaneko
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Junichi Arita
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kiyoshi Hasegawa
- Artificial Organ and Transplantation Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Bunkyo-ku, Tokyo, Japan
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Wong TC, Fung JY, Pang HH, Leung CK, Li H, Sin S, Ma K, She BW, Dai JW, Chan AC, Cheung T, Lo C. Analysis of Survival Benefits of Living Versus Deceased Donor Liver Transplant in High Model for End-Stage Liver Disease and Hepatorenal Syndrome. Hepatology 2021; 73:2441-2454. [PMID: 33006772 PMCID: PMC8252626 DOI: 10.1002/hep.31584] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 09/09/2020] [Accepted: 09/15/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIMS Previous recommendations suggested living donor liver transplantation (LDLT) should not be considered for patients with Model for End-Stage Liver Disease (MELD) > 25 and hepatorenal syndrome (HRS). APPROACH AND RESULTS Patients who were listed with MELD > 25 from 2008 to 2017 were analyzed with intention-to-treat (ITT) basis retrospectively. Patients who had a potential live donor were analyzed as ITT-LDLT, whereas those who had none belonged to ITT-deceased donor liver transplantation (DDLT) group. ITT-overall survival (OS) was analyzed from the time of listing. Three hundred twenty-five patients were listed (ITT-LDLT n = 212, ITT-DDLT n = 113). The risk of delist/death was lower in the ITT-LDLT group (43.4% vs. 19.8%, P < 0.001), whereas the transplant rate was higher in the ITT-LDLT group (78.3% vs. 52.2%, P < 0.001). The 5-year ITT-OS was superior in the ITT-LDLT group (72.6% vs. 49.5%, P < 0.001) for patients with MELD > 25 and patients with both MELD > 25 and HRS (56% vs. 33.8%, P < 0.001). Waitlist mortality was the highest early after listing, and the distinct alteration of slope at survival curve showed that the benefits of ITT-LDLT occurred within the first month after listing. Perioperative outcomes and 5-year patient survival were comparable for patients with MELD > 25 (88% vs. 85.4%, P = 0.279) and patients with both MELD > 25 and HRS (77% vs. 76.4%, P = 0.701) after LDLT and DDLT, respectively. The LDLT group has a higher rate of renal recovery by 1 month (77.4% vs. 59.1%, P = 0.003) and 3 months (86.1% vs, 74.5%, P = 0.029), whereas the long-term estimated glomerular filtration rate (eGFR) was similar between the 2 groups. ITT-LDLT reduced the hazard of mortality (hazard ratio = 0.387-0.552) across all MELD strata. CONCLUSIONS The ITT-LDLT reduced waitlist mortality and allowed an earlier access to transplant. LDLT in patients with high MELD/HRS was feasible, and they had similar perioperative outcomes and better renal recovery, whereas the long-term survival and eGFR were comparable with DDLT. LDLT should be considered for patients with high MELD/HRS, and the application of LDLT should not be restricted with a MELD cutoff.
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Affiliation(s)
- Tiffany Cho‐Lam Wong
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - James Yan‐Yue Fung
- Department of MedicineThe University of Hong KongHong KongChina,Department of MedicineQueen Mary HospitalHong KongChina
| | - Herbert H. Pang
- School of Public HealthThe University of Hong KongHong KongChina
| | | | - Hoi‐Fan Li
- Department of SurgeryThe University of Hong KongHong KongChina
| | - Sui‐Ling Sin
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Ka‐Wing Ma
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Brian Wong‐Hoi She
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Jeff Wing‐Chiu Dai
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Albert Chi‐Yan Chan
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Tan‐To Cheung
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
| | - Chung‐Mau Lo
- Department of SurgeryThe University of Hong KongHong KongChina,Department of SurgeryQueen Mary HospitalHong KongChina
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Sanchez LO, Francoz C. Global strategy for the diagnosis and management of acute kidney injury in patients with liver cirrhosis. United European Gastroenterol J 2021; 9:220-228. [PMID: 33337286 PMCID: PMC8259425 DOI: 10.1177/2050640620980713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 11/18/2021] [Indexed: 12/18/2022] Open
Abstract
Acute kidney injury (AKI) is a clinical syndrome that complicates the course and worsens clinical outcomes in patients with chronic liver diseases. It is a common complication in hospitalised patients with liver cirrhosis, especially those with decompensated cirrhosis, associated with a high mortality rate. Considering its impact on patient prognosis, efforts should be made to diagnose and tailor therapeutic interventions for AKI at an early stage. In the past decade, a significant progress has been made to understand the key events and define major prognostic factors for the onset and progression of AKI in the cirrhotic population leading hepatologists to redefine the classic definition of hepatorenal syndrome and renal failure in this specific population.
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Affiliation(s)
- Lukas Otero Sanchez
- Department of Gastroenterology, Hepatopancreatology and Digestive OncologyUniversité Libre de BruxellesBrusselsBelgium
- Belgium Laboratory of Experimental Gastroenterology, Université Libre de BruxellesBrusselsBelgium
| | - Claire Francoz
- Department of Hepatology and Liver Intensive CareHospital BeaujonClichyFrance
- INSERM U1149Centre de Recherche sur L'InflammationParisFrance
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8
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Tariq R, Singal AK. Management of Hepatorenal Syndrome: A Review. J Clin Transl Hepatol 2020; 8:192-199. [PMID: 32832400 PMCID: PMC7438356 DOI: 10.14218/jcth.2020.00011] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 04/23/2020] [Accepted: 05/08/2020] [Indexed: 12/11/2022] Open
Abstract
Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negatively impacts pre- and post-transplant patient survival and healthcare burden. Reduced effective blood volume with consequent reduced renal blood flow, along with systemic inflammation in patients with decompensated cirrhosis, result in susceptibility to HRS. In this article, we will review updates over the last 5 years on the changing definition with diagnostic criteria and nomenclature of AKI and HRS, data on medical treatment with vasoconstrictors, and urinary biomarkers in diagnosis of etiology of AKI. We will also discuss the significance of liver transplantation evaluation once the diagnosis of HRS is established and the post-transplant immunosuppression management. We will also review one of the challenging issues that remains among transplant-eligible patients, that of allocation of simultaneous liver kidney transplant. Finally, we will review the new implemented policy from the Organ Procurement Transplant Network on simultaneous liver kidney allocation.
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Affiliation(s)
- Raseen Tariq
- Department of Medicine, Rochester General Hospital, Rochester, NY, USA
| | - Ashwani K. Singal
- Division of Gastroenterology and Hepatology, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD, USA
- Correspondence to: Ashwani K. Singal, Division of Gastroenterology and Hepatology, University of South Dakota, Sanford School of Medicine, Transplant Hepatologist and Chief Clinical Research Program, Avera Transplant and Research Institutes, Sioux Falls, SD 57105, USA. Tel: +1-605-322-8545, Fax: +1-605-322-8536, E-mail:
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9
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Is living donor liver transplantation justified in high model for end-stage liver disease candidates (35+)? Curr Opin Organ Transplant 2019; 24:637-643. [DOI: 10.1097/mot.0000000000000689] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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10
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da Silva Boteon APC, Chauhan A, Boteon YL, Tillakaratne S, Gunson B, Elsharkawy AM, Ford A, Bangash M, Murphy N, Armstrong MJ, Rajoriya N, Perera MTPR. Predictive factors for 28-day mortality in acute-on-chronic liver failure patients admitted to the intensive care unit. Dig Liver Dis 2019; 51:1416-1422. [PMID: 31064706 DOI: 10.1016/j.dld.2019.04.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 04/06/2019] [Accepted: 04/09/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is an entity comprising an acute deterioration of liver function in cirrhotic patients, associated with organ failure(s) and high short-term mortality. We aimed to identify predictive factors for short-term mortality in patients admitted with ACLF that may benefit most from liver transplantation. METHODS Retrospective analysis of patients admitted in ACLF to a tertiary intensive care unit between 2013 and 2017 was performed. The EASL-CLIF acute-on-chronic liver failure in cirrhosis (CANONIC) criteria were used to define ACLF grade. Multivariable analysis using 28-day mortality as an end-point was performed, including severity-of-disease scores and clinical parameters. RESULTS Seventy-seven patients were admitted in ACLF over the study period. The commonest aetiology of liver disease was alcohol related 52/77(68%) and the commonest precipitant of ACLF was variceal haemorrhage 38/77(49%). Overall 28-day mortality was 42/77(55%) [ACLF-(grade)1:3/42(7%); ACLF-2:10/42(24%); and, ACLF-3:29/42(69%);p = 0.002]. On multivariable analysis MELD ≥ 26 [odds ratio(OR) = 11.559; 95% confidence interval(CI):2.820-47.382;p = 0.001], ACLF-3 (OR = 3.287; 95%CI:1.047-10.325;p = 0.042) at admission and requirement for renal replacement therapy (OR = 5.348; 95%CI:1.385-20.645;p = 0.015) were independently associated with 28-day mortality. CONCLUSION Patients admitted with ACLF to intensive care have a high mortality rate. Defined early thresholds at admission can identify patients at the highest risk that may benefit most from liver transplantation.
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Affiliation(s)
| | - Abhishek Chauhan
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Centre for Liver and Gastrointestinal Research, Institute for Immunology and Immunotherapy,University of Birmingham, Birmingham, United Kingdom; National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Yuri Longatto Boteon
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Centre for Liver and Gastrointestinal Research, Institute for Immunology and Immunotherapy,University of Birmingham, Birmingham, United Kingdom; National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Suchintha Tillakaratne
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Bridget Gunson
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Ahmed Mohamed Elsharkawy
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Abby Ford
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor Bangash
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Nick Murphy
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Matthew J Armstrong
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; National Institute for Health Research (NIHR) Birmingham Biomedical Research Centre, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, Birmingham, United Kingdom
| | - Neil Rajoriya
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - M Thamara P R Perera
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom.
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Abstract
Hepatorenal syndrome (HRS) is a form of kidney function impairment that characteristically occurs in cirrhosis. Recent changes in terminology have led to acute HRS being referred to as acute kidney injury (AKI)-HRS and chronic HRS as chronic kidney disease (CKD)-HRS. AKI-HRS is characterized by a severe impairment of kidney function owing to vasoconstriction of the renal arteries in the absence of substantial abnormalities in kidney histology. Pathogenetic mechanisms involve disturbances in circulatory function due to a marked splanchnic arterial vasodilation, which triggers the activation of vasoconstrictor factors. An intense systemic inflammatory reaction that is characteristic of advanced cirrhosis may also be involved. The main triggering factors of AKI-HRS are bacterial infections, particularly spontaneous bacterial peritonitis. The diagnosis of AKI-HRS is a challenge because of a lack of specific diagnostic tools and mainly involves the differential diagnosis from other forms of AKI, particularly acute tubular necrosis. The prognosis of patients with AKI-HRS is poor, with a median survival of ≤3 months. The ideal treatment for AKI-HRS is liver transplantation in patients without contraindications. Medical therapy consists of vasoconstrictor drugs to counteract splanchnic arterial vasodilation together with volume expansion with albumin. Effective measures to prevent AKI-HRS include early identification and treatment of bacterial infections and the administration of albumin in patients with spontaneous bacterial peritonitis.
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Affiliation(s)
- Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain. .,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain. .,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain.
| | - Elsa Solà
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Catalonia, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Madrid, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, University of Southern California, Los Angeles, CA, USA
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA
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12
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Utako P, Emyoo T, Anothaisintawee T, Yamashiki N, Thakkinstian A, Sobhonslidsuk A. Clinical Outcomes after Liver Transplantation for Hepatorenal Syndrome: A Systematic Review and Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:5362810. [PMID: 29992152 PMCID: PMC5994306 DOI: 10.1155/2018/5362810] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 03/21/2018] [Accepted: 04/03/2018] [Indexed: 02/07/2023]
Abstract
AIMS Hepatorenal syndrome (HRS) decreases survival of cirrhotic patients. The outcomes of HRS after liver transplantation (LT) were inconsistently reported. We conducted a systematic review and meta-analysis study to estimate the post-LT rates of death and HRS reversal. METHODS A thorough search of literatures was performed on PubMed, Scopus, and conference abstracts for reports on post-LT survival and HRS reversal. Data for the posttransplant rates of HRS reversal, death, and acute rejection were extracted. The rates were pooled using inverse variance method if there was no heterogeneity between studies. Otherwise, the random effect model was applied. RESULTS Twenty studies were included. Pooling HRS reversal rates indicated high heterogeneity with a pooled rate of 0.834 (95% CI: 0.709-0.933). The pooled overall death rates for HRS and non-HRS after LT were 0.25 (95% confidence interval (CI): 0.18-0.33) and 0.19 (95% CI: 0.14-0.26). The risk ratio of death between HRS and non-HRS patients was 1.29 (95% CI: 1.14-1.47, P < 0.001). The probability of death at 1, 3, and 5 years tended to be higher among HRS. CONCLUSIONS HRS is reversible in about 83% of patients after LT. However, the posttransplant mortality rate of HRS patients is still increased.
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Affiliation(s)
- Piyapon Utako
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thapanakul Emyoo
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thunyarat Anothaisintawee
- Department of Family Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Noriyo Yamashiki
- Organ Transplantation Unit, Kyoto University Hospital, Kyoto, Japan
| | - Ammarin Thakkinstian
- Section for Clinical Epidemiology and Biostatistics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Abhasnee Sobhonslidsuk
- Division of Gastroenterology and Hepatology, Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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13
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Feng S. Living donor liver transplantation in high Model for End-Stage Liver Disease score patients. Liver Transpl 2017; 23:S9-S21. [PMID: 28719072 DOI: 10.1002/lt.24819] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 06/28/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Sandy Feng
- Department of Surgery, Division of Transplant Surgery, University of California, San Francisco, San Francisco, CA
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14
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Pretransplant Type 2 Hepatorenal Syndrome Is Associated With Persistently Impaired Renal Function After Liver Transplantation. Transplantation 2016; 99:1441-6. [PMID: 25643142 DOI: 10.1097/tp.0000000000000557] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND Type 2 hepatorenal syndrome (HRS2) is a functional renal impairment complicating end-stage liver disease. Although it is reversible after liver transplantation, long-term posttransplant outcomes in HRS2 patients remain ill-defined. METHODS Retrospective, matched case-control (1:2) study of all adult HRS2 patients transplanted in our institution between 2000 and 2012. The HRS2 patients were identified from our electronic transplant database, and matched with controls for the following variables: age, sex, etiology, diabetes mellitus, and year of transplant. RESULTS Forty-two HRS2 patients were compared to 83 controls. At the time of transplant, HRS2 patients had an estimated glomerular filtration rate of 41 ± 1 mL/min per 1.73 m. The HRS2 patients had greater intraoperative packed red blood cell transfusion (P = 0.002), and longer intensive care unit (P = 0.01) as well as total hospital length of stay (P = 0.03). Reversal of HRS2 occurred in 88.1% patients, 5.7 ± 0.5 days after transplantation. Although HRS2 patients had lower initial exposure to calcineurin inhibitors, a greater proportion of HRS2 patients had chronic kidney disease stage 3 (CKD3) at 3 (53.8% vs 28.4%; P = 0.007) and 12 months (59.5% vs 38.2%; P = 0.03) compared to controls. One-year survival was similar between the 2 groups (log-rank P = 0.82). On multivariate analysis, pretransplant HRS2 was associated with CKD3 at 3 (odds ratio, 3.73; 95% confidence interval, 1.54-9.03; P = 0.004) and 12 months (odds ratio, 3.23; 95% confidence interval, 1.37-7.64; P = 0.007) after transplantation. CONCLUSIONS Liver transplantation reverses HRS2 in the majority of patients with survival outcomes comparable to matched controls, despite longer stays in intensive care unit and in hospital. Pretransplant HRS2 is associated with early posttransplant CKD3, despite calcineurin-inhibitor minimization.
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15
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Samstein B, Smith AR, Freise CE, Zimmerman M, Baker T, Othloff KM, Fisher RA, Merion RM. Complications and Their Resolution in Recipients of Deceased and Living Donor Liver Transplants: Findings From the A2ALL Cohort Study. Am J Transplant 2016; 16:594-602. [PMID: 26461803 PMCID: PMC4733444 DOI: 10.1111/ajt.13479] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Revised: 06/19/2015] [Accepted: 07/19/2015] [Indexed: 01/25/2023]
Abstract
The purpose of this study was to explore long-term complications in recipients of deceased donor liver transplant (DDLT) and living donor liver transplant (LDLT) in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL). We analyzed 471 DDLTs and 565 LDLTs from 1998 to 2010 that were followed up to 10 years for 36 categories of complications. Probabilities of complications and their resolutions were estimated using the Kaplan-Meier method, and predictors were tested in Cox proportional hazards models. Median follow-up for DDLT and LDLT was 4.19 and 4.80 years, respectively. DDLT recipients were more likely to have hepatocellular carcinoma and higher disease severity, including Model for End-Stage Liver Disease score. Complications occurring with higher probability in LDLT included biliary-related complications and hepatic artery thrombosis. In DDLT, ascites, intra-abdominal bleeding, cardiac complications and pulmonary edema were significantly more probable. Development of chronic kidney disease stage 4 or 5 was less likely in LDLT recipients (hazard ratio [HR] 0.41, p = 0.02). DDLT and LDLT had similar risk of grade 4 complications (HR 0.89, p = 0.60), adjusted for other risk factors. Once a complication occurred, the time to resolution did not differ between LDLT and DDLT. Future efforts should be directed toward reducing the occurrence of complications after liver transplantation.
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Affiliation(s)
- B Samstein
- Department of Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - AR Smith
- Department of Biostatistics, University of Michigan, Ann Arbor, MI,Arbor Research Collaborative for Health, Ann Arbor, MI
| | - CE Freise
- Department of Surgery, University of California, San Francisco, San Francisco, CA
| | - M Zimmerman
- Division of Transplant Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - T Baker
- Department of Surgery, Northwestern University, Chicago, IL
| | - KM Othloff
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - RA Fisher
- Division of Transplantation, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - RM Merion
- Arbor Research Collaborative for Health, Ann Arbor, MI,Department of Surgery, University of Michigan, Ann Arbor, MI
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16
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Jindal A, Bhadoria AS, Maiwall R, Sarin SK. Evaluation of acute kidney injury and its response to terlipressin in patients with acute-on-chronic liver failure. Liver Int 2016; 36:59-67. [PMID: 26081914 DOI: 10.1111/liv.12895] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 06/02/2015] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Patients with acute-on-chronic liver failure (ACLF) have high mortality. Cirrhotics with acute kidney injury (AKI) have poor outcome but relevance of AKI and response to terlipressin in ACLF is not known. METHODS Consecutive ACLF patients with AKI at admission were compared with those without AKI (controls) for mortality at day 7, month 1 and 3, presence of hepatic encephalopathy (HE), spontaneous bacterial peritonitis (SBP) and acute variceal bleed (AVB). Patients were also compared based on severity of AKI (mild; S.cr 1.5-3 mg/dl and marked; S.cr >3 mg/dl). Response to terlipressin was also evaluated. RESULTS Of 241 ACLF patients, 55 (22.8%) had AKI at admission. Patients with AKI had higher mortality at day 7, 1 and 3 month and more often developed HE [54.1% vs. 30.6%; P = 0.001] and SBP [9.1% vs. 5.9%; P = 0.02]. Patients with marked AKI neither had higher mortality or complications in comparison to mild AKI. Presence of AKI [Odds ratio; OR, 2.4], S.bilirubin >20 mg/dl [OR, 3.1] and INR [OR, 2.9] were independent baseline predictors of mortality. Terlipressin was used in 28 of 55 patients with AKI who were volume non-responsive (hepatorenal syndrome, AKI-HRS). Ten (35.7%) of these showed response (S.Cr < 1.5 mg/dl) [median 4 days] and had lower mortality compared to terlipressin non-responders (10% vs. 50%, P = 0.05). There was no difference in terlipressin response in mild vs. marked AKI. CONCLUSIONS Almost one-fourth of the ACLF patients have AKI at admission and presence of AKI, but not its severity predicts complications and high mortality. Terlipressin effectively reverses AKI-HRS within a week in ~35% of ACLF patients resulting in improved survival.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Ajeet S Bhadoria
- Department of Biostatistics and Clinical Reserch, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India.,Special Centre for Molecular Medicine, Jawaharlal Nehru University (JNU), New Delhi, India
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17
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Srivastava S, Shalimar, Vishnubhatla S, Prakash S, Sharma H, Thakur B, Acharya SK. Randomized Controlled Trial Comparing the Efficacy of Terlipressin and Albumin with a Combination of Concurrent Dopamine, Furosemide, and Albumin in Hepatorenal Syndrome. J Clin Exp Hepatol 2015; 5:276-85. [PMID: 26900268 PMCID: PMC4723649 DOI: 10.1016/j.jceh.2015.08.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 08/24/2015] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Terlipressin with albumin is recommended in hepatorenal syndrome (HRS). Terlipressin is expensive and not licensed in many countries. Alternative therapy is necessary. We compared the efficacy of terlipressin and albumin with concurrent low-dose dopamine, furosemide, and albumin in HRS. METHODS In an open-label, randomized trial, forty consecutive patients each with HRS type I and HRS type II received either concurrent infusion of terlipressin 0.5 mg for every 6 hr and albumin 20 g/day for 5 days (n = 20) or a combination of dopamine 2 μg/kg/min, furosemide 0.01 mg/kg/hr, and albumin 20 g/day (triple therapy), in one of two therapeutic arms. Twenty-four-hour urine output, urinary sodium, and plasma renin activity (PRA) were assessed before and after treatment. RESULTS The two groups were comparable at baseline in both HRS-I and II. In HRS-I, 24 hr urine output and urine sodium at the end of 5 days increased in both treatment groups (terlipressin, urine output 278 ± 136 to 765 ± 699 ml/day, P < 0.01; urine sodium 28 ± 25.1 to 39 ± 32.1 meq/l, P = 0.05. Triple therapy: urine output 219 ± 134 to 706 ± 595 ml/day, P < 0.01; urine sodium 25 ± 18.3 to 41 ± 27.5 meq/l, P < 0.01). PRA (ng/ml/hr) decreased from 28.1 ± 9.76 to 24.2 ± 9.5 (P = 0.01) and from 29.5 ± 15.8 to 27.3 ± 17.1 (P = 0.02) in the terlipressin and triple therapy groups, respectively. In HRS-II, similar significant improvement (P < 0.01) was seen in 24 hr urine output and urine sodium; decrease in PRA (P < 0.05) was documented after treatment in both the arms. Post-treatment changes in parameters were comparable between the two arms, in both HRS-I and HRS-II cases. CONCLUSIONS Concurrent triple therapy improved renal function in HRS and was less expensive than terlipressin (Registration: CTRI/2011/07/001860; www.ctri.nic.in).
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Affiliation(s)
- Siddharth Srivastava
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Sreenivas Vishnubhatla
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shyam Prakash
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Hanish Sharma
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi 110029, India,Address for correspondence: Subrat K. Acharya, Professor and Head of the Department, Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India. Tel.: +91 11 26589130/26594934; fax: +91 11 26589130.
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18
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Erly B, Carey WD, Kapoor B, McKinney JM, Tam M, Wang W. Hepatorenal Syndrome: A Review of Pathophysiology and Current Treatment Options. Semin Intervent Radiol 2015; 32:445-54. [PMID: 26622108 PMCID: PMC4640915 DOI: 10.1055/s-0035-1564794] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Brian Erly
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - William D. Carey
- Department of Gastroenterology, Cleveland Clinic, Cleveland, Ohio
| | - Baljendra Kapoor
- Section of Interventional Radiology, Imaging Institute, Cleveland Clinic, Cleveland, Ohio
| | | | - Mathew Tam
- Department of Radiology, Southend University Hospital, Essex, United Kingdom
| | - Weiping Wang
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
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19
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Asrani SK, Simonetto DA, Kamath PS. Acute-on-Chronic Liver Failure. Clin Gastroenterol Hepatol 2015; 13:2128-39. [PMID: 26188138 PMCID: PMC4625547 DOI: 10.1016/j.cgh.2015.07.008] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/30/2015] [Accepted: 07/09/2015] [Indexed: 12/18/2022]
Abstract
Over the past 2 decades, the concept of acute-on-chronic liver failure (ACLF) has been proposed as an alternate path in the natural history of decompensated cirrhosis. ACLF thus is characterized by the presence of a precipitating event (identified or unidentified) in subjects with underlying chronic liver disease leading to rapid progression of liver injury and ending in multi-organ dysfunction characterized by high short-term mortality. Multiple organ failure and an increased risk for mortality are key to the diagnosis of ACLF. The prevalence of ACLF ranges from 24% to 40% in hospitalized patients. The pathophysiological basis of ACLF can be explained using the following 4-part model: predisposing event, injury caused by a precipitating event, response to injury, and organ failure. Although several mathematic scores have been proposed for identifying outcomes with ACLF, it is as yet unclear whether these organ failure scores are truly prognostic or only reflective of the dying process. Treatment paradigms continue to evolve but consist of early recognition, supportive intensive care, and consideration of liver transplantation before onset of irreversible multiple organ failure.
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Affiliation(s)
- Sumeet K Asrani
- Division of Hepatology, Baylor University Medical Center, Dallas, Texas
| | - Douglas A Simonetto
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - Patrick S Kamath
- Division of Hepatology, Baylor University Medical Center, Dallas, Texas; Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota.
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20
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Prediction of gross post-transplant outcomes based on the intra-operative decline in C-reactive protein in living donor liver transplantation. Transplant Proc 2015; 47:431-7. [PMID: 25769586 DOI: 10.1016/j.transproceed.2015.01.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2014] [Accepted: 01/14/2015] [Indexed: 12/13/2022]
Abstract
BACKGROUND C-reactive protein (CRP), a marker of infection and inflammation, is produced mainly in the liver. Its slow onset and various influencing factors have limited studies on the intra-operative changes in CRP in living donor liver transplantation (LDLT). In this study, we asked whether the intra-operative changes in CRP predicts post-transplant outcome. METHODS The peri-transplant data of 263 LDLT patients were reviewed. "Intra-operative CRP decline" was calculated by subtracting the pretransplant CRP from the 1-day post-transplant CRP. A negative value defined an intra-operative decline. Peri-transplant variables were compared between patients with and without gross post-transplant outcomes (GPOs), including death, allograft dysfunction, infection, and kidney injury. Multivariate logistic regression was used to develop a model to predict GPO, and area receiver operating characteristic curve (AUC) analysis was used to evaluate the prognostic accuracies for GPO. RESULTS GPOs were determined in 95 LDLT patients (36.1%). GPO-positive patients had a lesser change in CRP levels (0.51 versus 1.16 mg/dL) and a higher incidence of a decline in CRP (34.7% versus 13.7%) during LDLT (P < .05) than did GPO-negative patients. The AUC of the intra-operative CRP change (0.585; P = .018) did not significantly differ from that of the pretransplant CRP. After multivariate adjustment, a patient with an intra-operative decline in CRP had a 3.21-fold higher risk for GPO occurrence (P = .001). CONCLUSIONS GPO occurrence was related to the intra-operative decline of CRP in LDLT patients. However, multivariate compensation might be required for the clinical utilization of intra-operative decline in CRP as a prognostic indicator.
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21
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Won Y, Kim H, Lim B, Ahn H, Hwang M, Lee I. Effect of Perioperative Terlipressin on Postoperative Renal Function in Patients Who Have Undergone Living Donor Liver Transplantation: A Meta-Analysis of Randomized Controlled Trials. Transplant Proc 2015; 47:1917-25. [DOI: 10.1016/j.transproceed.2015.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Revised: 04/13/2015] [Accepted: 06/16/2015] [Indexed: 02/06/2023]
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22
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Wong F. Treatment to improve acute kidney injury in cirrhosis. CURRENT TREATMENT OPTIONS IN GASTROENTEROLOGY 2015; 13:235-48. [PMID: 25773606 DOI: 10.1007/s11938-015-0050-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OPINION STATEMENT Acute kidney injury (AKI) is an ominous complication of decompensated cirrhosis, which can be fatal if not treated promptly. It is important that clinicians recognize that AKI has occurred and institute timely treatment. Recent establishment of diagnostic criteria and treatment guidelines are most useful, and these will be further refined as treatments are being modified to improve patient outcome. To manage such a patient, firstly, the cause of the AKI needs to be identified and any precipitating factors corrected. Bacterial infections are a common cause of AKI in cirrhosis, and it is recommended to offer empirical antibiotics in cases of suspicious bacterial infection until all the cultures are negative. Patients should be given albumin infusion in doses of 1 g/kg of body weight for at least 2 days. This can improve the filling of the central circulation, and also absorb many of the bacterial products or inflammatory cytokines that play a role in mediating the renal dysfunction. Often, albumin infusion alone may be sufficient to reverse the AKI. For patients who have acute or type 1 hepatorenal syndrome (HRS1), which is a special form of AKI, pharmacotherapy in the form of vasoconstrictor will be needed. The vasoconstrictor can be terlipressin, norepinephrine, or midodrine, depending on the local availability of drugs or facilities. Currently, approximately 40 % of patients will respond to a combination of vasoconstrictor and albumin. All patients with HRS1 should be assessed for liver transplant. If accepted for liver transplantation, those patients who do not respond to vasocontrictors and albumin need to be started on renal replacement therapy, which otherwise has no place in the treatment of HRS1. Once listed, liver transplantation should occur promptly, preferable under 2 weeks. Otherwise, the chances for renal recovery after liver transplant are significantly reduced, necessitating a renal transplant at the future date.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, ON, Canada,
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23
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Zhang Z, Maddukuri G, Jaipaul N, Cai CX. Role of renal replacement therapy in patients with type 1 hepatorenal syndrome receiving combination treatment of vasoconstrictor plus albumin. J Crit Care 2015; 30:969-74. [PMID: 26051980 DOI: 10.1016/j.jcrc.2015.05.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 04/24/2015] [Accepted: 05/07/2015] [Indexed: 12/14/2022]
Abstract
PURPOSE Utilization of renal replacement therapy (RRT) in cirrhotic patients has been controversial and is typically dependent on the status of transplantation. A better understanding of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS with prolonged patient survival. The role of RRT in HRS patients receiving such treatment, however, has not yet been examined. METHODS A total of 80 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. The effects of RRT status on clinical outcome were analyzed. RESULTS Both short-term (30 days) and long-term (180 days) survival was similar between RRT and non-RRT groups of patients, but the length of hospital stay was significantly longer among patients in the RRT group, which remain unchanged despite adjustment of status for liver transplantation. CONCLUSIONS Based on our observation, routine use of RRT may not be beneficial in patients with type 1 HRS receiving combination treatment of vasoconstrictor plus albumin. Further prospective studies are needed to validate these findings and refine the specific indications for RRT in this patient population.
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Affiliation(s)
- Zhiwei Zhang
- Division of Nephrology, Department of Medicine, VA Loma Linda Healthcare System and Loma Linda University, Loma Linda, CA 92357.
| | - Geetha Maddukuri
- Division of Nephrology, Department of Medicine, VA St Louis Healthcare System and St Louis University, St Louis, MO 63106
| | - Navin Jaipaul
- Division of Nephrology, Department of Medicine, VA Loma Linda Healthcare System and Loma Linda University, Loma Linda, CA 92357
| | - Cindy X Cai
- Division of Gastroenterology, Department of Medicine, VA Loma Linda Healthcare System and Loma Linda University, Loma Linda, CA 92357.
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24
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Wong F, Leung W, Al Beshir M, Marquez M, Renner EL. Outcomes of patients with cirrhosis and hepatorenal syndrome type 1 treated with liver transplantation. Liver Transpl 2015; 21:300-7. [PMID: 25422261 DOI: 10.1002/lt.24049] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2014] [Accepted: 11/16/2014] [Indexed: 02/07/2023]
Abstract
Hepatorenal syndrome type 1 (HRS1) is acute renal failure in the setting of advanced cirrhosis, and it results from hemodynamic derangements, which should be fully reversible after liver transplantation. However, the rate of hepatorenal syndrome (HRS) reversal and factors predicting renal outcomes after transplantation have not been fully elucidated. The aim of this study was to assess outcomes of HRS1 patients after liver transplantation and factors predicting HRS reversal. A chart review of all liver transplant patients with HRS1 (according to International Ascites Club criteria) at Toronto General Hospital from 2001 to 2010 was conducted. Patient demographic data, pretransplant and posttransplant laboratory data, and the presence of and time to posttransplant HRS reversal (serum creatinine < 1.5 mg/dL) were extracted from the center's transplant electronic database. Patients were followed until death or the end of the 2011 calendar year. Sixty-two patients (mean age, 54.7 ± 1.2 years; mean Model for End-Stage Liver Disease score, 35 ± 1) with HRS1 (serum creatinine, 3.37 ± 0.13 mg/dL) at liver transplant were enrolled. Thirty-eight patients received midodrine, octreotide, and albumin without success and subsequently received renal dialysis. One further patient received dialysis without pharmacotherapy. After liver transplantation, HRS1 resolved in 47 of 62 patients (75.8%) at a mean time of 13 ± 2 days. Patients without HRS reversal had significantly higher pretransplant serum creatinine levels (3.81 ± 0.34 versus 3.23 ± 0.14 mg/dL, P = 0.06), a longer duration of HRS1 {25 days [95% confidence interval (CI), 16-42 days] versus 10 days (95% CI, 10-18 days), P = 0.02}, a longer duration of pretransplant dialysis [27 days (95% CI, 13-41 days) versus 10 days (95% CI, 6-14 days), P = 0.01], and increased posttransplant mortality (P = 0.0045) in comparison with those whose renal function recovered. The only predictor of HRS1 nonreversal was the duration of pretransplant dialysis with a 6% increased risk of nonreversal with each additional day of dialysis. In conclusion, our study suggests that patients with HRS1 should receive a timely liver transplant to improve their outcome.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Canada
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Goldaracena N, Marquez M, Selzner N, Spetzler VN, Cattral MS, Greig PD, Lilly L, McGilvray ID, Levy GA, Ghanekar A, Renner EL, Grant DR, Selzner M. Living vs. deceased donor liver transplantation provides comparable recovery of renal function in patients with hepatorenal syndrome: a matched case-control study. Am J Transplant 2014; 14:2788-95. [PMID: 25277134 DOI: 10.1111/ajt.12975] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Revised: 07/22/2014] [Accepted: 08/04/2014] [Indexed: 01/25/2023]
Abstract
Outcomes of living versus deceased donor liver transplantation in patients with chronic liver disease and hepatorenal syndrome (HRS) was compared using a matched pair study design. Thirty patients with HRS receiving a live donor liver transplantation (LDLT) and 90 HRS patients receiving a full graft deceased donor liver transplantation (DDLT) were compared. LDLT versus DDLT of patients with HRS was associated with decreased peak aspartate aminotransferase levels (339 ± 214 vs. 935 ± 1253 U/L; p = 0.0001), and similar 7-day bilirubin (8.42 ± 7.89 vs. 6.95 ± 7.13 mg/dL; p = 0.35), and international normalized ratio levels (1.93 ± 0.62 vs. 1.78 ± 0.78; p = 0.314). LDLT vs. DDLT had a decreased intensive care unit (2 [1-39] vs. 4 [0-93] days; p = 0.004), and hospital stay (17 [4-313] vs. 26 [0-126] days; p = 0.016) and a similar incidence of overall postoperative complications (20% vs. 27%; p = 0.62). No difference was detected between LDLT and DDLT patients regarding graft survival at 1 (80% vs. 82%), at 3 (69% vs. 76%) and 5 years (65% vs. 76%) (p = 0.63), as well as patient survival at 1 (83% vs. 82%), 3 (72% vs. 77%) and 5 years (72% vs. 77%) (p = 0.93). The incidence of chronic kidney disease post-LT (10% vs. 6%; p = 0.4) was similar between both groups. LDLT results in identical long-term outcome when compared with DDLT in patients with HRS.
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Affiliation(s)
- N Goldaracena
- Multi Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Ontario, Canada
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Philips CA, Sarin SK. Potent antiviral therapy improves survival in acute on chronic liver failure due to hepatitis B virus reactivation. World J Gastroenterol 2014; 20:16037-16052. [PMID: 25473156 PMCID: PMC4239490 DOI: 10.3748/wjg.v20.i43.16037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 06/02/2014] [Accepted: 07/30/2014] [Indexed: 02/06/2023] Open
Abstract
Acute on chronic liver failure (ACLF) is a disease entity with a high mortality rate. The acute event arises from drugs and toxins, viral infections, bacterial sepsis, interventions (both surgical and non-surgical) and vascular events on top of a known or occult chronic liver disease. ACLF secondary to reactivation of chronic hepatitis B virus is a distinct condition; the high mortality of which can be managed in the wake of new potent antiviral therapy. For example, lamivudine and entecavir use has shown definite short-term survival benefits, even though drug resistance is a concern in the former. The renoprotective effects of telbivudine have been shown in a few studies to be useful in the presence of renal dysfunction. Monotherapy with newer agents such as tenofovir and a combination of nucleos(t)ides is promising for improving survival in this special group of liver disease patients. This review describes the current status of potent antiviral therapy in patient with acute on chronic liver failure due to reactivation of chronic hepatitis B, thereby providing an algorithm in management of such patients.
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27
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Abstract
The Model for End-Stage Liver Disease (MELD) has been the single best predictor of outcome of the progression of cirrhosis. Acute-on-chronic liver failure (ACLF) has been proposed as an alternative path in the natural history of cirrhosis. ACLF occurs in patients with chronic liver disease and is characterized by a precipitating event, resulting in acute deterioration in liver function, multiorgan system failure, and high short-term mortality. In this review, the natural course of patients with ACLF, especially as it relates to management of cirrhotic patients on the transplant waiting list, and its impact on liver transplantation outcomes are defined.
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Maddukuri G, Cai CX, Munigala S, Mohammadi F, Zhang Z. Targeting an early and substantial increase in mean arterial pressure is critical in the management of type 1 hepatorenal syndrome: a combined retrospective and pilot study. Dig Dis Sci 2014; 59:471-81. [PMID: 24146317 DOI: 10.1007/s10620-013-2899-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Accepted: 09/23/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Appreciation of the central role for arterial vasodilatation in the pathogenesis of hepatorenal syndrome (HRS) has led to routine use of vasoconstrictors in combination with albumin as a medical therapy for HRS. Various vasoconstrictors have been explored but the optimal approach for such therapies has not yet been established. AIMS The purpose of this study was to examine the role of targeting an early and substantial increase in mean arterial pressure (MAP) in the management of type 1 HRS, a condition associated with very poor prognosis. METHODS A total of 59 patients with type 1 HRS who received a combination therapy of vasoconstrictors and albumin were enrolled into a retrospective cohort study. Subjects having a substantial increase of more than 10 mmHg in MAP by day 3 after initiation of therapy were categorized as MAP responders and the rest as MAP non-responders. In addition, five patients were enrolled into a prospective pilot study in which a titration protocol of vasoconstrictors was followed to achieve early goal-directed therapy (EGDT). RESULTS MAP responders achieved significantly higher incidence of treatment success or total response, less requirement of dialysis and more incidence of liver transplantation. More importantly, this response is associated with better short-term and long-term overall survival as well as transplant-free survival. The effectiveness of such an approach was further confirmed in the pilot study which followed an EGDT protocol. CONCLUSIONS Using an early and substantial increase in MAP as a therapeutic target is associated with favorable clinical outcomes in the management of type 1 HRS.
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Affiliation(s)
- Geetha Maddukuri
- Division of Nephrology, Department of Medicine, St. Louis University, St. Louis, MO, 63110, USA
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29
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Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Garcia-Tsao G, Arroyo V, Kamath PS. Acute-on chronic liver failure. J Hepatol 2012; 57:1336-48. [PMID: 22750750 DOI: 10.1016/j.jhep.2012.06.026] [Citation(s) in RCA: 426] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 06/19/2012] [Accepted: 06/19/2012] [Indexed: 12/12/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is an increasingly recognised entity encompassing an acute deterioration of liver function in patients with cirrhosis, which is usually associated with a precipitating event and results in the failure of one or more organs and high short term mortality. Prospective data to define this is lacking but there is a large body of circumstantial evidence suggesting that this condition is a distinct clinical entity. From the pathophysiologic perspective, altered host response to injury and infection play important roles in its development. This review focuses upon the current understanding of this syndrome from the clinical, prognostic and pathophysiologic perspectives and indicates potential biomarkers and therapeutic targets for intervention.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, Rowland Hill Street, London, United Kingdom.
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30
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Nadim MK, Sung RS. Living donor liver transplantation for hepatorenal syndrome: to do or not to do? That is the question. Liver Transpl 2012; 18:1138-9. [PMID: 22740330 DOI: 10.1002/lt.23498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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31
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Teperman L. Living donation for the very ill patient with type I hepatorenal syndrome: are we ready? Liver Transpl 2012; 18:753-4. [PMID: 22511366 DOI: 10.1002/lt.23455] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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