Fulminant hepatitis

Fulminant hepatic failure

In recent years, considerable progress has been made in developing specific and supportive medical measures that have improved prognosis in FHF. Although new techniques for cell culture and perfusion have also resulted in a number of promising devices for the provision of temporary liver support, their clinical efficacy is as yet uncertain. Controlled multicenter trials in well-defined patient groups and with standardized outcome measures will be essential to evaluate the clinical value of these devices properly. The same considerations must also apply in assessing the efficacy of hepatocyte transplantation in FHF. A better understanding of mechanisms responsible for liver cell death and multiorgan failure, and the development of strategies to enhance liver regeneration may, in the future, allow a more targeted approach to therapy.

Treatment of fulminant hepatic failure with intravenous prostaglandin E1

Fulminant hepatic failure (FHF) is a severe, life-threatening disorder. Previous studies have suggested that intravenous prostaglandin treatment may improve survival in FHF. The present study was performed to further investigate the possible benefit of intravenous prostaglandin E1 (PGE1) for patients with FHF. A total of 18 patients, all excluded as candidates for hepatic transplantation, were studied. Thirteen of 18 participated in a randomized, double-blind, placebo-controlled trial. PGE1 was administered by continuous infusion at a dose of 10 to 40 microg/h as tolerated. After 48 hours of blinded treatment, 3 of 7 patients randomized to placebo were converted to open-label PGE1 for lack of biochemical and/or clinical improvement. Mean values for alanine transaminase, aspartate transaminase, total bilirubin, prothrombin time, factor V percent, factor VII percent, hepatic encephalopathy score, days from onset of symptoms to initiation of treatment, and cause of FHF were similar between treatment groups. Ten of 18 patients (55%) enrolled in this trial survived. However, survival was not different between PGE1-(60%) and placebo (50%) treated patients. The greatest predictor of survival was the number of days from onset of symptoms to hospitalization, which was significantly (P = .002) shorter for survivors (3.3 v 12.4 days), regardless of PGE1 treatment. Six of 8 patients (75%) who began PGE1 therapy and 4 of 5 placebo-treated patients (80%) hospitalized within 10 days of onset of symptoms survived. By contrast, all 5 patients who were hospitalized and subsequently began PGE1 treatment 10 days or longer after the onset of symptoms died. We conclude that early recognition and hospitalization is the most important factor in reduction of mortality from FHF. It is unclear whether PGE1 treatment is beneficial when administered during this period. However, it is apparent that PGE1 was not effective for treatment of FHF if treatment started more than 10 days after onset of this clinical syndrome.

Fulminant hepatic failure

Fulminant hepatic failure is a devastating illness that carries considerable mortality and affects patients with previously healthy livers. Although the etiology of FHF remains unclear in a significant number of cases, viral hepatitis and drug-induced liver injury account for the majority of identifiable causes. The clinical presentation varies widely, but is always characterized by the presence of encephalopathy. Markedly elevated transaminases are seen, but do not correlate with extent of liver injury. Prothrombin time, bilirubin, creatinine, and arterial pH are prognostic indicators of survival in FHF. FHF and its consequences must be readily recognized so that appropriate triage and treatment can be administered. All patients should be managed in an intensive care setting pending transfer to a liver transplantation center. Supportive care remains the mainstay of treatment, with liver transplantation reserved for select patients.

Ribavirin Inhibits Viral-Induced Macrophage Production of TNF, IL-1, the Procoagulant fgl2 Prothrombinase and Preserves Th1 Cytokine Production But Inhibits Th2 Cytokine Response

Ribavirin, a synthetic guanosine analogue, possesses a broad spectrum of activity against DNA and RNA viruses. It has been previously shown to attenuate the course of fulminant hepatitis in mice produced by murine hepatitis virus strain 3. We therefore studied the effects of ribavirin on murine hepatitis virus strain 3 replication, macrophage production of proinflammatory mediators including TNF, IL-1, and the procoagulant activity (PCA), fgl2 prothrombinase; and Th1/Th2 cytokine production. Although ribavirin had inhibitory effects on viral replication (<1 log), even at high concentrations complete eradication of the virus was not seen. In contrast, at physiologic concentrations (up to 500 μg/ml), ribavirin markedly reduced viral-induced parameters of macrophage activation. With ribavirin treatment, the concentrations of PCA, TNF-α and IL-1β all decreased to basal concentrations: PCA from 941 ± 80 to 34 ± 11 mU/106 cells; TNF-α from 10.73 ± 2.15 to 2.74 ± 0.93 ng/ml; and IL-1β from 155.91 ± 22.62 to 5.74 ± 0.70 pg/ml. The inhibitory effects of ribavirin were at the level of gene transcription as evidenced by Northern analysis. Both in vitro and in vivo, ribavirin inhibited the production of IL-4 by Th2 cells, whereas it did not diminish the production of IFN-γ in Th1 cells. In contrast, ribavirin had no inhibitory effect on TNF-α and IL-1β production in LPS-stimulated macrophages. These results suggest that the beneficial effects of ribavirin are mediated by inhibition of induction of macrophage proinflammatory cytokines and Th2 cytokines while preserving Th1 cytokines.