Combined blood purification for treating acute fatty liver of pregnancy complicated by acute kidney injury: a case series

EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy

Liver diseases in pregnancy comprise both gestational liver disorders and acute and chronic hepatic disorders occurring coincidentally in pregnancy. Whether related to pregnancy or pre-existing, liver diseases in pregnancy are associated with a significant risk of maternal and fetal morbidity and mortality. Thus, the European Association for the Study of Liver Disease invited a panel of experts to develop clinical practice guidelines aimed at providing recommendations, based on the best available evidence, for the management of liver disease in pregnancy for hepatologists, gastroenterologists, obstetric physicians, general physicians, obstetricians, specialists in training and other healthcare professionals who provide care for this patient population.

Pr-AKI: Acute Kidney Injury in Pregnancy – Etiology, Diagnostic Workup, Management

Despite significant improvements in inpatient and outpatient management, pregnancy-related acute kidney injury (Pr-AKI) remains an important risk factor for early and late maternal and fetal morbidity and mortality. There is a discrepancy between the incidence of Pr-AKI in developing and in developed countries, with the former experiencing a decrease and the latter an increase in Pr-AKI in recent decades. Whereas septic and hemorrhagic complications predominated in the past, nowadays hypertensive disorders and thrombotic microangiopathy are the leading causes of Pr-AKI. Modern lifestyles and the availability and widespread use of in-vitro fertilization techniques in industrialized countries have allowed more women of advanced age to become pregnant. This has led to a rise in the percentage of high-risk pregnancies due to the disorders and comorbidities inherent to or accompanying aging, such as diabetes, arterial hypertension and preexisting chronic kidney disease. Last but not least, the heterogeneity of symptoms, the often overlapping clinical and laboratory characteristics and the pathophysiological changes related to pregnancy make the diagnosis and management of Pr-AKI a difficult and challenging task for the treating physician. In addition to general supportive management strategies such as volume substitution, blood pressure control, prevention of seizures or immediate delivery, each disease entity requires a specific therapy to reduce maternal and fetal complications. In this review, we used the current literature to provide a summary of the physiologic and pathophysiologic changes in renal physiology which occur during pregnancy. In the second part, we present common and rare disorders which lead to Pr-AKI and provide an overview of the available treatment options.

Potential predictors for prognosis and postpartum recovery time of acute fatty liver of pregnancy

BACKGROUND

Acute fatty liver of pregnancy (AFLP) is a potentially lethal condition of pregnant women with a high mortality rate. Potential predictors related to postpartum recovery time and prognostic factors of AFLP are still unclear. This study aimed to evaluate potential predictors for prognosis and postpartum recovery time of AFLP.

METHODS

We retrospectively analyzed the clinical data of 76 AFLP patients in our hospital from 2002 to 2017 and investigated potential predictors using univariate analysis and multivariate logistic regression analysis.

RESULTS

Hepatic encephalopathy (HE) was found to be associated with prognosis in AFLP patients (P = 0.005, OR = 26.844). The postpartum recovery time analysis showed that AFLP patients with a age < 25 had the shortest recovery time, but no significant difference (P = 0.134, OR = 5.952). The postpartum recovery time of patients with liver failure (LF) was significantly prolonged compared to those without LF (P = 0.036, OR = 10.052). Cryoprecipitate, and plasma infusion showed no significant effect on prognosis or recovery time. Artificial liver support therapy (ALST) had no effect on prognosis, but it might affect postpartum recovery time with no statistical significance (P = 0.128, OR = 5.470).

CONCLUSION

HE is a potential predictor for prognosis of AFLP. LF is a potential predictor for postpartum recovery time.

Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome

Acute kidney injury that occurs during pregnancy or in the post-partum period (PR-AKI) is a serious obstetric complication with risk of significant associated maternal and fetal morbidity and mortality. Recent data indicates that the incidence of PR-AKI is increasing, although accurate calculation is limited by the lack of a uniform diagnostic criteria that is validated in pregnancy. Hypertensive and thrombotic microangiopathic disorders of pregnancy have been identified as major contributors to the burden of PR-AKI. As is now accepted regarding preeclampsia, HELLP syndrome and atypical hemolytic uremic syndrome, it is believed that PR-AKI may have long-term renal, cardiovascular and neurocognitive consequences that persist beyond the post-partum period. Further research regarding PR-AKI could be advanced by the development of a pregnancy-specific validated definition and classification system; and the establishment of refined animal models that would allow researchers to further elucidate the mechanisms and sequelae of the disorder.

A successful use of therapeutic plasma exchange in a fulminant form of acute fatty liver of pregnancy

Acute fatty liver of pregnancy (AFLP) continues to raise special concerns since its first post-mortem description by Sheehan in 1940. While early diagnosis and expedite delivery are the cornerstone of management, this condition remains fatal for both mother and fetus. Acute fulminant liver failure is the most serious and life-threatening AFLP-related complication and can require liver transplant despite aggressive supportive management. In lieu of transplant, therapeutic plasma exchange (PE) has emerged as a life-saving alternative and has, in few reports, demonstrated efficacy for the reversal of this dangerous condition. Here we present a case report of a patient diagnosed with fulminant liver failure complicating an AFLP and progressed to severe hepatic encephalopathy who was successfully treated with five rounds of plasma exchange.

Treating acute fatty liver of pregnancy with artificial liver support therapy: Systematic review

BACKGROUND

Acute fatty liver of pregnancy (AFLP) is a serious disease with high mortality. Recent data suggest that postpartum application of artificial liver support therapy (ALST) in AFLP management improves disease outcome. In current study, we tend to further evaluate whether the type, the timing, and the number of postpartum ALST sessions and other clinical factors including complications and liver and renal function will influence disease outcome in ALST era.

METHODS

Medical records of 15 AFLP patients having postpartum ALST in our hospital from 2010 to 2016 were first retrospectively reviewed. A systematic review and statistical analysis was then conducted with our cases and those having postpartum ALST reported in PubMed, Embase, Cochrane, and ClinicalTrials.gov till the end of June 2016.

RESULTS

Nine relevant studies were identified in the public databases. A total of 104 cases were enrolled for analysis including 15 cases from our hospital and 89 cases from the identified 9 studies. Univariate analysis revealed that 2 complications, postpartum hemorrhage and multiple organ dysfunctions (MODS), were associated with the outcome of AFLP patients undergoing postpartum ALST. Binary logistic regression analysis further indicated that MODS was the only independent factor affecting disease outcome. Surprisingly, factors including pre-ALST serum levels of total bilirubin and creatinine, the type and number of postpartum ALST sessions, time interval between delivery and ALST were unrelated to disease outcome.

CONCLUSION

Current data suggest that postpartum ALST improves the outcome of AFLP patients but more properly designed experiments are needed to confirm this point. Our study further indicates that occurrence of MODS carries a bad prognosis even in ALST era. Our study provides valuable information on guiding the clinical application of postpartum ALST in AFLP management.

Acute Kidney Injury in Pregnancy: The Changing Landscape for the 21st Century

Pregnancy-related acute kidney injury (Pr-AKI) remains a large public health problem, with decreasing incidences in developing countries but seemingly increasing incidences in the United States and Canada. These epidemiologic changes are reflective of the advances in medical and obstetric care, as well as changes in underlying maternal risk factors. The risk factors associated with advanced maternal age, such as hypertension, diabetes, chronic kidney disease, and those associated with reproductive technologies such as multiple gestations, are increasing. Traditional causes of Pr-AKI, such as septic abortions and puerperal sepsis, have been replaced by hypertensive diseases, such as preeclampsia and thrombotic microangiopathies comprising thrombotic thrombocytopenic purpura (TTP) and atypical hemolytic uremic syndrome (aHUS). In this review, we discuss the global impact of Pr-AKI on maternal and fetal outcomes, the predominant etiologies, and key clinical features to distinguish diagnoses, such as preeclampsia/hemolysis elevated liver function test and low platelet (HELLP) syndrome, acute fatty liver disease of pregnancy (AFLP), and other thrombotic microangiopathies. New insights into the pathogenesis of preeclampsia, TTP/aHUS, and AFLP that have unearthed possible therapeutic targets are summarized. We also delve into special consideration needed to give to pyelonephritis and postobstructive causes of Pr-AKI. With each diagnosis, we offer the latest treatment recommendations, such as the positive reports from the use of eculizumab to treat aHUS. In the end, we hope to arm the clinician with the best tools to understand and address this morbid problem that does not seem to be disappearing.

[Acute fatty liver of pregnancy and mitochondrial fatty acid oxidation. Consequences for the offspring]

Acute fatty liver of pregnancy (AFLP) is a rare liver disease unique to pregnancy that can lead to acute liver failure. The prognosis, initially often fatal for both mother and child, has been improved by prompt delivery. The diagnosis should be highly suspected if the mother presents epigastric pain, nausea and/or vomiting, or polyuria-polydipsia in the third trimester of pregnancy. AFLP has been found associated with a genetic deficiency of fatty acid beta-oxidation, which may cause sudden death in infancy. Consequently, the mother and her newborn should undergo screening for this deficiency.

Noninvasive Swansea criteria are valuable alternatives for diagnosing acute fatty liver of pregnancy in a Chinese population

BACKGROUND

This study aims to assess the diagnostic and prognostic value of Swansea criteria in diagnosing acute fatty liver of pregnancy (AFLP) in a Chinese population.

METHODS

A retrospective study was conducted on 52 Chinese women diagnosed with AFLP. All selected cases were reassessed using the Swansea criteria with special focus on the noninvasive criteria, since performing a liver biopsy for this indication is rare in a Chinese population.

RESULTS

Ninety point four percent of patients fulfilled five or more of the Swansea criteria. Thirty-one cases were positive for six or more Swansea criteria, but there were no significance differences between patients when using a cutoff criteria <6 or >6. When patients were positive for less than seven criteria, frequency of stillbirth, continuous blood purification (CBP) treatment, hysterectomy, and postpartum hemorrhage were not increased. However, patients who were positive for seven or more criteria had a significantly higher risk of stillbirth and a higher rate of CBP treatment (p < 0.05). Areas under the receiver operating characteristic (ROC) curve of postpartum hemorrhage was 0.670, which reached a statistical significance (p = 0.040). We observed a significantly elevated postpartum hemorrhage along with positivity of the Swansea criteria (p = 0.040).

CONCLUSIONS

Swansea criteria without liver biopsy are good screening tools for AFLP diagnosis, and may be useful for assessing disease severity.

Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy

BACKGROUND

Acute fatty liver of pregnancy (AFLP) in the third trimester or early postpartum period can lead to fatal liver damage. Its traditional therapy is not very effective in facilitating hepatic recovery. The safety and effect of plasma exchange (PE) in combination with continuous renal replacement therapy (CRRT) (PE+CRRT) for AFLP still needs evaluation.

METHODS

Five AFLP patients with hepatic encephalopathy and renal failure were subjected to PE+CRRT in our department from 2007 to 2012. Their symptoms, physical signs and results were observed, and all relevant laboratory tests were compared before and after PE+CRRT.

RESULTS

All the 5 patients were well tolerated to the therapy. Four of them responded to the treatment and showed improvement in clinical symptoms/signs and laboratory results, and they were cured and discharged home after the treatment. One patient succeeded in bridging to transplantation for slowing down hepatic failure and its complications process after 2 treatment sessions. Intensive care unit stay and hospital stay were 9.4 (range 5-18) and 25.0 days (range 11-42), respectively.

CONCLUSION

PE+CRRT is safe and effective and should be used immediately at the onset of hepatic encephalopathy and/or renal failure in patients with AFLP.