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Fernández J, Bassegoda O, Toapanta D, Bernal W. Acute liver failure: A practical update. JHEP Rep 2024; 6:101131. [PMID: 39170946 PMCID: PMC11337735 DOI: 10.1016/j.jhepr.2024.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 08/23/2024] Open
Abstract
Acute liver failure is a rare and dynamic condition, with a broad aetiology and an incompletely understood pathophysiology. Management of this life-threatening disease requires critical care and organ support and frequently early liver transplantation. Proper identification, prevention and treatment of complications such as intracranial hypertension and sepsis are critical to optimising outcomes. The identification of the cause of acute liver failure and the prompt initiation of the aetiological treatment can also improve prognosis. Survival has progressively improved in parallel to advances in medical treatment. Intracranial hypertension complicating hepatic encephalopathy is less frequent than in the past and intracranial pressure monitoring now relies on non-invasive techniques. Current prognostic models have good accuracy to identify patients who will die without liver transplantation but are not able to identify those in whom transplantation is futile. New prognostic markers to select patients for transplantation are still in the pipeline. Therapeutic plasma exchange and, in some centers, early renal replacement therapy are well established treatments for the disease. The use of other artificial liver devices in clinical practice is not supported by evidence. This review is intended to provide a clinical update on the management of acute liver failure, incorporating the most recent advances in the field.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
- EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, United Kingdom
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2
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Brozat JF, Pohl J, Engelmann C, Tacke F. [Liver transplantation in acute and acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01158-4. [PMID: 39043956 DOI: 10.1007/s00063-024-01158-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/04/2024] [Indexed: 07/25/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are diseases with a rapidly progressive course and high mortality. Apart from treating the underlying triggers and intensive care measures, there are very limited therapeutic options for either condition. Liver transplantation is often the only life-saving treatment, but it cannot always be employed due to contraindications and severe disease progression. ACLF is characterized by underlying liver cirrhosis and typical triggers such as bacterial infections, bleeding, or alcohol binges. ALF occurs in previously healthy livers, usually as a result of purely hepatotoxic events. Disease differences are also reflected in the course and regulations of liver transplantation. Newer prognostic parameters and prioritization programs for ACLF can help improve both waiting list mortality and outcomes after transplantation.
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Affiliation(s)
- Jonathan F Brozat
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Julian Pohl
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Cornelius Engelmann
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland.
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3
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Dong V, Robinson AM, Dionne JC, Cardoso FS, Rewa OG, Karvellas CJ. Continuous renal replacement therapy and survival in acute liver failure: A systematic review and meta-analysis. J Crit Care 2024; 81:154513. [PMID: 38194760 DOI: 10.1016/j.jcrc.2023.154513] [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] [Received: 09/03/2023] [Revised: 12/05/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Acute liver failure (ALF) is a rare syndrome leading to significant morbidity and mortality. An important cause of mortality is cerebral edema due to hyperammonemia. Different therapies for hyperammonemia have been assessed including continuous renal replacement therapy (CRRT). We conducted a systematic review and meta-analysis to determine the efficacy of CRRT in ALF patients. MATERIALS AND METHODS We searched MEDLINE, EMBASE, Cochrane Library, and Web of Science. Inclusion criteria included adult patients admitted to an ICU with ALF. Intervention was the use of CRRT for one or more indications with the comparator being standard care without the use of CRRT. Outcomes of interest were overall survival, transplant-free survival (TFS), mortality and changes in serum ammonia levels. RESULTS In total, 305 patients underwent CRRT while 1137 patients did not receive CRRT. CRRT was associated with improved overall survival [risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70-0.99, p-value 0.04, I2 = 50%] and improved TFS (RR 0.65, 95% CI 0.49-0.85, p-value 0.002, I2 = 25%). There was a trend towards higher mortality with no CRRT (RR 1.24, 95% CI 0.84-1.81, p-value 0.28, I2 = 37%). Ammonia clearance data was unable to be pooled and was not analyzable. CONCLUSION Use of CRRT in ALF patients is associated with improved overall and transplant-free survival compared to no CRRT.
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Affiliation(s)
- Victor Dong
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
| | - Andrea M Robinson
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Joanna C Dionne
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Filipe S Cardoso
- Intensive Care Unit and Transplant Unit, Nova University, R. da Beneficência 8, Lisbon 1050-099, Portugal.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada; Department of Medicine, Division of Gastroenterology, University of Alberta, 8540 112 St NW, Edmonton, Alberta T6G 2P8, Canada.
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Murakami S, Uchida T, Imamura M, Suehiro Y, Namba M, Fujii Y, Uchikawa S, Teraoka Y, Fujino H, Ono A, Nakahara T, Murakami E, Okamoto W, Yamauchi M, Kawaoka T, Miki D, Hayes CN, Tsuge M, Ohira M, Ohdan H, Oka S. Correlation between serum pro-inflammatory cytokine levels and the prognosis of the patients with acute liver failure. J Gastroenterol Hepatol 2023; 38:1637-1646. [PMID: 37475200 DOI: 10.1111/jgh.16300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 05/31/2023] [Accepted: 07/02/2023] [Indexed: 07/22/2023]
Abstract
BACKGROUND AND AIM The prognosis of acute liver failure (ALF) remains poor, and liver transplantation is an alternative treatment option. Assessing the prognosis of ALF is important in determining treatment strategies. Here, we investigated clinical factors including serum pro-inflammatory cytokine levels that are associated with the prognosis of ALF. METHODS Sixty-six patients who developed ALF were enrolled in this study. Serum concentrations of 12 pro-inflammatory cytokines were measured on admission. The prognosis and factors associated with survival and development of hepatic coma were analyzed. RESULTS Of 66 patients, 4 patients underwent liver transplantation, and 49 patients were rescued without liver transplantation, while the remaining 13 patients died. Serum concentrations of interleukin (IL)-1β, IL-4, IL-6, IL-8, IL-13, TNF, IFN -γ, IP-10, and G-CSF were significantly elevated in ALF patients. IL-4 and IL-8 levels were higher in patients who underwent liver transplantation or died than in rescued patients. Multivariable analysis identified age ≥ 55 years and IL-4 ≥ 1.2 pg/mL on admission as independent factors for mortality. Serum IL-8 levels were higher in patients with hepatic coma, and prothrombin-international normalized ratio ≥ 3.5 and IL-8 ≥ 77.2 pg/mL on admission were associated with development of hepatic coma after admission. CONCLUSION Serum levels of several pro-inflammatory cytokines were elevated in ALF patients. IL-4 and IL-8 were correlated with survival and development of hepatic coma after admission, respectively. Measurement of serum pro-inflammatory cytokines seems to be useful for the management of ALF.
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Affiliation(s)
- Serami Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Takuro Uchida
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Michio Imamura
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yosuke Suehiro
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Maiko Namba
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yasutoshi Fujii
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Shinsuke Uchikawa
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Yuji Teraoka
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Hatsue Fujino
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Atsushi Ono
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Takashi Nakahara
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Eisuke Murakami
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Wataru Okamoto
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
- Cancer Treatment Center, Hiroshima University Hospital, Hiroshima, Japan
| | - Masami Yamauchi
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Tomokazu Kawaoka
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Daiki Miki
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - C Nelson Hayes
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Masataka Tsuge
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
| | - Masahiro Ohira
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
- Medical Center for Translational and Clinical Research, Hiroshima University Hospital, Hiroshima, Japan
| | - Hideki Ohdan
- Department of Gastroenterological and Transplant Surgery, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shiro Oka
- Department of Gastroenterology, Graduate School of Biomedical and Health Science, Hiroshima University, Hiroshima, Japan
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Roychoudhury A, Dear JW, Kersaudy-Kerhoas M, Bachmann TT. Amplification-free electrochemical biosensor detection of circulating microRNA to identify drug-induced liver injury. Biosens Bioelectron 2023; 231:115298. [PMID: 37054598 DOI: 10.1016/j.bios.2023.115298] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 03/23/2023] [Accepted: 04/04/2023] [Indexed: 04/15/2023]
Abstract
Drug-induced liver injury (DILI) is a major challenge in clinical medicine and drug development. There is a need for rapid diagnostic tests, ideally at point-of-care. MicroRNA 122 (miR-122) is an early biomarker for DILI which is reported to increase in the blood before standard-of-care markers such as alanine aminotransferase activity. We developed an electrochemical biosensor for diagnosis of DILI by detecting miR-122 from clinical samples. We used electrochemical impedance spectroscopy (EIS) for direct, amplification free detection of miR-122 with screen-printed electrodes functionalised with sequence specific peptide nucleic acid (PNA) probes. We studied the probe functionalisation using atomic force microscopy and performed elemental and electrochemical characterisations. To enhance the assay performance and minimise sample volume requirements, we designed and characterised a closed-loop microfluidic system. We presented the EIS assay's specificity for wild-type miR-122 over non-complementary and single nucleotide mismatch targets. We successfully demonstrated a detection limit of 50 pM for miR-122. Assay performance could be extended to real samples; it displayed high selectivity for liver (miR-122 high) comparing to kidney (miR-122 low) derived samples extracted from murine tissue. Finally, we successfully performed an evaluation with 26 clinical samples. Using EIS, DILI patients were distinguished from healthy controls with a ROC-AUC of 0.77, a comparable performance to qPCR detection of miR-122 (ROC-AUC: 0.83). In conclusion, direct, amplification free detection of miR-122 using EIS was achievable at clinically relevant concentrations and in clinical samples. Future work will focus on realising a full sample-to-answer system which can be deployed for point-of-care testing.
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Affiliation(s)
- Appan Roychoudhury
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - James W Dear
- Centre for Cardiovascular Science, University of Edinburgh, The Queen's Medical Research Institute, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Maïwenn Kersaudy-Kerhoas
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK; Institute of Biological Chemistry, Biophysics and Bioengineering, Heriot-Watt University, Edinburgh, EH14 4AS, UK
| | - Till T Bachmann
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Muacevic A, Adler JR, Himanshu D, Bharti V, Sharma D. Acute Liver Failure Prognostic Criteria: It's Time to Revisit. Cureus 2023; 15:e33810. [PMID: 36819396 PMCID: PMC9929612 DOI: 10.7759/cureus.33810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2023] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION Acute liver failure (ALF) is a devastating disease, and patients are at a higher risk of death without liver transplantation. Indicators are needed to identify the risk of death in ALF, which will help in the timely referral of patients to specialized centers. Clichy criteriaand King's College Hospital (KCH) criteria are the most widely used prognostic criteria. Real-life application of Clichy criteria is limited due to the non-availability of factor V level measurement. KCH criteria have good specificity but low sensitivity to predict outcomes. Therefore, we attempted to use the model for end-stage liver disease (MELD) score and chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score in ALF patients as prognostic indicators and need for liver transplantation. METHODS Forty-one patients with ALF were enrolled in the study. On the day of admission, MELD and CLIF-SOFA scores were calculated for each patient. Area under receiver operating characteristics (AUROC) curve, sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and diagnostic accuracy (DA) of MELD and CLIF-SOFA score were calculated to predict the outcome of the patients. RESULTS Out of 41 patients, nine patients left against medical advice. The sensitivity, specificity, PPV, NPV, and DA for the MELD score of enrolled patients in the study were 81.5%, 62.5%, 59.5%, 83.3%, 70.1%, and for the CLIF-SOFA score of enrolled patients in the study were 88.9%, 90.0%, 85.7%, 92.3%, 89.6% respectively. Patients who did not survive had higher INR, MELD, CLIF-SOFA scores, and hepatic encephalopathy (HE) grades. Five patients who had a combination of MELD ≥30 and CLIF-SOFA ≥10, expired. CONCLUSION In our study, we used MELD score and CLIF-SOFA as prognostic markers, and we concluded that CLIF-SOFA is a better predictor of mortality than MELD score in terms of sensitivity, specificity, NPV, PPV, and diagnostic accuracy. AUROC for CLIF-SOFA score is higher when compared to the MELD score.
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Driever EG, Lisman T. Effects of Inflammation on Hemostasis in Acutely Ill Patients with Liver Disease. Semin Thromb Hemost 2022; 48:596-606. [PMID: 35135033 DOI: 10.1055/s-0042-1742438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patients with liver diseases are in a rebalanced state of hemostasis, due to simultaneous decline in pro- and anticoagulant factors. This balance seems to remain even in the sickest patients, but is less stable and might destabilize when patients develop disease complications. Patients with acute decompensation of cirrhosis, acute-on-chronic liver failure, or acute liver failure often develop complications associated with changes in the hemostatic system, such as systemic inflammation. Systemic inflammation causes hemostatic alterations by adhesion and aggregation of platelets, release of von Willebrand factor (VWF), enhanced expression of tissue factor, inhibition of natural anticoagulant pathways, and inhibition of fibrinolysis. Laboratory tests of hemostasis in acutely-ill liver patients may indicate a hypocoagulable state (decreased platelet count, prolongations in prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels) due to decreased synthetic liver capacity or consumption, or a hypercoagulable state (increased VWF levels, hypofibrinolysis in global tests). Whether these changes are clinically relevant and should be corrected with antithrombotic drugs or blood products is incompletely understood. Inflammation and activation of coagulation may cause local ischemia, progression of liver disease, and multiorgan failure. Anti-inflammatory treatment in acutely-ill liver patients may be of potential interest to prevent thrombotic or bleeding complications and halt progression of liver disease.
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Affiliation(s)
- Ellen G Driever
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Pop TL, Aldea CO, Delean D, Bulata B, Boghiţoiu D, Păcurar D, Ulmeanu CE, Grama A. The Role of Predictive Models in the Assessment of the Poor Outcomes in Pediatric Acute Liver Failure. J Clin Med 2022; 11:432. [PMID: 35054127 PMCID: PMC8778932 DOI: 10.3390/jcm11020432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES In children, acute liver failure (ALF) is a severe condition with high mortality. As some patients need liver transplantation (LT), it is essential to predict the fatal evolution and to refer them early for LT if needed. Our study aimed to evaluate the prognostic criteria and scores for assessing the outcome in children with ALF. METHODS Data of 161 children with ALF (54.66% female, mean age 7.66 ± 6.18 years) were analyzed based on final evolution (32.91% with fatal evolution or LT) and etiology. We calculated on the first day of hospitalization the PELD score (109 children), MELD, and MELD-Na score (52 children), and King's College Criteria (KCC) for all patients. The Nazer prognostic index and Wilson index for predicting mortality were calculated for nine patients with ALF in Wilson's disease (WD). RESULTS PELD, MELD, and MELD-Na scores were significantly higher in patients with fatal evolution (21.04 ± 13.28 vs. 13.99 ± 10.07, p = 0.0023; 36.20 ± 19.51 vs. 20.08 ± 8.57, p < 0.0001; and 33.07 ± 8.29 vs. 20.08 ± 8.47, p < 0.0001, respectively). Moreover, age, bilirubin, albumin, INR, and hemoglobin significantly differed in children with fatal evolution. Function to etiology, PELD, MELD, MELD-Na, and KCC accurately predicted fatal evolution in toxic ALF (25.33 vs. 9.90, p = 0.0032; 37.29 vs. 18.79, p < 0.0001; 34.29 vs. 19.24, p = 0.0002, respectively; with positive predicting value 100%, negative predicting value 88.52%, and accuracy 89.23% for King's College criteria). The Wilson index for predicting mortality had an excellent predictive strength (100% sensibility and specificity), better than the Nazer prognostic index. CONCLUSIONS Prognostic scores may be used to predict the fatal evolution of ALF in children in correlation with other parameters or criteria. Early estimation of the outcome of ALF is essential, mainly in countries where emergency LT is problematic, as the transfer to a specialized center could be delayed, affecting survival chances.
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Affiliation(s)
- Tudor Lucian Pop
- 2nd Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Cornel Olimpiu Aldea
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Dan Delean
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Bogdan Bulata
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Dora Boghiţoiu
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Daniela Păcurar
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Coriolan Emil Ulmeanu
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Alina Grama
- 2nd Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
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Abstract
Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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10
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Abstract
Acute liver failure is a rare syndrome and is primarily caused by paracetamol toxicity in developed nations. Survival for patients with acute liver failure has steadily improved over the last few decades from approximately 20% to greater than 60%. This marked improvement in survival has been due to a combination of improvements in medical practice and the use of emergency liver transplantation in selected patients. Early recognition and timely initial management in the non-specialist centre can significantly improve outcomes. Patients should be simultaneously discussed with a transplant centre and referred to critical care. Close liaison with transplant centres to ensure timely transfer in deteriorating patients is important.
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Affiliation(s)
- Mohammed A Arshad
- Queen Elizabeth Hospital, Birmingham, UK and Birmingham Liver Failure Research Group, Birmingham, UK
| | - Nicholas Murphy
- Queen Elizabeth Hospital, Birmingham, UK, Birmingham Liver Failure Research Group, Birmingham, UK, and honorary reader, University of Birmingham, Birmingham, UK
| | - Mansoor N Bangash
- Queen Elizabeth Hospital, Birmingham, UK, Birmingham Liver Failure Research Group, Birmingham, UK, and honorary senior clinical lecturer, University of Birmingham, Birmingham, UK
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Driever EG, Stravitz RT, Zhang J, Adelmeijer J, Durkalski V, Lee WM, Lisman T. VWF/ADAMTS13 Imbalance, But Not Global Coagulation or Fibrinolysis, Is Associated With Outcome and Bleeding in Acute Liver Failure. Hepatology 2021; 73:1882-1891. [PMID: 32767567 PMCID: PMC8251778 DOI: 10.1002/hep.31507] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/03/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent studies of acute liver failure (ALF) in man and animals have suggested that rebalanced hemostasis occurs, with distinct hypercoagulable features clinically evidenced by a low risk of bleeding. Rodent models have shown a link between intrahepatic microthrombus formation and progression of ALF. We sought to confirm these earlier findings in a large series of patients with well-characterized ALF from the Acute Liver Failure Study Group. APPROACH AND RESULTS Citrated plasma samples taken on admission from 676 patients with ALF or acute liver injury (international normalized ratio ≥2.0 without hepatic encephalopathy) were used to determine levels of von Willebrand factor (VWF), a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity, thrombomodulin-modified thrombin generation, and clot lysis time (CLT) and compared with the levels in 40 healthy controls. Patients had 3-fold increased VWF levels, 4-fold decreased ADAMTS13 activity, similar thrombin generating capacity, and 2.4-fold increased CLT, compared with controls. Increasing disease severity was associated with progressively more elevated VWF levels as well as hypofibrinolysis. Patients who died or underwent liver transplantation within 21 days of admission had higher VWF levels, lower ADAMTS13 activity, but similar thrombin generation and a similar proportion of patients with severe hypofibrinolysis, when compared with transplant-free survivors. Likewise, patients with bleeding complications had higher VWF levels and lower ADAMTS13 activity compared to those without bleeding. Thrombin generation and CLT did not differ significantly between bleeding and nonbleeding patients. CONCLUSIONS Rebalanced hemostatic status was confirmed in a large cohort of patients with acute liver injury/ALF, demonstrating that VWF/ADAMTS13 imbalance is associated with poor outcome and bleeding. The association between VWF/ADAMTS13 imbalance and bleeding suggests that bleeding in ALF relates more to systemic inflammation than a primary coagulopathy.
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Affiliation(s)
- Ellen G. Driever
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - R. Todd Stravitz
- Section of Hepatology and Hume‐Lee Transplant CenterVirginia Commonwealth UniversityRichmondVA
| | - Jingwen Zhang
- Department of BiostatisticsMedical University of South CarolinaCharlestonSC
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Valerie Durkalski
- Department of BiostatisticsMedical University of South CarolinaCharlestonSC
| | - William M. Lee
- Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical CenterDallasTX
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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Wong NZ, Schaubel DE, Reddy KR, Bittermann T. Transplant center experience influences spontaneous survival and waitlist mortality in acute liver failure: An analysis of the UNOS database. Am J Transplant 2021; 21:1092-1099. [PMID: 32741074 DOI: 10.1111/ajt.16234] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 01/25/2023]
Abstract
Transplant centers coordinate complex care in acute liver failure (ALF), for which liver transplant (LT) can be lifesaving. We studied associations between waitlist outcomes and center (1) ALF waitlist volume (low: <20; medium: 20-39; high: 40+ listings) and (2) total LT volume (<600, 600-1199, 1200+ LTs) in a retrospective cohort of 3248 adults with ALF listed for LT at 92 centers nationally from 2002 to 2019. Predicted outcome probabilities (LT, died/too sick, spontaneous survival [SS]) were obtained with multinomial regression, and observed-to-expected ratios were calculated. Median center outcome rates were 72.6% LT, 18.2% died/too sick, and 6.1% SS. SS was significantly higher with greater center ALF volume (median 0% for low-, 5.9% for medium-, and 8.6% for high-volume centers; P = .039), while waitlist mortality was highest at low-volume centers (median 21.4%, IQR: 16.1%-26.7%; P = .042). Significant heterogeneity in center performance was observed for waitlist mortality (observed-to-expected ratio range: 0-4.1) and particularly for SS (0-6.4), which persisted despite accounting for recipient case mix. This novel study demonstrates that increased center experience is associated with greater SS and reduced waitlist mortality for ALF. More-focused management pathways are needed to improve ALF outcomes at less-experienced centers and to identify opportunities for improvement at large.
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Affiliation(s)
- Natalie Z Wong
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas E Schaubel
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - K Rajender Reddy
- Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Therese Bittermann
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Division of Gastroenterology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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14
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Anaesthesia for Liver Transplantation: An Update. ACTA ACUST UNITED AC 2020; 6:91-100. [PMID: 32426515 PMCID: PMC7216023 DOI: 10.2478/jccm-2020-0011] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Accepted: 01/30/2020] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is a challenging surgery performed on patients with complex physiology profiles, complicated by multi-system dysfunction. It represents the treatment of choice for end-stage liver disease. The procedure is performed under general anaesthesia, and a successful procedure requires an excellent understanding of the patho-physiology of liver failure and its implications. Despite advances in knowledge and technical skills and innovations in immunosuppression, the anaesthetic management for LT can be complicated and represent a real challenge. Monitoring devices offer crucial information for the successful management of patients. Hemodynamic instability is typical during surgery, requiring sophisticated invasive monitoring. Arterial pulse contour analysis and thermo-dilution techniques (PiCCO), rotational thromboelastometry (RO-TEM), transcranial doppler (TCD), trans-oesophageal echocardiography (TEE) and bispectral index (BIS) have been proven to be reliable monitoring techniques playing a significant role in decision making. Anaesthetic management is specific according to the three critical phases of surgery: pre-anhepatic, anhepatic and neo-hepatic phase. Surgical techniques such as total or partial clamping of the inferior vena cava (IVC), use of venovenous bypass (VVBP) or portocaval shunts have a significant impact on cardiovascular stability. Post reperfusion syndrome (PRS) is a significant event and can lead to arrhythmias and even cardiac arrest.
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Krauskopf J, Gosink MM, Schomaker S, Caiment F, Warner R, Johnson K, Kleinjans J, Aubrecht J. The MicroRNA-based Liquid Biopsy Improves Early Assessment of Lethal Acetaminophen Poisoning: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e919289. [PMID: 32086430 PMCID: PMC7049075 DOI: 10.12659/ajcr.919289] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 01/24/2020] [Accepted: 11/04/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND Acetaminophen overdose is the most common cause of acute liver failure. Nevertheless, new biomarker approaches enabling early prediction of the outcome of the acetaminophen overdose are needed. Recently, using next-generation sequencing analysis of serum from human study participants we uncovered injury-specific signatures of circulating microRNAs (miRNAs) that represented underlying molecular mechanisms of toxicity. This case study is first to show the application of miRNA profiling to assess prognosis of acetaminophen poisoning. CASE REPORT The patient was admitted to the hospital following supra therapeutic acetaminophen ingestion. The patient showed elevated levels of biomarkers of hepatocellular injury alanine aminotransferase, aspartate transaminase, and glutamate dehydrogenase. Even though treatment with N-acetyl cysteine was initiated 24 hours post-ingestion, levels of alanine-aminotransferase and aspartate transaminase peaked at about 40 hours post ingestion of acetaminophen. We analyzed global circulating miRNA levels from 24 consecutive serum samples from this study participant covering the period from admission to time of death. CONCLUSIONS The resulting global miRNA profiles were compared with profiles from study participants with non-lethal acetaminophen poisoning and healthy controls. At the admission, the miRNA profiles of both lethal and non-lethal acetaminophen poisoning showed induction of cellular stress and oxidative damage. Later, the miRNA profiles of the lethal poisoning featured fibrosis and coagulation pathways while profiles of non-lethal cases resembled those of healthy study participants. Although additional confirmatory studies are needed, our case study is first to indicate that global miRNA profiles to be used as liquid biopsies have potential to facilitate the assessment of acetaminophen poisoning.
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Affiliation(s)
- Julian Krauskopf
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Mark M. Gosink
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Shelli Schomaker
- Drug Safety Research and Development, Pfizer, Inc., Groton, CT, U.S.A
| | - Florian Caiment
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Roscoe Warner
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Kent Johnson
- Department of Pathology, University of Michigan, Ann Arbor, MI, U.S.A
| | - Jos Kleinjans
- Department of Toxicogenomics, Maastricht University, Maastricht, The Netherlands
| | - Jiri Aubrecht
- Drug Safety Research and Development, Pfizer, Inc., Groton, CT, U.S.A
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16
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Acute Liver Failure: From Textbook to Emergency Room and Intensive Care Unit With Concomitant Established and Modern Novel Therapies. J Clin Gastroenterol 2019; 53:89-101. [PMID: 30575637 DOI: 10.1097/mcg.0000000000001162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute liver failure is a rare hepatic emergent situation that affects primarily young people and has often a catastrophic or even fatal outcome. Definition of acute liver failure has not reached a universal consensus and the interval between the appearance of jaundice and hepatic encephalopathy for the establishment of the acute failure is a matter of debate. Among the wide variety of causes, acetaminophen intoxication in western societies and viral hepatitis in the developing countries rank at the top of the etiology list. Identification of the clinical appearance and initial management for the stabilization of the patient are of vital significance. Further advanced therapies, that require intensive care unit, should be offered. The hallmark of treatment for selected patients can be orthotopic liver transplantation. Apart from well-established treatments, novel therapies like hepatocyte or stem cell transplantation, additional new therapeutic strategies targeting acetaminophen intoxication and/or hepatic encephalopathy are mainly experimental, and some of them do not belong, yet, to clinical practice. For clinicians, it is substantial to have the alertness to timely identify the patient and transfer them to a specialized center, where more treatment opportunities are available.
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Saluja V, Sharma A, Pasupuleti SS, Mitra LG, Kumar G, Agarwal PM. Comparison of Prognostic Models in Acute Liver Failure: Decision is to be Dynamic. Indian J Crit Care Med 2019; 23:574-581. [PMID: 31988548 PMCID: PMC6970204 DOI: 10.5005/jp-journals-10071-23294] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Background and aims Acute liver failure (ALF) is a rare disease entity with a high mortality. Management is dependent on accurate prognostication. Materials and methods One hundred consecutive patients presenting with ALF were prospectively evaluated. The King's college criteria (KCC), ALF early dynamic model (ALFED), sequential organ failure assessment (SOFA) score, and acute physiology and health evaluation II (APACHE II) scores were compared to predict mortality. Results There were significant differences in means of all the scores between survivors and nonsurvivors. The SOFA 48 hours had the highest area under receiver operating characteristic curve (AUC) (0.857) closely followed by the ALFED score (0.844). The optimal cutoff for the SOFA score at 48 hours to predict subsequent survival outcome is ≥10 and for the ALFED score is ≥5. Sequential organ failure assessment 48 hours had a good sensitivity of 87%, and the ALFED score showed a good specificity of 84%. The decision curve analysis showed that between a threshold probability of 0.13 and 0.6, use of the SOFA score provided the maximum net benefit and at threshold probabilities of >0.6, the use of ALFED score provided the maximum clinical benefit. Conclusion Dynamic scoring results in better prognostication in ALF. The SOFA 48 hours and ALFED score have good prognostication value in nonacetaminophen-induced liver failure. How to cite this article Saluja V, Sharma A, Pasupuleti SSR, Mitra LG, Kumar G, Agarwal PM. Comparison of Prognostic Models in Acute Liver Failure: Decision is to be Dynamic. Indian J Crit Care Med 2019;23(12):574–581.
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Affiliation(s)
- Vandana Saluja
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anamika Sharma
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samba Sr Pasupuleti
- Department of Statistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Lalita G Mitra
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Prashant M Agarwal
- Department of Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
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