Liver transplantation for acute liver failure: analysis of applicability

Liver transplantation for acute liver failure

Before liver transplantation became widely applicable as a treatment option, the mortality rate for acute liver failure was as high as 85%. Today, acute liver failure is a relatively common transplant indication in some settings, but the results of liver transplantation in this context appear to be worse than those for chronic forms of liver disease. In this review, we discuss the indications and contraindications for urgent liver transplantation. In particular, we consider the roles of auxiliary, ABO-incompatible, and urgent living donor liver transplantation and address the management of a «status 1» patient with total hepatectomy and portocaval shunt for toxic liver syndrome.

Timing and benefit of liver transplantation in acute liver failure

The case for using emergency liver transplantation in acute liver failure was made two decades ago by a series of single centre experiences. The development of models identifying a poor prognosis assisted the selection of patients for liver transplantation but none of these delivers both high sensitivity and specificity for prediction of death. Enhanced sensitivity favours the individual patient while enhanced specificity targets the pool of organs available at those who will derive greatest benefit. The non-transplant survival rates have improved considerably for certain cohorts of patients and these prognostic models have not been adjusted to reflect these changes. The presumption of transplant benefit can no longer be taken as established in paracetamol-related acute liver failure and a policy review is appropriate. In other scenarios, such as seronegative hepatitis and the phenotype of sub-acute liver failure, spontaneous survival rates remain low and the basis for liver transplantation remains sound. Outcomes after liver transplantation are improving but are not yet comparable to elective transplantation. The understanding of factors associated with failure after liver transplantation is improving but accurate definition of futility has not yet been attained.

Outcomes after living donor liver transplantation for acute liver failure in Japan: results of a nationwide survey

Nationwide surveys of acute liver failure (ALF) are conducted annually in Japan, and 20% of patients with ALF undergo liver transplantation (LT). We extracted data for 212 patients who underwent LT for ALF from the nationwide survey database of the Intractable Liver Diseases Study Group of Japan. After the exclusion of 3 patients who underwent deceased donor LT, 209 recipients of living donor liver transplantation (LDLT) were analyzed. ALF patients were placed into 3 subgroups according to the time from the onset of the disease to the occurrence of encephalopathy: patients who presented with encephalopathy within 10 days of the disease's onset were classified as having acute ALF, patients who presented within 11 to 56 days were classified as having subacute ALF, and patients who presented within 9 to 24 weeks were classified as having late-onset hepatic failure (LOHF). Long-term follow-up data were obtained from the registry of the Japanese Liver Transplantation Society. The 2 data sets were merged, and descriptive and survival data were analyzed. A Cox regression analysis was performed to define factors predicting overall mortality, short-term mortality (≤90 days after LT), and long-term mortality (>90 days after LT). One hundred ninety of the analyzed patients (91%) were adults (age ≥ 18 years); 70 patients (34%) were diagnosed with acute ALF, 124 (59%) were diagnosed with subacute ALF, and 15 (7%) were diagnosed with LOHF. Hepatitis B virus was the most common cause of acute ALF (61%), whereas autoimmune hepatitis (14%) and drug allergy-induced hepatitis (14%) were more frequent in patients with subacute ALF or LOHF. The cumulative patient survival rates 1, 5, and 10 years after LT were 79%, 74%, and 73%, respectively. Patient age was associated with short- and long-term mortality after LT, whereas ABO incompatibility affected short-term mortality, and donor age affected long-term mortality. In conclusion, the long-term outcomes of LDLT for ALF in this study were excellent, regardless of the etiology or classification. The majority of the donors were living donors. Increasing the deceased donor pool might be an urgent necessity.

Hepatoprotective effect and mechanistic insights of deoxyelephantopin, a phyto-sesquiterpene lactone, against fulminant hepatitis

Deoxyelephantopin (DET) is an abundant sesquiterpene lactone isolated from an anecdotally hepatoprotective phytomedicine, Elephantopus scaber. Our objective in this study was to provide scientific evidence for the in vivo efficacy and the underlying mechanisms of action of DET in lipopolysaccharide/d-galactosamine (LPS/D-GalN)-induced fulminant hepatitis. We investigated both the protective effect of pretreatment with DET (10 mg/kg body weight, Pre-DET10) prior to administration of LPS/D-GalN and the therapeutic effect of treatment with 10 mg/kg DET (Post-DET10) or the hepatoprotective drug silymarin (Post-SM10) following the administration of LPS/D-GalN. Our data showed that Pre-DET10 prevented LPS/D-GalN-induced infiltration of F4/80 monocytes/macrophages and an increase of nitrotyrosine and cyclooxygenase-2 protein in liver tissues. Further, Post-DET10 and Psot-SM10 treatments protected against liver cell apoptosis. All three treatments suppressed serum aminotransferase activities, tumor necrosis factor-alpha and interleukin-6 levels, and serum and hepatic matrix metalloproteinase-9 activity. The Pre-DET10 or Post-DET10 and Post-SM10 treatments in combination with inhibition of heme oxygenase-1 expression ultimately decreased protection of mice from LPS/D-GalN-induced mortality, with decreased survival from 75% and 62.5% to 50%, respectively. Results obtained from serial liver scintigraphy with (99m)Tc-diisopropyl iminodiacetic acid (DISIDA) on single-photon emission computed tomography analysis showed that both liver uptake and excretion times of DISIDA were significantly delayed in LPS/D-GalN-treated animals and were effectively recovered by DET and silymarin treatment. This report demonstrates that DET functions in the modulating multiple molecular targets or signaling pathways that counteract inflammation during the progression of fulminant hepatitis and may serve as a novel lead compound for future development of anti-inflammatory or hepatoprotective agents.

Liver transplantation for acute liver failure

Liver transplantation is now an integral part of the management of acute liver failure. The challenge for clinicians is to select the appropriate candidates with a combination of need and high likelihood of benefiting from the transplant. This is achieved through a combination of prognostic modelling and ongoing clinical evaluation. Although the outcomes after liver transplantation are good the survival rates do not quite match those achieved after elective transplantation.

Bioactive phytochemicals of leaf essential oils of Cinnamomum osmophloeum prevent lipopolysaccharide/D-galactosamine (LPS/D-GalN)-induced acute hepatitis in mice

The purpose of this study was to investigate the bioactive phytochemicals of leaf essential oils of Cinnamomum osmophloeum on lipopolysaccharide/D-galactosamine (LPS/D-GalN)-induced acute hepatitis. The results revealed that post-treatment with 100 μmol/kg trans-cinnamaldehyde, (-)-aromadendrene, T-cadinol, or α-cadinol significantly decreased the aspartate aminotransferase (AST), alanine aminotransferase (ALT), tumor necrosis factor-α (TNF-α), and interleukin 6 (IL-6) levels in serum. Moreover, both T-cadinol and α-cadinol treatments decreased the expressions of cleaved caspase-3 and cleaved poly-ADP ribose polymerase (PARP) in the liver tissues when compared with the LPS/D-GalN group. Liver histopathology also showed that silymarin, trans-cinnamaldehyde, (-)-aromadendrene, T-cadinol, or α-cadinol significantly reduced the incidence of liver lesions induced by LPS/D-GalN. These results suggest that the above phytochemicals exhibit potent hepatoprotection against LPS/D-GalN-induced liver damage in mice, and their hepatoprotective effects may be due to the modulation of anti-inflammatory activities.

Na+/H+ exchanger inhibitor, FR183998, has protective effect in lethal acute liver failure and prevents iNOS induction in rats

BACKGROUND/AIMS

Selective inhibition of Na(+)/H(+) exchanger (NHE) improves organ dysfunctions including heart ischemia-reperfusion injury. In vivo and in vitro studies were designed to investigate whether NHE inhibitor has a protective effect in lethal acute liver failure, and if so, what are the mechanisms involved.

METHODS

NHE inhibitor (FR183998) was administered to rats treated with d-galactosamine/lipopolysaccharide (GalN/LPS), or incubated with cultured hepatocytes stimulated by pro-inflammatory cytokine, interleukin (IL)-1beta.

RESULTS

FR183998 reduced the increases of pro-inflammatory cytokines such as TNF-alpha, interferon-gamma and CINC-1, but enhanced the anti-inflammatory cytokine, IL-10, leading to the prevention of liver injury and increased survival rate in GalN/LPS-treated animals. FR183998 prevented the activation of transcription factor NF-kappaB induced by GalN/LPS. In vivo and in vitro experiments revealed that FR183998 reduced inducible nitric oxide synthase (iNOS) induction and NO production. Further FR183998 decreased levels of iNOS antisense-transcript in GalN/LPS-treated liver and IL-1beta-treated hepatocytes.

CONCLUSIONS

FR183998 may reduce a variety of inflammatory mediators such as cytokines and NO in part through the inhibition of NF-kappaB activation, resulting in the prevention of fulminant liver failure, and may inhibit iNOS gene expression at steps of iNOS promoter transactivation and its mRNA stabilization through NF-kappaB and iNOS antisense-transcript, respectively.

Protective effect of neutrophil elastase inhibitor (FR136706) in lethal acute liver failure induced by D-galactosamine and lipopolysaccharide in rats

BACKGROUND/AIMS

It has been reported that liver dysfunction with ischemia-reperfusion is improved through selective inhibition of neutrophil elastase (NE) by NE inhibitor. This study was designed to investigate whether NE inhibitor has protective effect in lethal acute liver failure.

MATERIALS AND METHODS

Rats were treated with D-galactosamine plus lipopolysaccharide (GalN/LPS) to induce acute liver failure. NE inhibitor (FR136706) was administered intravenously before GalN/LPS injection.

RESULTS

NE inhibitor increased the survival rate to approximately 80% compared with less than 10% in GalN/LPS-treated rats. NE inhibitor prevented GalN/LPS-induced increase of enzymes and total bilirubin in serum, which are related to liver injury. Histopathological analysis revealed that NE inhibitor decreased the incidence of hepatic apoptosis and neutrophil infiltration in the liver. NE inhibitor inhibited the increased concentration of proinflammatory cytokines (tumor necrosis factor-alpha, interleukin-6 and interferon-gamma), and chemokines (CINC-1 and MIP-2) in serum or liver caused by GalN/LPS, and enhanced anti-inflammatory cytokine, interleukin-10 concentration. NE inhibitor prevented the activation of the transcription factor, nuclear factor-kappa B, induced by GalN/LPS. NE inhibitor also reduced the induction of inducible nitric oxide synthase mRNA and its protein in GalN/LPS-treated liver, and resulted in a decrease in nitric oxide production.

CONCLUSIONS

These results indicate that NE inhibitor, FR136706, inhibits the induction of a variety of inflammatory mediators such as cytokines, chemokines, and nitric oxide, in part through the inhibition of nuclear factor-kappa B activation, resulting in the prevention of fulminant liver failure.

Acute liver failure in Spain: analysis of 267 cases

The cause of acute liver failure (ALF) is a major determinant of its outcome. Acetaminophen (paracetamol) overdose is a leading cause of ALF in some developed countries, whereas in others, such as Spain, it is extremely rare. To analyze the etiology, characteristics, and outcome of ALF in Spain, we performed a retrospective analysis of 267 patients whom we observed from 1992 to 2000. Seventeen tertiary-care hospitals with active liver transplantation (LT) programs contributed data. Causes of ALF were viral hepatitis in 98 (37%; hepatitis B virus in 75 patients), unknown in 86 (32%), drug or toxic reactions in 52 (19.5%; acetaminophen overdose in 6), and miscellaneous in 31 (11.6%). Overall survival was 58%. LT was performed in 150 patients, with a survival of 69%. Despite fulfilling criteria, 51 patients were not transplanted because of contraindications; their survival was only 7.8%. Forty-seven (85.5%) of 55 patients without transplant criteria survived. Hepatitis B virus is the most common cause of ALF in Spain, although the origin of 30% of cases remains undetermined. Acetaminophen overdose represents a very rare cause of ALF. LT was performed in >50% of cases. Patients without transplant criteria had a very good prognosis; those who fulfilled these criteria but who had contraindications for transplantation had a high mortality rate.

Fulminant hepatic failure: a Portuguese experience

BACKGROUND

Fulminant hepatic failure (FHF) is a rare condition. Several series have been reported either by individual centres or in multicentre studies but, to our knowledge, this is the first report from a Portuguese population and might be a good example of FHF cases in a SouthWestern European population.

AIMS

To present the experience in FHF of a Portuguese Hepatogastroenterological Intensive Care Unit.

MATERIALS AND METHODS

Retrospective study of 61 cases of FHF consecutively admitted between February 1992 and October 2006. Definition and classification of FHF were those suggested by Trey and Davidson (1970) and O'Grady et al. (1993), respectively. Criteria and contraindications for hepatic transplantation (HT) were those proposed by Bernuau et al. (1991) and Muñoz (1993), respectively.

RESULTS

Fifty-seven per cent of patients were women and median age was 37 years (range: 8-73). Most common cause of FHF was indeterminate (26%) followed by viral (23%) and drug-induced (23%), with 51% of cases with a hyperacute evolution. Global HT rate was 54% with criteria for HT present in 87% of the patients resulting in an applicability rate of 62%. Overall survival was 69% and transplant-free survival was 15%; transplanted patients had survival rates of 70 and 68% at 6 and 12 months, respectively.

CONCLUSIONS

Drug-induced and viral agents were responsible for almost half of FHF cases with a clear predominance of hyperacute presentation. The HT rate was 54% and the applicability rate was 62%. The overall 1 year survival of 69% might reflect the adequacy of the HT criteria used.

A retrospective autopsy study of histopathologic spectrum and etiologic trend of fulminant hepatic failure from north India

Background

Fulminant hepatic failure (FHF) is rapidly fatal and liver transplant is the treatment of choice. The condition is known for its heterogeneity of defining criteria, clinical presentation, histologic spectrum and etiologic factors. The etiology of FHF varies widely, some of which includes viral hepatitis, drug overdose and idiosyncratic drug reactions. The identification of the etiology of FHF is critically important, because it influences the management. A histopathological classification of FHF has not been reported earlier in the literature.

Methods

The current study was conducted retrospectively on 224 autopsies at a tertiary care hospital in India. In all of these cases the liver was examined grossly and microscopically. Clinical findings, serological data and immunohistochemical findings were correlated with the morphological subtypes and a consensus morphological classification was formulated.

Results

Young females, especially those in the reproductive age group were most susceptible to the disease. Hepatotropic viruses and drugs were the likely causes in most of the patients. Clinical presentation is important, as delayed onset of encephalopathy or the subacute FHFs lead to maximum mortality. After careful gross and microscopic examination the morphological findings of FHF were divided into four distinct categories. Histologic typing can sometimes be misleading if solely made on H & E slides without application of special stains.

Conclusion

Fulminant hepatic failure is a medical emergency, proper histological categorization can help in deciding the treatment modalities.

MELD is superior to King's college and Clichy's criteria to assess prognosis in fulminant hepatic failure

Assessment of prognosis in fulminant hepatic failure (FHF) is essential for the need and appropriate timing of orthotopic liver transplantation (OLT). In this study we investigated the prognostic efficacy of King's College criteria, Clichy's criteria, Model for End-Stage Liver Disease (MELD), and Pediatric End-Stage Liver Disease (PELD) in 120 consecutive patients with FHF. Survival with medical therapy (18%), death without OLT (15%), and receipt of a liver transplant were similar in adults (n = 64) and children (n = 56). MELD scores were significantly higher in patients who died compared to those who survived without OLT, both in adults (38 +/- 7 vs. 26 +/- 7, P = 0.0003) and children (39 +/- 7 vs. 23 +/- 6, P = 0.0004). Using logistic regression analysis in this cohort of patients, concordance statistics were significantly higher for MELD (0.95) and PELD (0.99) when compared to King's College (0.74) and Clichy's criteria (0.68). When data was analyzed in a Cox model including patients receiving transplants and censoring the time from admission, the concordance statistic for MELD (0.77) and PELD (0.79) remained significantly higher than that of King's College criteria but not higher than that of Clichy's criteria. In conclusion, this study is the first to show that MELD and PELD are superior to King's College and Clichy's criteria to assess prognosis in FHF. However, because data was generated from a single center and included a rather low number of patients who survived or died without OLT, further confirmation of our findings is required.

Hyperlactatemia in patients with non-acetaminophen-related acute liver failure

AIM: To characterize hyperlactatemia in patients with non-acetaminophen acute liver failure (ALF) in an attempt to clarify the mechanisms implicated and the role as a prognosis factor.

METHODS: In the setting of liver transplantation, 63 consecutive patients with non-acetaminophen acute liver failure were studied in relation to tissue oxygenation, hemodynamic and metabolic parameters. Before and after transplantation, the number of infected patients and outcome were registered.

RESULTS: Acute ALF showed higher levels of lactate than subacute ALF (5.4 ± 1 mmol/L versus 2.2 ± 0.6 mmol/L, P = 0.01). Oxygenation parameters were within the normal range. Lactate levels showed good correlation with respiratory quotient (r = 0.759, P < 0.005), mean glucose administration (r = 0.664, P = 0.01) and encephalopathy (r = 0.698, P = 0.02), but not with splanchnic arteriovenous difference in PCO2, pH and the presence of infection (P = 0.1). Portal vein lactate was higher (P < 0.05) than arterial and mixed venous lactate, suggesting its production of hyperlactatemia in the intestine and spleen. The presence of infection was an independent predictor of survival.

CONCLUSION: Hyperlactatemia is not a prognosis factor due to byproduct of the overall acceleration in glycolysis.

Fulminant hepatic failure and the potential role of liver dialysis

Fulminant hepatic failure (FHF) carries a high mortality. We aimed to review the prognostic factors and explore the potential role of Liver Dialysis (LD). Fifty-two patients were reviewed. The etiologies were acetaminophen toxicity (33%), viral hepatitis (18%), autoimmune (10%), idiosyncratic drug reactions (8%), others (6%) and undetermined (25%). Patients with acetaminophen had a significantly higher survival compared to the non-acetaminophen group (p=0.04). Patients with grade 3 encephalopathy had a mortality of 68%, among 5 patients with grade IV encephalopathy, 2 survived and both had had treatment with LD. Chi-square with Fisher's exact test was used for statistical analysis. Our study confirmed that the diagnosis of non-acetaminophen induced FHF and reduced initial serum factor V level are associated with fatal outcome. Timely OLT significantly improved the survival. The role of LD in hepatic regeneration or as a bridge to OLT needs to be further studied with prospective control trials.

Phosphorus ans an early predictive factor in patients with acute liver failure

BACKGROUND

This study analyzes the prognostic significance of serum phosphorus in patients with acute liver failure (ALF).

METHODS

We performed a retrospective analysis of 112 patients with ALF. Univariate and bivariate analyses based on Kaplan-Meier recovery curves and a multivariate Classification Tree Structure Survival Analysis were performed to identify independent predictors of outcome. The variables analyzed were age, gender, race, ABO blood group, etiology of liver disease, grade of encephalopathy, serum bilirubin, prothrombin time, creatinine, serum phosphorus, phosphorus administered, phosphorus binders, and hemodialysis.

RESULTS

The median follow-up time was 5 days, the median age was 28 years, and 62% of the patients were female. The patients' outcomes were as follows: 28% recovered, 52% required orthotopic liver transplantation, and 20% died. White patients showed the best prognosis (58% recovered in the first week), and Hispanics showed the worst prognosis (0.3% recovered at 1 week) (P=0.0001). Encephalopathy and bilirubin were significant predictors of recovery (P<0.0001 and P=0.004). The analysis of the serum phosphorus showed a statistically significant better prognosis in patients with low phosphorus (P<0.001). The recovery rate at 1 week was 74% in patients with serum phosphorus less than 2.5 mg/dL, 45% if phosphorus ranged between 2.5 to 5 mg/dL, and 0% if phosphorus was more than 5 mg/dL. The bivariate analysis on the effects of phosphorus administration showed that phosphorus replacement was associated with a significant improvement in recovery in patients with low (P<0.004) or normal serum phosphorus levels (P<0.017)

CONCLUSIONS

Hypophosphatemia and early phosphorus administration are associated with a good prognosis in ALF, whereas hyperphosphatemia is predictive of poor recovery.

Etiology and management of fulminant hepatic failure

Fulminant hepatic failure (FHF) remains a rare but devastating disease. Viruses and drug-induced hepatotoxicity are the most common causes of the syndrome, but the relevance of each differs depending on the geographic area. In a large proportion of patients no cause for FHF can be identified. Good intensive care is critical for patient survival. Orthotopic liver transplantation (OLT) remains a definitive therapeutic option. Prognostic indices have helped to optimize patient selection and timing for performance of OLT. However, the accuracy of these prognostic indices decreases when they are applied to different populations, probably because of regional differences in etiology and peculiar native host factors. More accurate prognostic criteria and new therapeutic alternatives to OLT are required.

Treatment of amatoxin poisoning: 20-year retrospective analysis

BACKGROUND

Amatoxin poisoning is a medical emergency characterized by a long incubation time lag, gastrointestinal and hepatotoxic phases, coma, and death. This mushroom intoxication is ascribed to 35 amatoxin-containing species belonging to three genera: Amanita, Galerina, and Lepiota. The major amatoxins, the alpha-, beta-, and gamma-amanitins, are bicyclic octapeptide derivatives that damage the liver and kidney via irreversible binding to RNA polymerase II.

METHODS

The mycology and clinical syndrome of amatoxin poisoning are reviewed. Clinical data from 2108 hospitalized amatoxin poisoning exposures as reported in the medical literature from North America and Europe over the last 20 years were compiled. Preliminary medical care, supportive measures, specific treatments used singly or in combination, and liver transplantation were characterized. Specific treatments consisted of detoxication procedures (e.g., toxin removal from bile and urine, and extracorporeal purification) and administration of drugs. Chemotherapy included benzylpenicillin or other beta-lactam antibiotics, silymarin complex, thioctic acid, antioxidant drugs, hormones and steroids administered singly, or more usually, in combination. Supportive measures alone and 10 specific treatment regimens were analyzed relative to mortality.

RESULTS

Benzylpenicillin (Penicillin G) alone and in association was the mostfrequently utilized chemotherapy but showed little efficacy. No benefit was found for the use of thioctic acid or steroids. Chi-square statistical comparison of survivors and dead vs. treated individuals supported silybin, administered either as mono-chemotherapy or in drug combination and N-acetylcysteine as mono-chemotherapy as the most effective therapeutic modes. Future clinical research should focus on confirming the efficacy of silybin, N-acetylcysteine, and detoxication procedures.

Neurological improvement during bioartificial liver sessions in patients with acute liver failure awaiting transplantation

BACKGROUND

Brain edema is the main cause of death in acute liver failure patients awaiting transplantation. We assessed the HepatAssist 2000, a liver-assist system containing porcine hepatocytes, as a bridge to transplantation in patients with acute liver failure.

METHODS

Thirteen patients suffering from acute liver failure with criteria for transplantation entered an open baseline-controlled study, with liver-assist treatment sessions at 24-hr intervals until transplantation. Neurological status was regularly evaluated using the Glasgow Coma Scale.

RESULTS

Three patients were not treated: one had an immediate transplantation and two improved spontaneously. Ten patients received one to three courses of HepatAssist. A significant neurological improvement (mean Glasgow Coma Scale before and after treatment: 6.5+/-3.7 and 9.6+/-4.4, respectively, P<0.02) was observed, which was related to the volume of plasma processed per square meter of body surface. A significant decrease was observed in mean levels of bilirubin (P=0.0005) and transaminases but not in the other indicators of liver function. Six patients had transient episodes of hemodynamic instability, and five had bleeding complications. Two patients died after transplantation. Eight patients survived with a mean follow-up of 24.3 (18-32) months.

CONCLUSION

The HepatAssist 2000 is well tolerated, improves cerebral function, and may be used as a bridge to transplantation for patients with liver failure.

Relevance of two-stage total hepatectomy and liver transplantation in acute liver failure and severe liver trauma

Emergency liver transplantation frequently is the only life-saving procedure in cases of acute liver failure. It remains unclear whether emergency hepatectomy with portocaval shunt followed by liver transplantation as a two-stage procedure should be performed in cases in which a donor organ is not yet available. It has been stated that "toxic liver syndrome" could be treated by means of this strategy. From 1990 to 1995 we performed emergency hepatectomies in eight cases of acute liver failure or traumatic liver rupture with exsanguinating bleeding. In six cases we were able to perform a subsequent liver transplantation. Five of the six patients who underwent an emergency hepatectomy died. Emergency hepatectomy led to a significant increase in epinephrine dosage until the transplantation was performed. Only after transplantation did the need for epinephrine therapy decrease. The need for oxygen support did not change during the entire observation period. Plasmatic coagulation was stabilized by substitution, showing significantly higher values at 24 h after transplantation than at 48 h before transplantation. Fibrinogen increased significantly after transplantation in this group of patients. The experiences gathered at our clinic, however, do not show advantages that would allow a recommendation of emergency hepatectomy and subsequent liver transplantation as a two-stage procedure except for situations of severe and uncontrollable hepatic bleeding. Considering the progressive destabilization of our patients, fast procurement of donor organs seems to be of imminent importance for the outcome.

Transjugular intrahepatic portosystemic shunt (TIPS) for severe veno-occlusive disease of the liver following bone marrow transplantation

Severe veno-occlusive disease (VOD) of the liver is a leading cause of mortality after bone marrow transplantation (BMT). Vascular and parenchymal injuries account for acute portal hypertension and liver failure is frequently present. We describe the results of transjugular intrahepatic portosystemic shunt (TIPS) for the management of VOD after BMT. TIPS was performed in 10 patients with histologically proven severe VOD. Portal hypertension was controlled by TIPS in all patients (mean hepatic venous pressure gradient before, 20 +/- 11 vs 6 +/- 5 mm Hg after TIPS, P < 0.01) without technical complications. Five patients with rapidly worsening VOD died within 10 days of TIPS without any improvement. The five remaining patients with less advanced disease showed improvement in various clinical and biological parameters. Four patients subsequently died. The lone survivor continues to do well with resolution of VOD 6 months after TIPS. TIPS can be performed safely and controls portal hypertension in VOD after BMT. Arguments from the present series and from eight previously reported cases favour earlier application of TIPS to obtain improved overall survival. Bone Marrow Transplantation (2000) 25, 987-992.

Acute liver failure: clinical features, outcome analysis, and applicability of prognostic criteria

Acute liver failure (ALF) is an uncommon condition associated with high morbidity and mortality. We performed a retrospective analysis of patients evaluated for ALF. The aim of our study is to determine the clinical features and outcome of such patients and to assess the validity of King's College Hospital (KCH) prognostic criteria. One hundred seventy-seven patients were evaluated for ALF during a period of 13 years. Mean age was 39 years, and 63% were women. The causes included viral hepatitis (31%), acetaminophen toxicity (19%), idiosyncratic drug reactions (12%), miscellaneous causes (11%), and an indeterminate group (28%). Twenty-five patients (14%) recovered with medical therapy (group I), 65 patients (37%) died without orthotopic liver transplantation (OLT; group II), and 87 patients (49%) underwent OLT (group III). Patients in group II were older and often had advanced encephalopathy, whereas those in group I had less hyperbilirubinemia and often had hyperacute failure. KCH criteria had high specificity and positive predictive value but low negative predictive value for a poor outcome. We conclude that early prognostication is needed in patients with ALF to assist decision making regarding OLT. The fulfillment of KCH criteria usually predicts a poor outcome, but a lack of fulfillment does not predict survival.

Auxiliary partial orthotopic liver transplantation for acute liver failure in two children

Acute liver failure in children and adults is associated with a high mortality rate. At present the treatment of choice is orthotopic whole-liver transplantation. However, allogeneic liver transplantation necessitates lifelong immunosuppressive therapy, which is associated with substantial risks to the patient. Temporary auxiliary partial orthotopic liver transplantation has been developed recently as an alternative, enabling the native liver to regenerate while avoiding the risks of long-term immunosuppressive treatment. Here we describe two cases of partial orthotopic liver transplantation in children. Auxiliary partial orthotopic liver transplantation was performed in two boys (5 and 6 years old) suffering from acute liver failure of unknown origin. The native left lateral liver lobes (segment II and II) were removed and replaced by left lateral liver grafts from young blood-group-compatible adults. In the first child the native liver, which was 80% necrotic at time of transplantation, showed regeneration within two weeks and the partially necrotic graft could be surgically removed on day 15 after auxiliary transplantation. Four years after transplantation, the child is in excellent condition with normal liver function and does not require any treatment. In the second case the native liver (90% necrotic at time of transplantation) regenerated within 6 weeks of transplantation, at which time the transplanted liver was removed. The patient developed aplastic anemia and died 2 months after transplantation from candida sepsis. The conclusion was that auxiliary partial liver transplantation in childhood provides a valuable option to maintain liver function in acute liver failure until functional recovery of the native liver. The main advantage over whole-liver transplantation is the chance to avoid lifelong immunosuppression. However, there is a higher surgical risk. Therefore, auxiliary transplantation should be considered carefully in every case of acute liver failure in children.

Xenogeneic transplantation of porcine hepatocytes into the CCl4 cirrhotic rat model

Liver support using extracorporeal devices and hepatocyte transplantation has received renewed interest for the management of acute and chronic liver failure. The aim of this study was to determine whether xenogeneic porcine hepatocytes could integrate into the liver parenchyma of cirrhotic Lewis rats when administered by an intrasplenic route. Cirrhosis was induced by carbon tetrachloride (CCl4) inhalation and confirmed histologically. Freshly isolated porcine hepatocytes were infused directly into the splenic pulp at laparotomy over a 5-15-min interval. Using (111)In-labeled hepatocytes, the degree of localization of porcine hepatocytes to the spleen and liver was found to be greater than 60% in both control and cirrhotic rats. Integration of porcine hepatocytes into the rat liver parenchyma was determined by immunohistochemical staining for porcine albumin in rat liver sections. Further confirmation was provided by in situ hybridization using a porcine-specific probe that binds to a distinct repetitive element (PRE) in porcine DNA. Evidence of integrated porcine hepatocytes was seen for over 50 days in animals under cyclosporine immunosuppression. These data demonstrate the integration of xenogeneic porcine hepatocytes into the liver of the cirrhotic rat and their ability to produce porcine albumin for up to 50 days.

Acute quadriplegic myopathy with myosin-deficient muscle fibres after liver transplantation: defining the clinical picture and delimiting the risk factors

BACKGROUND

In the last few years, rare cases of acute quadriplegic myopathy (AQM*) with myosin-deficient muscle fibres occurring after solid organ transplantation has been reported. The aim of the present study was to review all cases of AQM with myosin deficient fibres seen at our institution among a large series of patients after orthotopic liver transplants (OLT), with special attention to clinical aspects and associated risk factors. Additionally, an extensive review of all ultrastructurally demonstrated cases of AQM in transplant recipients is also included.

PATIENTS AND METHODS

Among patients involved in 281 consecutive liver transplant procedures performed in a 4-year period, 3 men and 1 woman developed an arreflexic, flaccid quadriplegia in the immediate postoperative period of OLT. After ruling out other causes of weakness, a muscle biopsy was performed and a loss of thick (myosin) filaments was confirmed by ultrastructural analysis in all cases. Accurate clinical, epidemiological, and evolutive data were recorded.

RESULTS

Corticosteroids had been used at usual dosage given to liver transplant recipients; all four patients had several intra- and postoperative complications leading to receiving significantly higher amounts of hemoderivates, to develop renal failure in all cases, and to require a significantly higher number of reoperations within a few days after transplantation than our contemporaneous global series of liver transplant recipients. AQM patients required a significantly longer intensive care unit and hospital stay. Muscular recovery was the rule, but currently a mild myopathic gait remains in three patients. These and other reported cases of AQM do not histologically and clinically differ from AQM seen in other critically ill patients who have not had transplants.

CONCLUSIONS

Patients with a complicated intra- and postoperative course of OLT who develop newly acquired acute muscle weakness should be suspected as having acute AQM with myosin-deficient muscle fibres. In this setting, differential diagnosis with other causes of weakness should be carried out, because the prognosis of this myopathy is good with early muscle rehabilitation therapy.

Fulminant hepatic failure

Fulminant hepatic failure is a disease of varied causes and a high mortality rate. A sudden onset, jaundice, hepatic encephalopathy, and multiorgan failure are the hallmarks of this syndrome. The management of patients with FHF requires a multidisciplinary approach and intense monitoring. The availability of liver transplantation has provided the means to rescue such patients from near-certain death. Early prognostication and timely availability of donor livers are requirements for a successful outcome. The development of effective artificial liver support devices may greatly prolong the window of opportunity to provide a donor liver, or alternatively, to allow the native liver to regenerate.

Ecstasy: a common cause of severe acute hepatotoxicity

BACKGROUND/AIMS

Ecstasy is a synthetic amphetamine recently identified as a possible cause of acute liver injury. This drug is consumed by young people and has a marked effect on improving sociability. The extent of ecstasy-associated severe hepatic damage is unknown to date.

METHODS

The clinical histories of 62 patients with acute liver failure admitted to the Intensive Care Liver Unit between January 1994 and December 1996 were reviewed to assess the frequency, the epidemiological, clinical and histological characteristics and the outcome of ecstasy-induced severe hepatitis.

RESULTS

Over this period of time, five patients (8%) were admitted because of ecstasy-induced acute liver failure, representing 31% of the cases with drug hepatotoxicity. Ecstasy was the second most common cause of liver injury in patients under the age of 25 years, being 20% in this subset of patients and 36% after ruling out the cases of viral etiology. All the patients had severe liver disease of acute onset, with jaundice, high peak of serum transaminases activity, hypoglycemia and low prothrombin activity, but no hepatic encephalopathy. Full recovery was observed in all cases from 3 to 12 months.

CONCLUSIONS

Ecstasy is responsible for a relatively high number of cases of acute liver failure in young people. Therefore, the use of this drug should be investigated in all patients with severe hepatitis of unclear origin. Efforts must be made to advise young people of the risks of ecstasy consumption.

Review article: the management of acute liver failure

Acute liver failure (ALF) is a relatively uncommon but dramatic clinical syndrome with high mortality rates, in which a previously normal liver fails within days or weeks. Paracetamol overdose remains the major cause of ALF in the UK, while viral hepatitis is the commonest cause world-wide. Cerebral oedema is the leading cause of death in patients with ALF. Despite advances in intensive care and the development of new treatment modalities, ALF remains a condition of high mortality best managed in specialist centres. Orthotopic liver transplantation is the only new treatment modality that has made a significant impact in improving outcome. Bioartificial liver support systems and hepatocyte transplantation are new promising treatment options that may change the management of ALF in the future.

Clinical economics review: liver transplantation

The economic assessment of liver transplantation is complex and involves the cost of the transplant procedure, the cost of alternative treatments and the positive economic contribution of successful outcomes. The one-year survival rates are currently in the order of 80-90% for elective transplants and 60-75% for emergency transplantation. The average cost of a liver transplant operation in the UK is between pounds 32,000 and pounds 45,000. Factors which have a major influence on costs are aetiology, patient status at the time of transplantation, retransplantation and duration of hospital stay. Rejection episodes, renal impairment and surgical complications are of intermediate importance. The cost of transplantation must be balanced against the cost of alternative treatments that would be required if the patient were not transplanted and the positive economic benefit derived from excellent rehabilitation in the majority of recipients.

Liver transplantation for acute liver failure: outcome analysis

Acute liver failure (ALF) remains a major cause of morbidity and mortality. Before the availability of liver transplantation only 20% of patients with ALF survived. The clinical dilemma relates to the prognostication of these patients, as early liver transplantation has been associated with better outcomes. The eligibility for liver transplantation must therefore be quickly established. The patient's age, aetiology of disease, interval between the onset of jaundice and encephalopathy, blood pH, prothrombin time, serum bilirubin and serum creatinine levels has been identified as useful prognostic markers. The degree of hepatocyte necrosis on liver biopsy and estimated hepatic volume by computed tomography may also be valuable predictors of survival; however, further studies are needed.

How valid is emergency liver transplantation for acute liver necrosis in patients with multiple-organ failure?

Multiple-organ failure (MOF), defined as the failure of initially uninvolved organs, is the final step of definitive and massive liver necrosis. Emergency liver transplantation (ELT) has radically modified the outcome of acute liver failure and early primary graft failure, but the results of ELT in cases of MOF are unknown. From May 1988 to June 1993, 243 patients underwent a liver transplantation (LT). Thirty-seven patients (15.2%) who had an acute liver necrosis complicated by a MOF underwent an ELT. Twenty-one patients were children. An emergency retransplantation was performed in 16 patients. Three or 4 organ-system failures (OSF) were present in 13 patients. Before ELT, the mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 26.3 +/- 5.1. Six-month and 1-year survival rates were 37.8% and 25.9%, respectively, after ELT complicated by MOF, and 78% and 73.5%, respectively, in other cases of LT. Twenty-six patients had surgical complications (70%), whereas thirty-one patients had medical complications (84%). Twenty-two patients died during the postoperative period (60%). Before ELT, infection (P < .05), cardiovascular failure (P < .03), and more than two OSF (P < .05) were more frequent in patients who died after intervention. The APACHE II score (P < .05) and the length of stay in the intensive care unit before ELT (P < .05) were lower among survivors. In the context of liver allograft shortage, our results suggest that an ELT should not be performed in patients with cardiac failure, more than two OSF, or an APACHE II score higher than 30.

Orthotopic liver transplantation in fulminant and subfulminant hepatitis. The Paul Brousse experience

OBJECTIVE

The authors report on the experience of orthotopic liver transplantation in fulminant hepatitis at Paul Brousse Hospital.

SUMMARY BACKGROUND DATA

Liver transplantation is a breakthrough in the treatment of patients with fulminant hepatitis. However, the indications, the timing for transplantation, the type of transplantation, and the use of ABO incompatible grafts in this setting still are debated.

METHODS

Transplantation was indicated in patients with confusion or coma and factor V less than 20%, younger than 30 years of age, and confusion or coma and factor V less than 30% older than 30 years of age.

RESULTS

Among 139 patients who met the aforementioned criteria for transplantation, 1 recovered, 22 died before transplantation, and 116 underwent transplants with a 1-year survival of 68%. Survival was 83% in patients with grade 1 and 2 comas at transplantation versus 56% (p < 0.001) in those with grade 3 comas; it was 51% versus 81% (p < 0.001) in those transplanted with high risk (ABO-incompatible, split, or steatotic) and low-risk grafts, respectively. In a multivariate analysis, steatotic and partial grafts were predictive of poorer patient survival, and ABO incompatibility was predictive of poorer graft survival.

CONCLUSIONS

Orthotopic liver transplantation is an effective treatment in fulminant hepatitis. Use of high-risk grafts permitted transplantation of 83% of patients, but was responsible for higher mortality.