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Allam J, Ibrahim A, Rockey DC. The primary cause of markedly elevated aminotransferases in hospitalized patients with cirrhosis in ischemic hepatitis. Eur J Gastroenterol Hepatol 2024; 36:1346-1351. [PMID: 39324878 DOI: 10.1097/meg.0000000000002855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/27/2024]
Abstract
BACKGROUND Marked elevation in aminotransferases (≥1000 IU/l) is typically associated with acute liver injury. Here, we hypothesized that the cause of elevation in aminotransferases ≥1000 in patients with cirrhosis is likely due to a limited number of disorders and may be associated with poor outcomes. AIM We aimed to investigate the most common etiologies of acute elevations in aminotransferases in patients with cirrhosis, and to examine their associated outcomes. METHODS From May 2012 to December 2022, all hospitalized patients with cirrhosis and an aspartate aminotransferase or alanine aminotransferase ≥ 1000 IU/l were identified through Medical University of South Carolina's Clinical Data Warehouse. Complete clinical data were abstracted for each patient, and in-hospital mortality was examined. RESULTS The cohort was made up of 152 patients, who were 57 ± 12 years old, with 51 (34%) women. Underlying liver disease included mainly hepatitis C cirrhosis, alcohol-related cirrhosis, metabolic dysfunction-associated steatohepatitis cirrhosis, autoimmune cirrhosis, primary sclerosing cholangitis cirrhosis, and cryptogenic cirrhosis. The most common cause of marked elevation in aminotransferases in cirrhotic patients was ischemic hepatitis (71%), followed by chemoembolization (7%), autoimmune hepatitis (6%), drug-induced liver injury (3%), post-transjugular intrahepatic portosystemic shunt placement (3%), rhabdomyolysis (3%), and hepatitis C (2%). During hospitalization and over a 1-month follow-up period, the mortality rate in patients with ischemic hepatitis was 73% (79/108), while that for other causes of liver injury was 20% (9/44). CONCLUSION Ischemic hepatitis is the leading cause of marked elevation of aminotransferases in patients with cirrhosis, with distinctive clinical characteristics than other etiologies, and significantly poorer outcomes.
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Affiliation(s)
- Jad Allam
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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2
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Clouston AD, Gouw ASH, Tiniakos D, Bedossa P, Brunt EM, Callea F, Dienes HP, Goodman ZD, Hubscher SG, Kakar S, Kleiner DE, Lackner C, Park YN, Roberts EA, Schirmacher P, Terracciano L, Torbenson M, Wanless IR, Zen Y, Burt AD. Severe acute liver disease in adults: Contemporary role of histopathology. Histopathology 2024; 85:549-561. [PMID: 38773813 DOI: 10.1111/his.15212] [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: 03/08/2024] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/24/2024]
Abstract
Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).
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Affiliation(s)
- Andrew D Clouston
- Centre for Liver Disease Research, School of Medicine (Southern), University of Queensland, Princess Alexandra Hospital, Ipswich, Australia
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dina Tiniakos
- Department of Pathology, Aretaieion Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Elizabeth M Brunt
- Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Hans-Peter Dienes
- Institute of Pathology, Meduniwien, Medical University of Vienn, Wien, Austria
| | - Zachary D Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Stefan G Hubscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Young N Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eve A Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Luigi Terracciano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ian R Wanless
- Department of Pathology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alastair D Burt
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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3
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Rule JA, Ajayi F, James LP, Tujios SR, Sussman NL, Rakela JL, Ganger D, Bass NL, Reuben A, Stravitz RT, Lee WM. Differentiating Ischemic Hepatitis from Acetaminophen Overdose in Acute Liver Failure: Role of Acetaminophen Adducts-Ischemic Hepatitis vs Acetaminophen Overdose. Dig Dis Sci 2024:10.1007/s10620-024-08602-7. [PMID: 39222204 DOI: 10.1007/s10620-024-08602-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
BACKGROUND AND AIMS Acetaminophen (APAP) hepatotoxicity and ischemic hepatic injury (IH) demonstrate remarkably similar biochemical patterns. Deciding between these two etiologies in the setting of acute liver failure (ALF) can be challenging. We reviewed all cases in the Acute Liver Failure Study Group (ALFSG) registry where these diagnoses were considered, to determine reasons for, and frequency of, difficulties making these diagnoses. We hypothesized that the newly developed APAP-CYS adduct assay could help in discerning the correct diagnosis. METHODS Among 3364 patients with ALF or acute liver injury (ALI: INR ≥ 2.0 but without encephalopathy) between 1998 and 2019, 1952 (58%) received a final diagnosis of either APAP (1681) or IH (271). We utilized a review committee of senior hepatologists as well as the APAP-CYS assay (where sera were available), measuring the presence of toxic by-products of APAP injury to optimize adjudication. RESULTS With these methods, a total of 575 adduct positive APAP cases included 488 recognized APAP, as well as an additional 87 patients previously diagnosed as other etiologies. Nine cases initially attributed to IH were deemed combination APAP-IH injuries. Conversely, 215 of the 280 IH subjects tested for adducts disclosed 173 confirmed as IH with adduct testing below the toxicity threshold, while 9 cases were revised from APAP to the IH-APAP combination phenotype, where both hypotension and APAP likely played a role. CONCLUSIONS Discerning APAP from IH can be difficult-in rare cases, combined injury is observed (18/1952). APAP-CYS testing resulted in revising the diagnosis in 14.6% of cases.
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Affiliation(s)
- Jody A Rule
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, USA
| | - Faith Ajayi
- Department of Internal Medicine UT Southwestern Medical Center, Dallas, TX, USA
| | - Laura P James
- Arkansas Children's Hospital, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Shannan R Tujios
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, USA
| | - Norman L Sussman
- Baylor College of Medicine, Houston, TX, USA
- Durect, Inc., Cupertino, CA, USA
| | - Jorge L Rakela
- Division of Gastroenterology and Hepatology, Department of Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Daniel Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Norman L Bass
- Department of Medicine, UCSF San Francisco, San Francisco, CA, USA
| | - Adrian Reuben
- Medical University of South Carolina, Charleston, SC, USA
| | - R Todd Stravitz
- Section of Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, Department of Internal Medicine, UT Southwestern Medical Center, 5959 Harry Hines Blvd. Ste. 420, Dallas, TX, USA.
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4
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Kwak JY, Jeon H, Kim SJ, Han JH, Cha RR, Lee SS. Etiology and Outcomes of Patients with Extreme Hyperbilirubinemia in Korea: A Retrospective Cohort Study. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2024; 84:9-16. [PMID: 39049460 DOI: 10.4166/kjg.2024.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 06/18/2024] [Accepted: 07/02/2024] [Indexed: 07/27/2024]
Abstract
Background/Aim Extreme hyperbilirubinemia is occasionally observed in intensive care unit (ICU) and non-ICU settings. This study examined the etiologies of extreme hyperbilirubinemia (bilirubin level ≥12 mg/dL) and the factors associated with the 30-day mortality. Methods This retrospective observational cohort study identified 439 patients with extreme hyperbilirubinemia at the Gyeongsang National University Changwon Hospital between 2016 and 2020. The patients were classified into three groups and 11 diseases according to their etiology. The risk factors associated with 30-day mortality at the baseline were investigated using the Cox proportional hazards model. Results Of 439 patients with extreme hyperbilirubinemia, 287, 78, and 74 were in the liver cirrhosis/malignancy group, the ischemic injury group, and the benign hepatobiliary-pancreatic etiological group, respectively, with corresponding 30-day mortality rates of 42.9%, 76.9%, and 17.6%. The most common disease leading to hyperbilirubinemia was a pancreatobiliary malignancy (28.7%), followed by liver cirrhosis (17.3%), hepatocellular carcinoma (10.9%), and liver metastases (8.4%). The etiologies of hyperbilirubinemia, obstructive jaundice, infection, albumin level, creatinine level, and prothrombin time-international normalized ratio were independently associated with the 30-day mortality. Conclusions This study suggests three etiologies of extreme hyperbilirubinemia in the ICU and non-ICU settings. The prognosis of patients with extreme hyperbilirubinemia depends largely on the etiology and the presence of obstructive jaundice.
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Affiliation(s)
- Ji Yoon Kwak
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Hankyu Jeon
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Seong Je Kim
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Ji Hee Han
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Ra Ri Cha
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Changwon Hospital, Changwon, Korea
- Institute of Health Sciences, Gyeongsang National University, Jinju, Korea
- Department of Internal Medicine, Gyeongsang National University School of Medicine and Gyeongsang National University Hospital, Jinju, Korea
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Smith JE, Rockey DC. Update on ischemic hepatitis. Curr Opin Gastroenterol 2024; 40:143-147. [PMID: 38547333 DOI: 10.1097/mog.0000000000001017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
PURPOSE OF REVIEW Ischemic hepatitis (IH) refers to diffuse liver injury secondary to hypoperfusion. The condition is usually seen in the critical care setting and is associated with significant mortality. IH typically occurs in the setting of systemic hypotension superimposed on some form of underlying cardiac dysfunction. This review aims to report what is known and what is new about the etiology, pathophysiology, and clinical features associated with IH. RECENT FINDINGS In recent years, studies on IH have largely confirmed earlier reports regarding etiologies, comorbid conditions, and associated mortality. Recent study has also shed light on the potential treatment of IH with N -acetyl-cysteine (NAC). SUMMARY IH is typically associated with underlying cardiac disease, and patients with IH have a very high mortality rate. Treatment remains largely supportive, although the utility of agents such as NAC are being explored.
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Affiliation(s)
| | - Don C Rockey
- Digestive Disease Research Center, Medical University of South Carolina, Charleston, South Carolina, USA
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6
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Haddadin R, Aboujaoude C, Trad G. Congestive Hepatopathy: A Review of the Literature. Cureus 2024; 16:e58766. [PMID: 38779242 PMCID: PMC11110487 DOI: 10.7759/cureus.58766] [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: 04/21/2024] [Indexed: 05/25/2024] Open
Abstract
Congestive hepatopathy (CH), stemming from compromised hepatic venous flow or heightened intrahepatic pressure, represents a significant consequence of cardiovascular conditions like congestive heart failure (CHF). This review of literature encapsulates the core aspects of this condition, characterized by hepatic congestion, cellular injury, and impaired liver function. Diagnostic challenges arise due to symptoms mirroring primary liver diseases. Management revolves around addressing the underlying cause and mitigating fluid retention. This review of literature provides a snapshot of CH's complexity, emphasizing its clinical implications and the need for comprehensive understanding in clinical practice.
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Affiliation(s)
| | | | - George Trad
- Internal Medicine, MountainView Hospital, Las Vegas, USA
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7
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Berry M, Wang AM, Lahham RF, Zhang X, Pacheco LD. Ischemic Hepatitis and Septic Shock Secondary to Murine Typhus Infection in Pregnancy. AJP Rep 2024; 14:e185-e187. [PMID: 38860133 PMCID: PMC11164574 DOI: 10.1055/a-2330-4249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 03/27/2024] [Indexed: 06/12/2024] Open
Abstract
Infection with murine typhus may be associated with significant morbidity. With nonspecific symptoms and laboratory abnormalities, diagnosis may be challenging. In this case, a pregnant patient presented with complaints of fevers and myalgias. Her laboratory results included severe transaminitis as well as thrombocytopenia and hyponatremia. She ultimately required vasopressor support and intensive care unit admission despite fluid resuscitation and broad-spectrum antibiotics. Empiric doxycycline was initiated due to suspicion for murine typhus, which laboratory testing later confirmed. Her clinical status improved with these interventions. This was a severe case of murine typhus resulting in septic shock and ischemic hepatitis. It is important to know the typical findings of murine typhus and consider it in a differential diagnosis, especially when practicing in endemic areas.
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Affiliation(s)
- Marissa Berry
- Division of Maternal Fetal Medicine, The Ohio State University, Columbus, Ohio
| | - Amanda M. Wang
- Division of Maternal-Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Rana F. Lahham
- Division of Maternal-Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Xue Zhang
- Division of Maternal-Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
| | - Luis D. Pacheco
- Division of Maternal-Fetal Medicine, The University of Texas Medical Branch, Galveston, Texas
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8
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Omran S, Greiner A. Ischemic hepatitis due to an occlusion of visceral arteries: a case report. J Surg Case Rep 2023; 2023:rjad671. [PMID: 38111497 PMCID: PMC10725822 DOI: 10.1093/jscr/rjad671] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 11/18/2023] [Indexed: 12/20/2023] Open
Abstract
Ischemic hepatitis due to mesenteric artery occlusion is extremely rare. This is due to the function of the collateral network of the celiac-mesenteric arterial system and portal venous flow. A 64-year-old male presented with abdominal pain, a significantly reduced general condition, a weight loss of 20 kg in 4 months. Computed tomography showed occlusion of the celiac trunk and the superior mesenteric artery and hypodense lesions in the liver. We performed an antegrade visceral reconstruction with a bifurcated 12-6 mm Dacron graft from the supra-celiac aortic donor to the superior mesenteric and celiac arteries. The postoperative course and follow-up were uneventful.
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Affiliation(s)
- Safwan Omran
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Andreas Greiner
- Charité – Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Department of Vascular Surgery, Hindenburgdamm 30, 12203 Berlin, Germany
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9
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Arif-Tiwari H, Porter KK, Kamel IR, Bashir MR, Fung A, Kaplan DE, McGuire BM, Russo GK, Smith EN, Solnes LB, Thakrar KH, Vij A, Wahab SA, Wardrop RM, Zaheer A, Carucci LR. ACR Appropriateness Criteria® Abnormal Liver Function Tests. J Am Coll Radiol 2023; 20:S302-S314. [PMID: 38040457 DOI: 10.1016/j.jacr.2023.08.023] [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: 08/15/2023] [Accepted: 08/22/2023] [Indexed: 12/03/2023]
Abstract
Liver function tests are commonly obtained in symptomatic and asymptomatic patients. Various overlapping lab patterns can be seen due to derangement of hepatocytes and bile ducts function. Imaging tests are pursued to identify underlying etiology and guide management based on the lab results. Liver function tests may reveal mild, moderate, or severe hepatocellular predominance and can be seen in alcoholic and nonalcoholic liver disease, acute hepatitis, and acute liver injury due to other causes. Cholestatic pattern with elevated alkaline phosphatase with or without elevated γ-glutamyl transpeptidase can be seen with various causes of obstructive biliopathy. Acute or subacute cholestasis with conjugated or unconjugated hyperbilirubinemia can be seen due to prehepatic, intrahepatic, or posthepatic causes. We discuss the initial and complementary imaging modalities to be used in clinical scenarios presenting with abnormal liver function tests. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.
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Affiliation(s)
- Hina Arif-Tiwari
- University of Arizona, Banner University Medical Center, Tucson, Arizona.
| | | | - Ihab R Kamel
- Panel Chair, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | - Alice Fung
- Oregon Health & Science University, Portland, Oregon
| | - David E Kaplan
- Perelman School of Medicine of the University of Pennsylvania, Philadelphia, Pennsylvania; American Association for the Study of Liver Diseases
| | - Brendan M McGuire
- University of Alabama at Birmingham, Birmingham, Alabama, Primary care physician
| | | | - Elainea N Smith
- University of Alabama at Birmingham Medical Center, Birmingham, Alabama
| | - Lilja Bjork Solnes
- Johns Hopkins Bayview Medical Center, Baltimore, Maryland; Commission on Nuclear Medicine and Molecular Imaging
| | | | - Abhinav Vij
- New York University Langone Medical Center, New York, New York
| | - Shaun A Wahab
- University of Cincinnati Medical Center, Cincinnati, Ohio
| | - Richard M Wardrop
- Cleveland Clinic, Cleveland, Ohio; American College of Physicians, Hospital Medicine
| | | | - Laura R Carucci
- Specialty Chair, Virginia Commonwealth University Medical Center, Richmond, Virginia
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10
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Beer BN, Besch L, Weimann J, Surendra K, Roedl K, Grensemann J, Sundermeyer J, Dettling A, Kluge S, Kirchhof P, Blankenberg S, Scherer C, Schrage B. Incidence of hypoxic hepatitis in patients with cardiogenic shock and association with mortality. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2023; 12:663-670. [PMID: 37410589 DOI: 10.1093/ehjacc/zuad076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/23/2023] [Accepted: 07/04/2023] [Indexed: 07/08/2023]
Abstract
AIMS Shock of any cause leads to end-organ damage due to ischaemia, especially in perfusion-sensitive organs such as the liver. In septic shock, hypoxic hepatitis (S-HH) is defined as the 20-fold increase of the upper normal limit of aspartate aminotransferase (ASAT) and alanine aminotransferase (ALAT) and is associated with a mortality of up to 60%. However, as pathophysiology, dynamics, and treatment differ between septic and cardiogenic shock (CS), the S-HH definition may not be suitable for CS. Therefore, we aim to evaluate if the S-HH definition is applicable in CS patients. METHODS AND RESULTS This analysis was based on a registry of all-comer CS patients treated between 2009 and 2019 at a tertiary care centre with exclusion of minors and patients without all necessary ASAT and ALAT values. N = 698. During in-hospital follow-up, 386 (55.3%) patients died. The S-HH was not significantly associated with in-hospital mortality in CS patients. To define HH among patients with CS (C-HH), optimal cut-off values were found to be ≥1.34-fold increase for ASAT and ≥1.51-fold increase for ALAT in serial measurements. The incidence of C-HH was 254/698 patients (36%) and C-HH showed a strong association with in-hospital mortality (odds ratio 2.36, 95% confidence interval: 1.61, 3.49). CONCLUSION The C-HH is a frequent and relevant comorbidity in patients with CS, although its definition varies from the established definition of HH in patients with septic shock. As C-HH contributed to excess mortality risk, these findings emphasize the need for further investigation of therapies reducing the occurrence of C-HH and also improving the associated outcome.
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Affiliation(s)
- Benedikt N Beer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Lisa Besch
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Jessica Weimann
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Kishore Surendra
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jörn Grensemann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Jonas Sundermeyer
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Angela Dettling
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
| | - Paulus Kirchhof
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
- Institute of Cardiovascular Sciences, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Stefan Blankenberg
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Clemens Scherer
- Department of Medicine I, University Hospital, LMU Munich, Marchioninistr. 15, Munich 81377, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Hamburg 20246, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
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11
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Fiel MI, Schiano TD. Systemic Disease and the Liver Part 2: Pregnancy-Related Liver Injury, Sepsis/Critical Illness, Hypoxia, Psoriasis, Scleroderma/Sjogren's Syndrome, Sarcoidosis, Common Variable Immune Deficiency, Cystic Fibrosis, Inflammatory Bowel Disease, and Hematologic Disorders. Surg Pathol Clin 2023; 16:485-498. [PMID: 37536884 DOI: 10.1016/j.path.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
The liver is involved in many multisystem diseases and commonly may manifest with abnormal liver chemistry tests. The liver test perturbations may be multifactorial in nature, however, as patients are receiving many different medications and can also have intrinsic liver disease that may be exacerbated by the systemic disorder. Some disorders have typical histologic findings that can be diagnosed on liver biopsy, whereas others will show a more nonspecific histology. Clinicians should be aware of these conditions so as to consider the performance of a liver biopsy at the most opportune time and setting to help establish the diagnosis of acute or chronic liver disease.
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Affiliation(s)
- Maria Isabel Fiel
- Department of Pathology, Molecular and Cell-Based Medicine, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place, New York, NY 10029, USA.
| | - Thomas D Schiano
- Division of Liver Diseases, Recanati-Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, One Gustave Levy Place-Box 1104, New York, NY 10029, USA
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Beech C, Liu C, Zhang X. Pathology of Acute and Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:581-593. [PMID: 37380284 DOI: 10.1016/j.cld.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Liver failure can develop as either acute liver failure in the absence of preexisting liver disease, or as acute-on-chronic liver failure in a patient with underlying chronic liver disease or cirrhosis. A timely liver biopsy is helpful to distinguish acute and chronic liver disease, identify precipitating factors, provide prognostic information based on pathologic changes, and aid in making appropriate decisions for patient management. This article will discuss the pathologic features of acute and acute-on-chronic liver failure. Developing an appreciation for the histopathologic patterns of injury observed in these entities is essential for a practical understanding of the diagnostic process.
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Affiliation(s)
- Cameron Beech
- Department of Pathology, ARUP Laboratories, University of Utah, Salt Lake City, UT 84112, USA
| | - Chen Liu
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520-8023, USA.
| | - Xuchen Zhang
- Department of Pathology, Yale School of Medicine, New Haven, CT 06520-8023, USA.
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13
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Imam MT, Almalki ZS, Alzahrani AR, Al-Ghamdi SS, Falemban AH, Alanazi IM, Shahzad N, Muhammad Alrooqi M, Jabeen Q, Shahid I. COVID-19 and severity of liver diseases: Possible crosstalk and clinical implications. Int Immunopharmacol 2023; 121:110439. [PMID: 37315370 PMCID: PMC10247890 DOI: 10.1016/j.intimp.2023.110439] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/16/2023]
Abstract
COVID-19-infected individuals and those who recovered from the infection have been demonstrated to have elevated liver enzymes or abnormal liver biochemistries, particularly with preexisting liver diseases, liver metabolic disorders, viral hepatitis, and other hepatic comorbidities. However, possible crosstalk and intricate interplay between COVID-19 and liver disease severity are still elusive, and the available data are murky and confined. Similarly, the syndemic of other blood-borne infectious diseases, chemical-induced liver injuries, and chronic hepatic diseases continued to take lives while showing signs of worsening due to the COVID-19 crisis. Moreover, the pandemic is not over yet and is transitioning to becoming an epidemic in recent years; hence, monitoring liver function tests (LFTs) and assessing hepatic consequences of COVID-19 in patients with or without liver illnesses would be of paramount interest. This pragmatic review explores the correlations between COVID-19 and liver disease severity based on abnormal liver biochemistries and other possible mechanisms in individuals of all ages from the emergence of the COVID-19 pandemic to the post-pandemic period. The review also alludes to clinical perspectives of such interactions to curb overlapping hepatic diseases in people who recovered from the infection or living with long COVID-19.
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Affiliation(s)
- Mohammad T Imam
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia
| | - Ziyad S Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam Bin Abdulaziz University, Al Kharj 11942, Saudi Arabia
| | - Abdullah R Alzahrani
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia
| | - Saeed S Al-Ghamdi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia
| | - Alaa H Falemban
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia
| | - Ibrahim M Alanazi
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia
| | - Naiyer Shahzad
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia
| | | | - Qaisar Jabeen
- Department of Pharmacology, Faculty of Pharmacy, The Islamia University of Bahawalpur, Bahawalpur, Pakistan
| | - Imran Shahid
- Department of Pharmacology and Toxicology, Faculty of Medicine, Umm Al-Qura University, Al-Abidiyah, Makkah 21955, Saudi Arabia.
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14
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Woźnica-Niesobska E, Leśnik P, Janc J, Zalewska M, Łysenko L. The Role of Plasminogen Activator Inhibitor 1 in Predicting Sepsis-Associated Liver Dysfunction: An Observational Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4846. [PMID: 36981754 PMCID: PMC10049524 DOI: 10.3390/ijerph20064846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/06/2023] [Accepted: 03/07/2023] [Indexed: 06/18/2023]
Abstract
Sepsis-associated liver dysfunction (SALD) is associated with a poor prognosis and increased mortality in the intensive care unit. Bilirubin is one of the components of Sequential Organ Failure Assessment used in Sepsis-3 criteria. Hyperbilirubinemia is a late and non-specific symptom of liver dysfunction. This study aimed to identify plasma biomarkers that could be used for an early diagnosis of SALD. This prospective, observational study was conducted on a group of 79 patients with sepsis and septic shock treated in the ICU. Plasma biomarkers-prothrombin time, INR, antithrombin III, bilirubin, aspartate transaminase (AST), alanine transaminase, alkaline phosphatase, gamma glutamyl transferase, albumin, endothelin-1, hepcidin, plasminogen activator inhibitor-1 (PAI-1), thrombin-antithrombin complex, and interferon-gamma inducible protein (10 kDa) were analysed. Plasma samples were obtained within 24 h after having developed sepsis/septic shock. Enrolled patients were followed for 14 days for developing SALD and 28 days for overall survival. A total of 24 patients (30.4%) developed SALD. PAI-1 with a cut-off value of 48.7 ng/mL was shown to be a predictor of SALD (AUC = 0.671, sensitivity 87.3%, and specificity 50.0%) and of 28-day survival in patients with sepsis/septic shock (p = 0.001). Measuring PAI-1 serum levels at the onset of sepsis and septic shock may be useful in predicting the development of SALD. This should be verified in multicenter prospective clinical trials.
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Affiliation(s)
- Ewa Woźnica-Niesobska
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-556 Wroclaw, Poland
| | - Patrycja Leśnik
- Department of Anaesthesiology and Intensive Therapy, 4th Military Clinical Hospital, 50-981 Wroclaw, Poland
| | - Jarosław Janc
- Department of Anaesthesiology and Intensive Therapy, 4th Military Clinical Hospital, 50-981 Wroclaw, Poland
| | - Małgorzata Zalewska
- Department of Infectious Diseases Liver Diseases and Acquired Immune Deficiencies, Wroclaw Medical University, 50-367 Wroclaw, Poland
| | - Lidia Łysenko
- Department of Anaesthesiology and Intensive Therapy, Wroclaw Medical University, 50-556 Wroclaw, Poland
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15
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Dezan MGF, Cavalcante LN, Cotrim HP, Lyra AC. Hepatobiliary disease after bone marrow transplant. Expert Rev Gastroenterol Hepatol 2023; 17:129-143. [PMID: 36655915 DOI: 10.1080/17474124.2023.2169671] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 01/13/2023] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Bone marrow transplantation (BMT) is the standard treatment for several hematologic pathologies. Post-BMT patients may develop hepatobiliary complications that impact morbidity and mortality. The differential diagnosis may include drug-induced liver injury (DILI), sepsis-associated liver injury (SALI), sinusoidal obstruction syndrome (SOS), graft-versus-host disease (GVHD), viral hepatitis, ischemic and fulminant hepatitis, among others. AREA COVERED Defining the etiology of hepatobiliary injury is challenging due to the overlapping symptoms. Thus, it is necessary to be aware of and understand the clinical characteristics of these hepatobiliary complications and provide adequate management with possible better outcomes. We reviewed the scientific literature focused on early hepatobiliary complications associated with BMT. We searched the PubMed database using the following descriptors: hepatic complications, drug-induced liver disease, graft-versus-host disease, cholestasis, sepsis, sinusoidal obstruction syndrome, cytomegalovirus, viral hepatitis, bone marrow transplantation, and hematopoietic stem cell transplantation. EXPERT OPINION Post-BMT hepatobiliary complications comprise several differential diagnoses and are challenges for the hepatologist's clinical practice. When evaluating these patients, it is necessary to consider the temporality between the use of certain medications, the increase in liver enzymes, and the presence of infection, in addition to applying diagnostic criteria and complementary tests for a specific diagnosis.
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Affiliation(s)
- Maria Gabriela Fernandes Dezan
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Lourianne Nascimento Cavalcante
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Helma Pinchemel Cotrim
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
| | - Andre Castro Lyra
- Instituto D'Or de Pesquisa e Ensino (IDOR) and Hospital São Rafael Gastro-Hepatology Service, Hospital São Rafael, Salvador, Bahia, Brazil
- Gastro-Hepatology Service - University Hospital Professor Edgard Santos (HUPES), PPGMS - Federal University of Bahia, Salvador, Bahia, Brazil
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Di-Iacovo N, Pieroni S, Piobbico D, Castelli M, Scopetti D, Ferracchiato S, Della-Fazia MA, Servillo G. Liver Regeneration and Immunity: A Tale to Tell. Int J Mol Sci 2023; 24:1176. [PMID: 36674692 PMCID: PMC9864482 DOI: 10.3390/ijms24021176] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 12/28/2022] [Accepted: 12/30/2022] [Indexed: 01/11/2023] Open
Abstract
The physiological importance of the liver is demonstrated by its unique and essential ability to regenerate following extensive injuries affecting its function. By regenerating, the liver reacts to hepatic damage and thus enables homeostasis to be restored. The aim of this review is to add new findings that integrate the regenerative pathway to the current knowledge. An optimal regeneration is achieved through the integration of two main pathways: IL-6/JAK/STAT3, which promotes hepatocyte proliferation, and PI3K/PDK1/Akt, which in turn enhances cell growth. Proliferation and cell growth are events that must be balanced during the three phases of the regenerative process: initiation, proliferation and termination. Achieving the correct liver/body weight ratio is ensured by several pathways as extracellular matrix signalling, apoptosis through caspase-3 activation, and molecules including transforming growth factor-beta, and cyclic adenosine monophosphate. The actors involved in the regenerative process are numerous and many of them are also pivotal players in both the immune and non-immune inflammatory process, that is observed in the early stages of hepatic regeneration. Balance of Th17/Treg is important in liver inflammatory process outcomes. Knowledge of liver regeneration will allow a more detailed characterisation of the molecular mechanisms that are crucial in the interplay between proliferation and inflammation.
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Affiliation(s)
- Nicola Di-Iacovo
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Stefania Pieroni
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Danilo Piobbico
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Marilena Castelli
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Damiano Scopetti
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Simona Ferracchiato
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Maria Agnese Della-Fazia
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
| | - Giuseppe Servillo
- Department of Medicine and Surgery, University of Perugia, Piazzale L. Severi 1, 06129 Perugia, Italy
- Centro Universitario di Ricerca sulla Genomica Funzionale (C.U.R.Ge.F.), University of Perugia, 06123 Perugia, Italy
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17
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Ischemic Pancreatitis Is an Important Cause of Acute Pancreatitis in the Intensive Care Unit. J Clin Gastroenterol 2023; 57:97-102. [PMID: 34974492 DOI: 10.1097/mcg.0000000000001651] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 11/12/2021] [Indexed: 12/14/2022]
Abstract
BACKGROUND Ischemic pancreatitis (IP) has mainly been described in case reports. The aims of the study were to assess the frequency, clinical characteristics and outcomes in patients with IP among patients hospitalized in the intensive care unit (ICU) for acute pancreatitis (AP). METHODS All patients with first time AP between 2011 and 2018 in the ICU of Landspitali Hospital, Iceland were retrospectively included. IP as an etiology required a clinical setting of circulatory shock, arterial hypotension, hypovolemia and/or arterial hypoxemia [PaO 2 of 60 mm Hg (8.0 kPa), or less] before the diagnosis of AP without prior history of abdominal pain to this episode. Other causes of AP were ruled out. IP patients were compared with patients with AP of other etiologies, also hospitalized in the ICU. RESULTS Overall 67 patients with AP were identified (median age 60 y, 37% females), 31% idiopathic, 24% alcoholic, 22% IP, 15% biliary, and 8% other causes. Overall, 15 (22%) fulfilled the predetermined criteria for IP, 9 males (64%), median age 62 years (interquartile range: 46 to 65). IP was preceded mainly by systemic shock (73%). Other causes included dehydration, hypoxia, or vessel occlusion to the pancreas. Necrosis of the pancreas was rare with one patient requiring pancreatic necrosectomy. Inpatient mortality was higher among patients with IP than in other patients with AP (33% vs. 14%, P =0.12). CONCLUSIONS IP was found in a significant proportion of AP patients hospitalized in the ICU. The main causes of IP were systemic shock and hypoxia. IP was associated with ∼30% mortality.
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18
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Elghannam MT, Hassanien MH, Ameen YA, ELattar GM, ELRay AA, Turky EA, ELTalkawy MD. COVID-19 and liver diseases. EGYPTIAN LIVER JOURNAL 2022; 12:43. [PMID: 35880136 PMCID: PMC9301896 DOI: 10.1186/s43066-022-00202-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022] Open
Abstract
Coronavirus causes an outbreak of viral pneumonia that spread throughout the world. Liver injury is becoming more widely recognized as a component of the clinical picture of COVID-19 infection. Hepatitis with serum ALT elevation has been reported in up to half of patients. Patients with CLD were at a higher risk of decompensation with liver failure, hospitalization, and mortality. The percentage of acute liver injury (ALI) varied from 5 to 28%. COVID-19 hinders HCV elimination by 2030. It is recommended to continue treatment of chronic HCV and chronic HBV if already receiving treatment. Consider using antiviral therapy to prevent viral flare-ups in patients with occult or resolved HBV and COVID-19 who are receiving immunosuppressive agents. Patients with AIH do not have an increased risk of adverse outcomes even in high-risk areas. There is an association between MAFLD and disease progression. Patients with any type of cancer are at a higher risk of infection and are more likely to develop more severe clinical outcomes. Most societies advise against immunosuppressant modifications in patients with mild COVID-19, whereas in rare cases such as severe lymphopenia, worsening pneumonia, or bacterial or fungal superinfection, reduction or discontinuation of antiproliferative agents and lymphocyte-depleting therapies has been suggested.
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19
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Sun R, Wang X, Jiang H, Yan Y, Dong Y, Yan W, Luo X, Miu H, Qi L, Huang Z. Prediction of 30-day mortality in heart failure patients with hypoxic hepatitis: Development and external validation of an interpretable machine learning model. Front Cardiovasc Med 2022; 9:1035675. [PMID: 36386374 PMCID: PMC9649827 DOI: 10.3389/fcvm.2022.1035675] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 10/11/2022] [Indexed: 12/02/2022] Open
Abstract
Background This study aimed to explore the impact of hypoxic hepatitis (HH) on survival in heart failure (HF) patients and to develop an effective machine learning model to predict 30-day mortality risk in HF patients with HH. Methods In the Medical Information Mart for Intensive Care (MIMIC)-III and IV databases, clinical data and survival situations of HF patients admitted to the intensive care unit (ICU) were retrospectively collected. Propensity Score Matching (PSM) analysis was used to balance baseline differences between HF patients with and without HH. Kaplan Meier analysis and multivariate Cox analysis were used to determining the effect of HH on the survival of CF patients. For developing a model that can predict 30-day mortality in CF patients with HH, the feature recurrence elimination (RFE) method was applied to feature selection, and seven machine learning algorithms were employed to model construction. After training and hyper-parameter optimization (HPO) of the model through cross-validation in the training set, a performance comparison was performed through internal and external validation. To interpret the optimal model, Shapley Additive Explanations (SHAP) were used along with the Local Interpretable Model-agnostic Explanations (LIME) and the Partial Dependence Plot (PDP) techniques. Results The incidence of HH was 6.5% in HF patients in the MIMIC cohort. HF patients with HH had a 30-day mortality rate of 33% and a 1-year mortality rate of 51%, and HH was an independent risk factor for increased short-term and long-term mortality risk in HF patients. After RFE, 21 key features (21/56) were selected to build the model. Internal validation and external validation suggested that Categorical Boosting (Catboost) had a higher discriminatory capability than the other models (internal validation: AUC, 0.832; 95% CI, 0.819–0.845; external validation: AUC, 0.757 95% CI, 0.739–0.776), and the simplified Catboost model (S-Catboost) also had good performance in both internal validation and external validation (internal validation: AUC, 0.801; 95% CI, 0.787–0.813; external validation: AUC, 0.729, 95% CI, 0.711–0.745). Conclusion HH was associated with increased mortality in HF patients. Machine learning methods had good performance in identifying the 30-day mortality risk of HF with HH. With interpretability techniques, the transparency of machine learning models has been enhanced to facilitate user understanding of the prediction results.
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Affiliation(s)
- Run Sun
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Xue Wang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Haiyan Jiang
- Medical School of Nantong University, Nantong University, Nantong, China
- Health Management Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Yan Yan
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Yansong Dong
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
| | - Wenxiao Yan
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Xinye Luo
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Hua Miu
- Medical School of Nantong University, Nantong University, Nantong, China
| | - Lei Qi
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
- *Correspondence: Lei Qi,
| | - Zhongwei Huang
- Department of Emergency Medicine, Affiliated Hospital of Nantong University, Nantong, China
- Medical School of Nantong University, Nantong University, Nantong, China
- Zhongwei Huang,
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20
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Immunomodulation by Hemoadsorption—Changes in Hepatic Biotransformation Capacity in Sepsis and Septic Shock: A Prospective Study. Biomedicines 2022; 10:biomedicines10102340. [PMID: 36289602 PMCID: PMC9598581 DOI: 10.3390/biomedicines10102340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/26/2022] Open
Abstract
Background: Sepsis is often associated with liver dysfunction, which is an indicator of poor outcomes. Specific diagnostic tools that detect hepatic dysfunction in its early stages are scarce. So far, the immune modulatory effects of hemoadsorption with CytoSorb® on liver function are unclear. Method: We assessed the hepatic function by using the dynamic LiMAx® test and biochemical parameters in 21 patients with sepsis or septic shock receiving CytoSorb® in a prospective, observational study. Points of measurement: T1: diagnosis of sepsis or septic shock; T2 and T3: 24 h and 48 h after the start of CytoSorb®; T4: 24 h after termination of CytoSorb®. Results: The hepatic biotransformation capacity measured by LiMAx® was severely impaired in up to 95 % of patients. Despite a rapid shock reversal under CytoSorb®, a significant improvement in LiMAx® values appeared from T3 to T4. This decline and recovery of liver function were not reflected by common parameters of hepatic metabolism that remained mostly within the normal range. Conclusions: Hepatic dysfunction can effectively and safely be diagnosed with LiMAx® in ventilated ICU patients under CytoSorb®. Various static liver parameters are of limited use since they do not adequately reflect hepatic dysfunction and impaired hepatic metabolism.
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21
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Sayaf K, Gabbia D, Russo FP, De Martin S. The Role of Sex in Acute and Chronic Liver Damage. Int J Mol Sci 2022; 23:ijms231810654. [PMID: 36142565 PMCID: PMC9505609 DOI: 10.3390/ijms231810654] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 09/07/2022] [Accepted: 09/09/2022] [Indexed: 11/16/2022] Open
Abstract
Acute and chronic hepatic damages are caused by xenobiotics or different diseases affecting the liver, characterized by different etiologies and pathological features. It has been demonstrated extensively that liver damage progresses differently in men and women, and some chronic liver diseases show a more favorable prognosis in women than in men. This review aims to update the most recent advances in the comprehension of the molecular basis of the sex difference observed in both acute and chronic liver damage. With this purpose, we report experimental studies on animal models and clinical observations investigating both acute liver failure, e.g., drug-induced liver injury (DILI), and chronic liver diseases, e.g., viral hepatitis, alcoholic liver disease (ALD), non-alcoholic fatty liver disease (NAFLD), autoimmune liver diseases, and hepatocellular carcinoma (HCC).
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Affiliation(s)
- Katia Sayaf
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35131 Padova, Italy
| | - Daniela Gabbia
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35131 Padova, Italy
| | - Francesco Paolo Russo
- Department of Surgery, Oncology and Gastroenterology, University of Padova, 35131 Padova, Italy
- Gastroenterology and Multivisceral Transplant Units, Azienda Ospedale—Università di Padova, 35131 Padova, Italy
- Correspondence:
| | - Sara De Martin
- Department of Pharmaceutical and Pharmacological Sciences, University of Padova, 35131 Padova, Italy
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22
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EBİK B, EKİN N, BACAKSIZ F, KILIC J. Kronik karaciğer hastalarında COVID-19; siroz hastaları için büyük tehlike. EGE TIP DERGISI 2022. [DOI: 10.19161/etd.1166881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aim: The aim of this study; to investigate the clinical course and mortality of COVID-19 in chronic liver patients with and without cirrhosis and to determine decompensation rates during COVID'19 in cirrhotic patients.
Materials and Methods: 96 patients with chronic liver disease (30 of them cirrhosis) and 153 patients without any comorbid disease were included in this study. It was examined whether there was a difference among these patient groups in terms of severity and mortality of COVID-19.
Results: Severe COVID-19 developed in 46.6% (14/30) cirrhotic patients, in 15.1% (10/66) non-cirrhotic patients, and in 12.4% (19/153) patients with no chronic liver disease (p
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Affiliation(s)
- Berat EBİK
- University of Health Sciences, Diyarbakır Gazi Yasargil Education and Research Hospital, Division of Gastroenterology, Diyarbakır, Turkiye
| | - Nazım EKİN
- University of Health Sciences, Diyarbakır Gazi Yasargil Education and Research Hospital, Division of Gastroenterology, Diyarbakır, Turkiye
| | - Ferhat BACAKSIZ
- University of Health Sciences, Diyarbakır Gazi Yasargil Education and Research Hospital, Division of Gastroenterology, Diyarbakır, Turkiye
| | - Jihat KILIC
- SBU Diyarbakır Gazi Yaşargil EAH, Internal Medicine Clinic, Diyarbakır, Turkiye
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23
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Li W, Huang R, Gong X, Zhao Z, Zhang L, Zhou Q, Jiang X, Tie H, Wan J, Wang B. Allicin attenuated hepatic ischemia/reperfusion injury in mice by regulating PPARγ-IRAK-M-TLR4 signal pathway. Food Funct 2022; 13:7361-7376. [PMID: 35730673 DOI: 10.1039/d2fo00751g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Hepatic ischemia/reperfusion (I/R) injury to the liver is a significant cause of morbidity and mortality following liver surgery, trauma, and hemorrhagic shock. It was reported that allicin, a type of garlic compound, had a protective effect against other hepatic diseases. Allicin's ability to protect against liver injury caused by ischemic reperfusion remains unknown. As a result, we conducted this study to determine allicin's effects and mechanism of action in hepatic I/R injury. Method: The liver I/R injury model was established by clamping the blood supply to the left and middle liver lobes. Three days prior to the hepatic I/R injury, different concentrations of allicin were gavaged. Then, hepatic function, histological changes, apoptosis markers, oxidative stress, and inflammatory cytokines were measured, and the molecular mechanisms were evaluated using western blot. Another separation experiment used IRAK-M knockout mice and peroxisome proliferator-activated receptor-gamma (PPARγ) inhibitor to deduce the molecular mechanisms. Results: Pretreatment with allicin prior to hepatic I/R injury reduced liver damage by inhibiting aminotransferase activity and alleviating liver injury. It significantly decreased cell apoptosis, interleukin-1β (IL-1β) and tumor necrosis factor-α (TNF-α) production, and hepatic oxidative stress. Furthermore, this study demonstrated that GW9662 (inhibitor of PPARγ) abrogated allicin's positive effect by inhibiting PPARγ expression while suppressing IRAK-M expression. Thus, the depletion of IRAK-M cannot influence the expression of PPARγ. The down-regulation of PPARγ-IRAK-M disabled the protection of allicin in I/R injury. Conclusion: Allicin protects against hepatic I/R injury via dose-dependent regulation of the PPARγ-IRAK-M-TLR4 signaling pathway, and it may be a potential drug in future clinical treatment.
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Affiliation(s)
- Weiwei Li
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Rui Huang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. .,Department of Anesthesiology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Zhejiang 310058, China
| | - Xia Gong
- Department of Anatomy, Chongqing Medical University, Chongqing 400016, China
| | - Zizuo Zhao
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Lidan Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
| | - Qin Zhou
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. .,Department of Anesthesiology, Army Medical Center of PLA, Army Medical University, Chongqing 400042, China
| | - Xujie Jiang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China. .,Department of Anesthesiology, Chengdu Fifth People's Hospital, Sichuan 611130, China
| | - Hongtao Tie
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Jingyuan Wan
- Key Laboratory of Biochemistry and Molecular Pharmacology, Chongqing Medical University, Chongqing 400016, China.
| | - Bin Wang
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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Jiao R, Liu M, Lu X, Zhu J, Sun L, Liu N. Development and Validation of a Prognostic Model to Predict the Risk of In-hospital Death in Patients With Acute Kidney Injury Undergoing Continuous Renal Replacement Therapy After Acute Type a Aortic Dissection. Front Cardiovasc Med 2022; 9:891038. [PMID: 35586649 PMCID: PMC9108198 DOI: 10.3389/fcvm.2022.891038] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to construct a model to predict the risk of in-hospital death in patients with acute renal injury (AKI) receiving continuous renal replacement therapy (CRRT) after acute type A aortic dissection (ATAAD) surgery. Methods We reviewed the data of patients with AKI undergoing CRRT after ATAAD surgery. The patients were divided into survival and nonsurvival groups based on their vital status at hospital discharge. The data were analyzed using univariate and multivariate logistic regression analyses. Establish a risk prediction model using a nomogram and its discriminative ability was validated using C statistic and the receiver operating characteristic (ROC) curve. Its calibration ability was tested using a calibration curve, 10-fold cross-validation and Hosmer–Lemeshow test. Results Among 175 patients, in-hospital death occurred in 61 (34.9%) patients. The following variables were incorporated in predicting in-hospital death: age > 65 years, lactic acid 12 h after CRRT, liver dysfunction, and permanent neurological dysfunction. The risk model revealed good discrimination (C statistic = 0.868, 95% CI: 0.806–0.930; a bootstrap-corrected C statistic of 0.859, the area under the ROC = 0.868). The calibration curve showed good consistency between predicted and actual probabilities (via 1,000 bootstrap samples, mean absolute error = 2.2%; Hosmer–Lemeshow test, P = 0.846). The 10-fold cross validation of the nomogram showed that the average misdiagnosis rate was 16.64%. Conclusion The proposed model could be used to predict the probability of in-hospital death in patients undergoing CRRT for AKI after ATAAD surgery. It had the potential to assist doctors to identify the gravity of the situation and make the targeted therapeutic measures.
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Affiliation(s)
- Rui Jiao
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Maomao Liu
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xuran Lu
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Junming Zhu
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lizhong Sun
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Aortic Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- *Correspondence: Lizhong Sun
| | - Nan Liu
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Nan Liu
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Dong L, Cheng Z, Liu F, Yu X, Han Z, Luo Y, Xu H, Chen R, Huang C, Yu J, Liang P. Dynamic changes in liver volume calculated using a three-dimensional visualization system after microwave ablation of hepatocellular carcinomas. Med Phys 2022; 49:4613-4621. [PMID: 35366342 DOI: 10.1002/mp.15641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 02/22/2022] [Accepted: 03/31/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES To investigate the changes in liver volume and function after microwave ablation (MWA) of hepatocellular carcinomas (HCCs). MATERIALS AND METHODS We retrospectively analyzed 76 patients with 106 nodules who underwent MWA for HCCs ≤5 cm between January 2015 and September 2017. Liver and ablation volumes were calculated using a three-dimensional visualization system on MRI. Multiple regression analysis was used to estimate the association between the ablation volume and liver volume changes. Deformable image registration (DIR) was performed to confirm the influence of liver volume changes on curative effect evaluation after ablation. RESULTS The initial liver and tumor volumes were 1262.1±259.91 cm3 (range: 864.9∼1966.8) and 2.5 cm3 (interquartile range [IQR]: 1.3∼8.8), respectively. Compared to the initial liver volumes, the entire live volume (ELV) increased by 10.1%±8.93% (range: -4.9%∼46.68%) on the 3rd day after ablation. Subsequently, it recovered to initial level at the 3rd month and maintained its level during the 1-year follow-up. The median total ablation volume was 34.9 cm3 (IQR: 20.4∼65.4) on the 3rd day after ablation, which decreased by 71.2% (IQR: 57.4%∼78.1%) one year after ablation. Alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (T-Bil) peaked within 3 days after MWA and recovered to normal within 1 month. The ablation volume proportion of the ELV was an independent risk factor for the increase in the ELV and AST, ALT, and T-Bil levels within 3 days after ablation. When DIR was conducted to fuse ablation zone and tumor, the reshaped tumor volumes were enlarged by 40% because of the increase in ELV. CONCLUSIONS MWA of HCCs based on the Milan criteria could induce temporary increases in ELV and RLV within 3 days after ablation, but both parameters recovered to initial levels 3 months after ablation. This indicates that MWA of early-stage HCCs would not lead to liver volume loss and could potentially protect liver function. The liver cannot be treated as an incompressible organ after ablation, and the appropriate deformation constraint should be designed for DIR to evaluate ablation margin accurately. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Linan Dong
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhigang Cheng
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Fangyi Liu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Xiaoling Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Zhiyu Han
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Yanchun Luo
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Hongli Xu
- Research Center of Medical Big Data, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Rendong Chen
- School of Mathematical Sciences, Zhejiang University, 38 Zheda Road, Hangzhou, Zhejiang, 310007, China
| | - Chongfei Huang
- School of Mathematical Sciences, Zhejiang University, 38 Zheda Road, Hangzhou, Zhejiang, 310007, China
| | - Jie Yu
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
| | - Ping Liang
- Department of Interventional Ultrasound, Chinese PLA General Hospital, 28 Fuxing Road, Beijing, 100853, China
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Jonsdottir S, Arnardottir MB, Andresson JA, Bjornsson HK, Lund SH, Bjornsson ES. Prevalence, clinical characteristics and outcomes of hypoxic hepatitis in critically ill patients. Scand J Gastroenterol 2022; 57:311-318. [PMID: 34846975 DOI: 10.1080/00365521.2021.2005136] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Hypoxic hepatitis (HH) is an important clinical entity in patients in the intensive care unit (ICU). The aims of the study were to assess the etiology, clinical characteristics and outcomes of HH in the ICU of a tertiary hospital. Secondary aim was to analyze the effects of concomitant ischemia in other organs than the liver. METHODS All patients with HH, 2011-2018, in a university hospital ICU were included. Data were collected on etiology, relevant clinical data and outcome. HH was defined by an increase in aminotransferases ≥10 times the upper limit of normal within 48 h from a clinical event of cardiac, circulatory or respiratory failure. Other causes of liver cell necrosis were excluded. RESULTS Of 9,931 patients hospitalized in the ICU, 159 (1.6%) fulfilled criteria for HH. In-hospital mortality occurred in 85 (53%) and 60 (38%) survived one year. Median ICU stay was five days (interquartile range (IQR) 3-10) and median hospital stay 16 days (IQR 7-32). Shock (48%), cardiac arrest (25%) and hypoxia (13%) were the most common causes of HH. Acute kidney injury (81%), rhabdomyolysis (50%), intestinal ischemia (6%) and ischemic pancreatitis (3%) occurred concomitantly. Age (odds ratio (OR) 1.05 (95% CI 1.02-1.09)), serum lactate (OR 2.61 (95% CI 1.23-5.50)) and lactate dehydrogenase (OR 1.14 (95% CI 1.02-1.27)) were predictors of mortality. CONCLUSIONS Hypoxic hepatitis was related to shock in approximately 50% of cases and associated with high in-hospital mortality. HH was commonly associated with ischemia in other organs. In-hospital mortality was associated with age, lactate and LD.
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Affiliation(s)
| | | | | | | | | | - Einar S Bjornsson
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland.,The National University Hospital of Iceland, Reykjavik, Iceland
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Dai L, Qiu J, Zhao R, Cao F, Qiu J, Wang D, Fan S, Xie E, Song J, Yu C. A Novel Sutureless Integrated Stented (SIS) Graft Prosthesis for Type A Aortic Dissection: A Pilot Study for a Prospective, Multicenter Clinical Trial. Front Cardiovasc Med 2022; 8:806104. [PMID: 35211519 PMCID: PMC8860904 DOI: 10.3389/fcvm.2021.806104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 12/06/2021] [Indexed: 11/21/2022] Open
Abstract
Aims Various kinds of surgical strategies and prostheses have been advocated to improve short-term and long-term outcomes in type A aortic dissection (TAAD). Large-scale repair of the pathological aorta is hard to generalize due to complex procedures. We aimed to investigate the performance, effectiveness and safety of a novel Sutureless Integrated Stented (SIS) graft prosthesis in TAAD patients undergoing total arch replacement (TAR) and frozen elephant trunk (FET) implantation surgery. Methods All patients admitted to Fuwai Hospital were prospectively screened. Urgent or scheduled surgery was arranged for eligible patients. The primary endpoint was operative mortality. Key secondary endpoints included stroke, spinal cord injury, unexpected aortic reoperation, and 1-year survival. Discharged patients were followed up with computed tomography angiography and transthoracic echocardiography at 3 months, 6 months, and 1 year after surgery. Performance, effectiveness and safety analyses were performed in those patients. Results Between August 1 and September 3, 2020, ten TAAD patients were enrolled in this study and successfully implanted with the SIS graft prosthesis. The median (IQR) age was 56.50 (43.75, 66.75) years (range from 31 to 75), and seven patients were male (70.0%). All patients underwent ascending aorta replacement + TAR + FET and additional procedures when necessary. The median (IQR) operation time, cardiopulmonary bypass time and cross clamp time were 270.50 (218.50, 312.50), 110.00 (88.00, 125.75), 69.50 (51.25, 82.75) min, respectively. Of note, the median (IQR) circulatory arrest time was 9.00 (8.00, 9.00) min (range from 4 to 12). The median (IQR) lowest nasopharyngeal temperature was 26.75 (25.98, 27.67) °C. Follow-up was 100% completed. During the 1-year follow-up, no patients died, no severe adverse events occurred, and rate of freedom from aortic reintervention was 100%. Conclusions The SIS graft prosthesis was implanted in a novel sutureless way, which simplified the surgical procedure, shortened the circulatory arrest time and avoided deep hypothermia. The preliminary clinical outcomes and follow-up outcomes demonstrated the effectiveness and safety of this prosthesis. A large-scale trial is being conducted to further assess these findings.
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Affiliation(s)
- Lu Dai
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jiawei Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Rui Zhao
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Fangfang Cao
- Adult Surgical Intensive Care Unit, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Juntao Qiu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - De Wang
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Shuya Fan
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Enzehua Xie
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Jian Song
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
| | - Cuntao Yu
- Department of Aortic Surgery, National Center for Cardiovascular Disease, Peking Union Medical College, Fuwai Hospital, Chinese Academy of Medical Sciences, Beijing, China
- *Correspondence: Cuntao Yu
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OUP accepted manuscript. Eur J Cardiothorac Surg 2022; 62:6575310. [DOI: 10.1093/ejcts/ezac128] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 01/31/2022] [Accepted: 02/23/2022] [Indexed: 11/13/2022] Open
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Kalas MA, Chavez L, Leon M, Taweesedt PT, Surani S. Abnormal liver enzymes: A review for clinicians. World J Hepatol 2021; 13:1688-1698. [PMID: 34904038 PMCID: PMC8637680 DOI: 10.4254/wjh.v13.i11.1688] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 07/24/2021] [Accepted: 08/23/2021] [Indexed: 02/06/2023] Open
Abstract
Liver biochemical tests are some of the most commonly ordered routine tests in the inpatient and outpatient setting, especially with the automatization of testing in this technological era. These tests include aminotransferases, alkaline phosphatase, gamma-glutamyl transferase, bilirubin, albumin, prothrombin time and international normalized ratio (INR). Abnormal liver biochemical tests can be categorized based on the pattern and the magnitude of aminotransferases elevation. Generally, abnormalities in aminotransferases can be classified into a hepatocellular pattern or cholestatic pattern and can be further sub-classified based on the magnitude of aminotransferase elevation to mild [< 5 × upper limit of normal (ULN)], moderate (> 5-< 15 × ULN) and severe (> 15 × ULN). Hepatocellular pattern causes include but are not limited to; non-alcoholic fatty liver disease/non-alcoholic steatohepatitis, alcohol use, chronic viral hepatitis, liver cirrhosis (variable), autoimmune hepatitis, hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, celiac disease, medication-induced and ischemic hepatitis. Cholestatic pattern causes include but is not limited to; biliary pathology (obstruction, autoimmune), other conditions with hyperbilirubinemia (conjugated and unconjugated). It is crucial to interpret these commonly ordered tests accurately as appropriate further workup, treatment and referral can greatly benefit the patient due to prompt treatment which can improve the natural history of several of the diseases mentioned and possibly reduce the risk of progression to the liver cirrhosis.
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Affiliation(s)
- M Ammar Kalas
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79905, United States
| | - Luis Chavez
- Department of Internal Medicine, Texas Tech University Health Science Center, El Paso, TX 79905, United States
| | - Monica Leon
- Department of General Surgery, University of Mexico, Ciudad de Mexico 01120, Mexico
| | - Pahnwat Tonya Taweesedt
- Department of Medicine, Corpus Christi Medical Center, Corpus Christi, TX 78412, United States
| | - Salim Surani
- Department of Medicine, Texas A&M University, College Station, TX 77843, United States
- Department of Anesthesiology, Mayo Clinic, Rochester, MN 55905, United States
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Liu M, Tan W, Yuan W, Wang T, Lu X, Liu N. Development and Validation of a Diagnostic Model to Predict the Risk of Ischemic Liver Injury After Stanford A Aortic Dissection Surgery. Front Cardiovasc Med 2021; 8:701537. [PMID: 34631813 PMCID: PMC8494972 DOI: 10.3389/fcvm.2021.701537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 08/23/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: To define the risk factors of ischemic liver injury (ILI) following Stanford A aortic dissection surgery and to propose a diagnostic model for individual risk prediction. Methods: We reviewed the clinical parameters of ILI patients who underwent cardiac surgery from Beijing Anzhen Hospital, Capital Medical University between January 1, 2015 and October 30, 2020. The data was analyzed by the use of univariable and multivariable logistic regression analysis. A risk prediction model was established and validated, which showed a favorable discriminating ability and might contribute to clinical decision-making for ILI after Stanford A aortic dissection (AAD) surgery. The discriminative ability and calibration of the diagnostic model to predict ILI were tested using C statistics, calibration plots, and clinical usefulness. Results: In total, 1,343 patients who underwent AAD surgery were included in the study. After univariable and multivariable logistic regression analysis, the following variables were incorporated in the prediction of ILI: pre-operative serum creatinine, pre-operative RBC count <3.31 T/L, aortic cross-clamp time >140 min, intraoperative lactic acid level, the transfusion of WRBC, atrial fibrillation within post-operative 24 h. The risk model was validated by internal sets. The model showed a robust discrimination, with an area under the receiver operating characteristic (ROC) curve of 0.718. The calibration plots for the probability of perioperative ischemic liver injury showed coherence between the predictive probability and the actual probability (Hosmer-Lemeshow test, P = 0.637). In the validation cohort, the nomogram still revealed good discrimination (C statistic = 0.727) and good calibration (Hosmer-Lemeshow test, P = 0.872). The 10-fold cross-validation of the nomogram showed that the average misdiagnosis rate was 9.95% and the lowest misdiagnosis rate was 9.81%. Conclusion: Our risk model can be used to predict the probability of ILI after AAD surgery and have the potential to assist clinicians in making treatment recommendations.
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Affiliation(s)
- Maomao Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen Tan
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wen Yuan
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Tengke Wang
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xuran Lu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nan Liu
- Center for Cardiac Intensive, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Okano H, Okado R, Ito H, Asakawa H, Nose K, Tsuruga S, Tochio T, Kumazawa H, Sakuno T, Isono Y, Tanaka H, Matsusaki S, Sase T, Saito T, Mukai K, Nishimura A. Ischemic hepatitis with infectious endocarditis: A case report. Biomed Rep 2021; 15:97. [PMID: 34631052 PMCID: PMC8493543 DOI: 10.3892/br.2021.1473] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/02/2021] [Indexed: 11/15/2022] Open
Abstract
A 58-year-old woman was admitted to Suzuka General Hospital with fever. She was diagnosed with infectious endocarditis based on the presence of anterior mitral leaflet vegetation on the echocardiography analysis and isolation of Pseudomonas guariconensis by blood culture. During treatment, the hepatic enzymes levels, including aspartate aminotransferase (AST), alanine aminotransferase (ALT), lactate dehydrogenase (LDH) and alkaline phosphatase (ALP) were increased without any abdominal symptoms. Prolonged prothrombin time (PT) and prothrombin time international normalized ratio were observed, and acute hepatic failure was diagnosed. However, the hepatic injury resolved spontaneously with restoration of the PT value after the hepatic enzymes (AST, ALT, LDH and ALP) peaked. Diffusion-weighted imaging of hepatic magnetic resonance imaging showed diffuse high intensity of the entire liver except for part of the left lobe. The hepatic injury was diagnosed as ischemic hepatitis caused by embolization from the vegetation associated with infectious endocarditis. The recovery from hepatic ischemia was thought to be due to hepatic blood supply from extrahepatic collateral blood. After antibiotic treatment, the patient underwent resection of the vegetation on the anterior mitral valve leaflet. Hepatic artery occlusion is rare, but it may cause severe hepatic complications. During follow-up of infectious endocarditis, clinicians should be aware of the potential for whole organ ischemic damage caused by vessel occlusion, as well as hepatic ischemic damage.
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Affiliation(s)
- Hiroshi Okano
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Ryo Okado
- Department of Cardiology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hisato Ito
- Department of Thoracic and Cardiovascular Surgery, School of Medicine, Mie University, Tsu, Mie 514-8507, Japan
| | - Hiroki Asakawa
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Kenji Nose
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Satomi Tsuruga
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomomasa Tochio
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hiroaki Kumazawa
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Takashi Sakuno
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Yoshiaki Isono
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Hiroki Tanaka
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Shimpei Matsusaki
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomohiro Sase
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Tomonori Saito
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Katsumi Mukai
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
| | - Akira Nishimura
- Department of Gastroenterology, Suzuka General Hospital, Suzuka, Mie 513-8630, Japan
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The Role of Hepatic Injury and Dysfunction in Pediatric Critical Care. J Pediatr Gastroenterol Nutr 2021; 73:428-429. [PMID: 34269329 DOI: 10.1097/mpg.0000000000003237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
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Secondary Hepatic Injury in Pediatric Intensive Care: Risk Factors and Prognostic Impact. J Pediatr Gastroenterol Nutr 2021; 73:471-477. [PMID: 34117196 DOI: 10.1097/mpg.0000000000003199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of this study was to assess the profile of secondary hepatic injury (SHI), to determine risk factors and to evaluate its impact on prognosis of pediatric intensive care patients. METHODS An exploratory observational and retrospective study was conducted in a Pediatric Intensive Care Unit. Two groups were defined: with SHI [alanine aminotransferase (ALT) ≥100 IU/L or gamma glutamyl transpeptidase (GGT)≥100 IU/L or direct bilirubin ≥30 μmol/L] and without. SHI was divided into 3 patterns: cytolysis, cholestasis, and mixed. RESULTS SHI occurred in 16.5%, cytolysis in 5%, cholestasis in 4%, and mixed pattern in 7%. Independent risk factors for SHI were: organ dysfunction score PELOD-2 in D1 in cytolysis (n = 28); total parenteral nutrition and Pediatric Index of Mortality 3 (PIM3) in cholestasis (n = 23); sepsis, oncologic comorbidities, PIM3, and respiratory dysfunction in mixed pattern (n = 37). The ALT was an independent risk factor and a good predictor of mortality (AUC = 0.865) with a cut-off of 137 IU/L. CONCLUSIONS SHI was associated with worst prognostic. ALT may be useful for detecting patients at increased risk of death, probably being a surrogate marker of the illness severity, reflecting a secondary injury.
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Rasmi Y, Babaei G, Nisar MF, Noreen H, Gholizadeh-Ghaleh Aziz S. Revealed pathophysiological mechanisms of crosslinking interaction of affected vital organs in COVID-19. COMPARATIVE CLINICAL PATHOLOGY 2021; 30:1005-1021. [PMID: 34539310 PMCID: PMC8432959 DOI: 10.1007/s00580-021-03269-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023]
Abstract
SARS-CoV-2 is one of the main serious challenges of human societies, which emerged in December 2019 from China and quickly extends to all parts of the world. The virus was previously believed to only affect the lungs and respiratory system, but subsequent research has revealed that it affects a variety of organs. For this reason, this disease is known as a multiorgan disease. Current article aimed to highlight latest information and updates about molecular studies regarding pathogenesis of SARS-CoV-2 in kidney, liver, and cardiovascular and respiratory systems, as well as the mechanisms of interaction of these organs with each other to cause clinical manifestations in patients.
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Affiliation(s)
- Yousef Rasmi
- Department of Clinical Biochemistry, Faculty of Medicine, Urmia Medical Sciences University (UMSU), Urmia, Iran
| | - Ghader Babaei
- Department of Clinical Biochemistry, Faculty of Medicine, Urmia Medical Sciences University (UMSU), Urmia, Iran
| | - Muhammad Farrukh Nisar
- Department of Physiology and Biochemistry, Cholistan University of Veterinary and Animal Sciences (CUVAS), Bahawalpur, 63100 Pakistan
| | - Hina Noreen
- Department of Physiology and Biochemistry, Cholistan University of Veterinary and Animal Sciences (CUVAS), Bahawalpur, 63100 Pakistan
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Bender JM, Worman HJ. Coronavirus Disease 2019 and Liver Injury: A Retrospective Analysis of Hospitalized Patients in New York City. J Clin Transl Hepatol 2021; 9:551-558. [PMID: 34447685 PMCID: PMC8369008 DOI: 10.14218/jcth.2020.00171] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 02/16/2021] [Accepted: 03/22/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND AIMS Coronavirus disease 2019 (COVID-19) is a global threat, affecting more than 100 million people and causing over 2 million deaths. Liver laboratory test abnormalities are an extrapulmonary manifestation of COVID-19, yet characterization of hepatic injury is incomplete. Our objective was to further characterize and identify causes of liver injury in patients with COVID-19. METHODS We conducted a retrospective cohort study of 551 patients hospitalized with COVID-19 at NewYork-Presbyterian Hospital/Columbia University Irving Medical Center between March 1, 2020 and May 31, 2020. We analyzed patient demographics, liver laboratory test results, vital signs, other relevant test results, and clinical outcomes (mortality and intensive care unit admission). RESULTS Abnormal liver laboratory tests were common on hospital admission for COVID-19 and the incidence increased during hospitalization. Of those with elevated serum alanine aminotransferase and/or alkaline phosphatase activities on admission, 58.2% had a cholestatic injury pattern, 35.2% mixed, and 6.6% hepatocellular. Comorbid liver disease was not associated with outcome; however, abnormal direct bilirubin or albumin on admission were associated with intensive care unit stay and mortality. On average, patients who died had greater magnitudes of abnormalities in all liver laboratory tests than those who survived. Ischemic hepatitis was a mechanism of severe hepatocellular injury in some patients. CONCLUSIONS Liver laboratory test abnormalities are common in hospitalized patients with COVID-19, and some are associated with increased odds of intensive care unit stay or death. Severe hepatocellular injury is likely attributable to secondary effects such as systemic inflammatory response syndrome, sepsis, and ischemic hepatitis.
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Affiliation(s)
- Joshua M. Bender
- Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
| | - Howard J. Worman
- Department of Medicine, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Department of Pathology and Cell Biology, Vagelos College of Physicians & Surgeons, Columbia University, New York, NY, USA
- Correspondence to: Howard J. Worman, Department of Medicine, Vagelos College of Physicians and Surgeons, Columbia University, New York, NY 10032, USA. ORCID: https://orcid.org/0000-0002-7063-7889. Tel: +1-212-305-1306, Fax: +1-212-342-5759, E-mail:
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36
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McCormick PA, Higgins M, McCormick CA, Nolan N, Docherty JR. Hepatic infarction, hematoma, and rupture in HELLP syndrome: support for a vasospastic hypothesis. J Matern Fetal Neonatal Med 2021; 35:7942-7947. [PMID: 34130599 DOI: 10.1080/14767058.2021.1939299] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Purpose: HELLP syndrome is a relatively uncommon pregnancy-related condition characterized by hemolysis, elevated liver function tests, and low platelets. It can be accompanied by life-threatening hepatic complications including hepatic infarction, hematoma formation, and hepatic rupture. HELLP syndrome occurs in approximately 0.2% of pregnancies. Major hepatic complications occur in less than 1% of HELLP patients suggesting an incidence of 1/50,000. The pathogenesis is incompletely understood and in particular, it is difficult to understand a disorder with both major thrombotic and bleeding manifestations.Methods: Literature review.Results: On the basis of reports in the published literature, and our own clinical experience, we suggest that vasospasm is one of the principal drivers with hepatic ischemia, infarction, and hemorrhage as secondary events. It is known that vasoactive substances are released by the failing placenta. We suggest these cause severe vasospasm, most likely affecting the small post-sinusoidal hepatic venules. This leads to patchy or confluent hepatic ischemia and/or necrosis with a resultant increase in circulating liver enzymes. Reperfusion is associated with a fall in platelet count and microvascular hemorrhage if the microvasculature is infarcted. Blood tracks to the subcapsular space causing hematoma formation. If the hematoma ruptures the patient presents with severe abdominal pain, intra-abdominal hemorrhage, and shock.Conclusions: We suggest that hepatic and other complications associated with HELLP syndrome including placental abruption, acute renal failure, and posterior reversible encephalopathy syndrome (PRES) may also be due to regional vasospasm.
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Affiliation(s)
- P A McCormick
- Liver Unit, St Vincent's University Hospital, Dublin, Ireland
| | - M Higgins
- University College Dublin Perinatal Research Centre, National Maternity Hospital, Dublin, Ireland
| | - C A McCormick
- Department of Obstetrics and Gynaecology, The Royal Women's Hospital, Melbourne, Australia
| | - N Nolan
- Histopathology Department, St Vincent's University Hospital, Dublin, Ireland
| | - J R Docherty
- Physiology Department, Royal College of Surgeons in Ireland, Dublin, Ireland
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37
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Di Giorgio A, Bartolini E, Calvo PL, Cananzi M, Cirillo F, Della Corte C, Dionisi-Vici C, Indolfi G, Iorio R, Maggiore G, Mandato C, Nebbia G, Nicastro E, Pinon M, Ranucci G, Sciveres M, Vajro P, D'Antiga L. Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group. Dig Liver Dis 2021; 53:545-557. [PMID: 33775575 DOI: 10.1016/j.dld.2021.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.
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Affiliation(s)
- A Di Giorgio
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy.
| | - E Bartolini
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - P L Calvo
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - F Cirillo
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - C Della Corte
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - G Indolfi
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - R Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - G Maggiore
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - G Nebbia
- Pediatric Liver Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Nicastro
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| | - M Pinon
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - G Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - M Sciveres
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - P Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
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Ghosh A, Onsager C, Mason A, Arriola L, Lee W, Mubayi A. The role of oxygen intake and liver enzyme on the dynamics of damaged hepatocytes: Implications to ischaemic liver injury via a mathematical model. PLoS One 2021; 16:e0230833. [PMID: 33886563 PMCID: PMC8061939 DOI: 10.1371/journal.pone.0230833] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 01/20/2021] [Indexed: 02/06/2023] Open
Abstract
Ischaemic Hepatitis (IH) or Hypoxic Hepatitis (HH) also known as centrilobular liver cell necrosis is an acute liver injury characterized by a rapid increase in serum aminotransferase. The liver injury typically results from different underlying medical conditions such as cardiac failure, respiratory failure and septic shock in which the liver becomes damaged due to deprivation of either blood or oxygen. IH is a potentially lethal condition that is often preventable if diagnosed timely. The role of mechanisms that cause IH is often not well understood, making it difficult to diagnose or accurately quantify the patterns of related biomarkers. In most patients, currently, the only way to determine a case of IH is to rule out all other possible conditions for liver injuries. A better understanding of the liver's response to IH is necessary to aid in its diagnosis, measurement, and improve outcomes. The goal of this study is to identify mechanisms that can alter associated biomarkers for reducing the density of damaged hepatocytes, and thus reduce the chances of IH. We develop a mathematical model capturing dynamics of hepatocytes in the liver through the rise and fall of associated liver enzymes aspartate transaminase (AST), alanine transaminase (ALT) and lactate dehydrogenase (LDH) related to the condition of IH. The model analysis provides a novel approach to predict the level of biomarkers given variations in the systemic oxygen in the body. Using IH patient data in the US, novel model parameters are described and then estimated for the first time to capture real-time dynamics of hepatocytes in the presence and absence of IH condition. The results may allow physicians to estimate the extent of liver damage in an IH patient based on their enzyme levels and receive faster treatment on a real-time basis.
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Affiliation(s)
- Aditi Ghosh
- Department of Mathematics, University of Wisconsin - Whitewater, Whitewater, WI, United States of America
- * E-mail:
| | - Claire Onsager
- Department of Mathematics, University of Wisconsin - Whitewater, Whitewater, WI, United States of America
| | - Andrew Mason
- Department of Mathematics, University of Wisconsin - Whitewater, Whitewater, WI, United States of America
| | - Leon Arriola
- Department of Mathematics, University of Wisconsin - Whitewater, Whitewater, WI, United States of America
| | - William Lee
- Department of Hepatology, University of Texas Southwestern Medical Center, Dallas, TX, United States of America
| | - Anuj Mubayi
- PRECESIONheor, Los Angeles, CA, United States of America
- Department of Mathematics, Illinois State State University, Normal, IL, United States of America
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Fortea JI, Puente Á, Cuadrado A, Huelin P, Pellón R, González Sánchez FJ, Mayorga M, Cagigal ML, García Carrera I, Cobreros M, Crespo J, Fábrega E. Congestive Hepatopathy. Int J Mol Sci 2020; 21:ijms21249420. [PMID: 33321947 PMCID: PMC7764741 DOI: 10.3390/ijms21249420] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 11/20/2020] [Accepted: 12/04/2020] [Indexed: 12/15/2022] Open
Abstract
Liver disease resulting from heart failure (HF) has generally been referred as “cardiac hepatopathy”. One of its main forms is congestive hepatopathy (CH), which results from passive venous congestion in the setting of chronic right-sided HF. The current spectrum of CH differs from earlier reports with HF, due to ischemic cardiomyopathy and congenital heart disease having surpassed rheumatic valvular disease. The chronic passive congestion leads to sinusoidal hypertension, centrilobular fibrosis, and ultimately, cirrhosis (“cardiac cirrhosis”) and hepatocellular carcinoma after several decades of ongoing injury. Contrary to primary liver diseases, in CH, inflammation seems to play no role in the progression of liver fibrosis, bridging fibrosis occurs between central veins to produce a “reversed lobulation” pattern and the performance of non-invasive diagnostic tests of liver fibrosis is poor. Although the clinical picture and prognosis is usually dominated by the underlying heart condition, the improved long-term survival of cardiac patients due to advances in medical and surgical treatments are responsible for the increased number of liver complications in this setting. Eventually, liver disease could become as clinically relevant as cardiac disease and further complicate its management.
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Affiliation(s)
- José Ignacio Fortea
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
- Correspondence: or ; Tel./Fax: +34-(94)-220-2520 (ext. 72929)
| | - Ángela Puente
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Antonio Cuadrado
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Patricia Huelin
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Raúl Pellón
- Radiology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (R.P.); (F.J.G.S.)
| | | | - Marta Mayorga
- Pathological Anatomy Service, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (M.M.); (M.L.C.)
| | - María Luisa Cagigal
- Pathological Anatomy Service, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (M.M.); (M.L.C.)
| | - Inés García Carrera
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
| | - Marina Cobreros
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
| | - Javier Crespo
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
| | - Emilio Fábrega
- Gastroenterology and Hepatology Department, University Hospital Marqués de Valdecilla, 39008 Santander, Spain; (Á.P.); (A.C.); (P.H.); (I.G.C.); (M.C.); (J.C.); (E.F.)
- Group of Clinical and Translational Research in Digestive Diseases, Health Research Institute Marqués de Valdecilla (IDIVAL), 39011 Santander, Spain
- Biomedical Research Networking Center in Hepatic and Digestive Diseases (CIBERehd), 28029 Madrid, Spain
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40
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Ji D, Zhang D, Yang T, Mu J, Zhao P, Xu J, Li C, Cheng G, Wang Y, Chen Z, Qin E, Lau G. Effect of COVID-19 on patients with compensated chronic liver diseases. Hepatol Int 2020; 14:701-710. [PMID: 32734407 PMCID: PMC7391917 DOI: 10.1007/s12072-020-10058-6] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIM Cytokine storm has been reported in patients with coronavirus disease 2019 (COVID-19) due to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. We examine the incidence of acute on chronic liver failure (ACLF) in COVID-19 patients with pre-existing compensated chronic liver disease (CLD). METHODS From 20 Jan 2020 to 7 Feb 2020, we studied 140 consecutive COVID-19 patients admitted to either Fuyang Second People's Hospital (FYSPH), Anhui or the Fifth Medical Center of Chinese PLA General Hospital (PLAGH) in Beijing, China. Pre-existing CLD includes those with liver cirrhosis assessed by APRI/FIB-4 score and /or ultrasound; NAFLD as identified by either ultrasound or hepatic steatosis index with significant liver fibrosis and chronic hepatitis B (CHB) or hepatitis C (CHC) infection. The diagnosis, grading of severity and clinical management of COVID-19 patients complied to the guideline and clinical protocol issued by the China National Health Commission. All patients had liver function test at least twice weekly till discharge with full recovery or death. RESULTS In total, 3 had liver cirrhosis, 6 patients had CHB, 13 had NAFLD with significant liver fibrosis (one also had CHB). On admission, none had liver decompensation. COVID-19 disease progression was significantly less frequent in non-CLD patients (10/118 8.5%) than CLD patients (13/22 59.1%, p < 0.001). One patient with CLD had acute-on-chronic liver failure (ACLF). CONCLUSION Disease progression is significantly higher in those COVID-19 patients with CLD as compared to those with no CLD. ACLF can also occur in patient with pre-existing compensated CLD who had severe COVID-19.
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Affiliation(s)
- Dong Ji
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Dawei Zhang
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Tieniu Yang
- Fuyang Hospital of Anhui Medical University, Anhui, 236000, China
| | - Jinsong Mu
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Peng Zhao
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Jing Xu
- Fuyang Second People's Hospital, Anhui, 236000, China
| | - Chen Li
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China
| | - Gregory Cheng
- Humanity and Health Clinical Trial Center, Humanity and Health Medical Group, Hong Kong SAR, China
| | - Yudong Wang
- Humanity and Health Clinical Trial Center, Humanity and Health Medical Group, Hong Kong SAR, China
| | - Zhu Chen
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China.
| | - Enqiang Qin
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China.
| | - George Lau
- The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, 100039, China.
- Humanity and Health Clinical Trial Center, Humanity and Health Medical Group, Hong Kong SAR, China.
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41
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Kasper P, Tacke F, Steffen HM, Michels G. [Hepatic dysfunction in sepsis]. Med Klin Intensivmed Notfmed 2020; 115:609-619. [PMID: 32725325 DOI: 10.1007/s00063-020-00707-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 04/27/2020] [Accepted: 05/22/2020] [Indexed: 01/05/2023]
Abstract
Sepsis represents a life-threatening condition that frequently accompanies acute hepatic dysfunction. As a result of systemic inflammation, immune dysregulation, and microcirculatory derangements, different types of liver dysfunction can occur, such as hypoxic hepatitis, sepsis-associated cholestasis, or liver failure. A very serious and late sequela is secondary sclerosing cholangitis of the critically ill patient. Clinical management of sepsis-related liver dysfunction includes the rapid identification and treatment of the suspected underlying infection, hemodynamic stabilization to improve hepatic perfusion, and the optimization of oxygen delivery to the liver. Despite maximum efforts in supportive treatment, the outcome of patients with sepsis or septic shock and concomitant severe hepatic dysfunction remains very poor.
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Affiliation(s)
- Philipp Kasper
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité Campus Mitte und Campus Virchow-Klinikum, Universitätsmedizin Berlin, Berlin, Deutschland
| | - Hans-Michael Steffen
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Köln, Kerpener Str. 62, 50937, Köln, Deutschland
| | - Guido Michels
- Klinik für Akut- und Notfallmedizin, St.-Antonius-Krankenhaus Eschweiler, Eschweiler, Deutschland
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42
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Abstract
Hospitalists often care for patients with liver disease, including those with acute liver injury and failure and patients with complications of decompensated cirrhosis. Acute liver failure is a true emergency, requiring intensive care and oftentimes transfer of the patient to a liver transplant center. Patients with decompensated cirrhosis have complications of portal hypertension, including variceal hemorrhage, ascites, spontaneous bacterial peritonitis, and hepatic encephalopathy. These complications increase the risk of mortality among patients with decompensated cirrhosis. Comanagement by the hospitalist with gastroenterology/hepatology can optimize care, especially for patients being considered for liver transplant evaluation.
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Affiliation(s)
- James F Crismale
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1109, New York, NY 10029, USA.
| | - Scott L Friedman
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1109, New York, NY 10029, USA
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43
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Maruyama H, Shiina S. Antioxidant therapy on ischemic hepatitis: here we are and where do we go? Hepatol Int 2020; 14:456-459. [PMID: 32347529 DOI: 10.1007/s12072-020-10044-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2020] [Accepted: 04/07/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Hitoshi Maruyama
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan.
| | - Shuichiro Shiina
- Department of Gastroenterology, Juntendo University, 2-1-1, Hongo, Bunkyo-ku, Tokyo, 113-8421, Japan
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44
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Schaefer EAK, Arvind A, Bloom PP, Chung RT. Interrelationship Between Coronavirus Infection and Liver Disease. Clin Liver Dis (Hoboken) 2020; 15:175-180. [PMID: 32489653 PMCID: PMC7242011 DOI: 10.1002/cld.967] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 05/07/2020] [Accepted: 05/08/2020] [Indexed: 02/06/2023] Open
Affiliation(s)
| | - Ashwini Arvind
- Liver Center and GI DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Patricia P. Bloom
- Liver Center and GI DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
| | - Raymond T. Chung
- Liver Center and GI DivisionMassachusetts General HospitalHarvard Medical SchoolBostonMA
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45
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Con D, Buckle A, Nicoll AJ, Lubel JS. Epidemiology and outcomes of marked elevations of alanine aminotransferase >1000 IU/L in an Australian cohort. JGH Open 2020; 4:106-112. [PMID: 32280751 PMCID: PMC7144769 DOI: 10.1002/jgh3.12224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/03/2019] [Accepted: 06/05/2019] [Indexed: 11/25/2022]
Abstract
Background and Aim Marked elevations of alanine aminotransferase (ALT) are caused by a limited number of underlying pathologies, including hepatic ischemia, drugs/toxins, viral hepatitis, and—rarely—autoimmune hepatitis. The aim of this study was to determine the relative incidence of pathologies resulting in ALT greater than 1000 IU/L and factors predicting clinical outcomes in an Australian cohort. Methods A retrospective cohort study of all adult patients with ALT levels greater than 1000 IU/L between January 2013 and December 2015 was conducted at a large teaching hospital network in Australia. Multivariable logistic regression analysis was used to determine predictors of etiology and mortality. Results There were 287 patients identified with ALT levels greater than 1000 IU/L. The most common causes were ischemia (44%), drugs/toxins (19%), biliary obstruction (16%), and viral hepatitis (7%). Independent predictors of a diagnosis of ischemic hepatitis included (adjusted odds ratio; 95% confidence interval): hypotension (29.2; 8.2–104.7), chronic obstructive pulmonary disease (COPD) (20.2; 2.8–145.3), coronary artery disease (12.9; 1.7–98.9), congestive cardiac failure (7.8; 1.2–49.2), diabetes mellitus (7.4; 1.6–33.9), metabolic acidosis (6.2; 2.0–19.4), gamma‐glutamyltransferase < 135 IU/L (5.1; 1.5–17.6), and albumin <34 g/L (3.4; 1.1–11.0). Independent risk factors for all‐cause 28‐day mortality included: septic shock (14.7; 4.3–50.7), metabolic acidosis (7.3; 2.5–21.3), history of COPD (5.4; 1.6–17.8), cardiogenic shock (4.3; 1.6–11.7), prothrombin time ≥ 20 s (3.7; 1.5–9.2), and age ≥ 65 years (3.0; 1.3–7.2). Conclusions Ischemic hepatitis was the most common cause of ALT levels greater than 1000 IU/L and was associated with high mortality.
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Affiliation(s)
- Danny Con
- Department of GastroenterologyEastern Health Melbourne Victoria Australia
| | - Andrew Buckle
- Department of GastroenterologyEastern Health Melbourne Victoria Australia
| | - Amanda J Nicoll
- Department of GastroenterologyEastern Health Melbourne Victoria Australia
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
| | - John S Lubel
- Eastern Health Clinical SchoolMonash University Melbourne Victoria Australia
- Central Clinical SchoolMonash University Melbourne Victoria Australia
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Lee F, Hutson JH, Boodhwani M, McDonald B, So D, De Roock S, Rubens F, Stadnick E, Ruel M, Le May M, Labinaz M, Chien K, Garuba HA, Mielniczuk LM, Chih S. Multidisciplinary Code Shock Team in Cardiogenic Shock: A Canadian Centre Experience. CJC Open 2020; 2:249-257. [PMID: 32695976 PMCID: PMC7365831 DOI: 10.1016/j.cjco.2020.03.009] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Accepted: 03/19/2020] [Indexed: 02/07/2023] Open
Abstract
Background Cardiogenic shock (CS) is associated with high mortality. We report on a “Shock Team” approach of combined interdisciplinary expertise for decision making, expedited assessment, and treatment. Methods We reviewed 100 patients admitted in CS over 52 months. Patients managed under a Code Shock Team protocol (n = 64, treatment) from 2016 to 2019 were compared with standard care (n = 36, control) from 2015 to 2016. The cohort was predominantly male (78% treatment, 67% control) with a median age of 55 years (interquartile range [IQR], 43-64) for treatment vs 64 years (IQR, 48-69) for control (P = 0.01). New heart failure was more common in the treatment group: 61% vs 36%, P = 0.02. Acute myocardial infarction comprised 13% of patients in CS. There were no significant differences between treatment and control in markers of clinical acuity, including median left ventricular ejection fraction (18% vs 20%), prevalence of moderate-severe right ventricular dysfunction (64% vs 56%), median peak serum lactate (5.3 vs 4.7 mmol/L), acute kidney injury (70% vs 75%), or acute liver injury (50% vs 31%). Inotropes, dialysis, and invasive ventilation were required in 92%, 33%, and 66% of patients, respectively. Temporary mechanical circulatory support was used in 45% of treatment and 28% of control patients (P = 0.08). There were no significant differences in median hospital length of stay (17.5 days), 30-day survival (71%), or survival to hospital discharge (66%). Over 240 days (IQR, 14,847) of median follow-up, survival was 67% for treatment vs 42% for control (hazard ratio, 0.53; 95% confidence interval, 0.28-0.99; P = 0.03). Conclusion A multidisciplinary Code Shock Team approach for CS is feasible and may be associated with improved long-term survival.
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Affiliation(s)
- Felicity Lee
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Jordan H Hutson
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Munir Boodhwani
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Bernard McDonald
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Derek So
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sophie De Roock
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Fraser Rubens
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Ellamae Stadnick
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Michel Le May
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Marino Labinaz
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Kevin Chien
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Habibat A Garuba
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Lisa M Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon Chih
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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Nagy Á, Holndonner-Kirst E, Eke C, Kertai MD, Fazekas L, Benke K, Pólos M, Szabolcs Z, Hartyánszky I, Gál J, Merkely B, Székely A. Model for end-stage liver disease scores in veno-arterial extracorporeal membrane oxygenation. Int J Artif Organs 2020; 43:684-691. [PMID: 32098569 DOI: 10.1177/0391398820906538] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION Veno-arterial extracorporeal membrane oxygenation is a valuable therapeutic approach in patients with severe heart failure due to different etiologies. Current prognosis with veno-arterial extracorporeal membrane oxygenation is unsatisfactory, and the risk stratification is still challenging. Therefore, we aimed to evaluate the predictive value of different baseline model for end-stage liver disease scores for survival in patients with veno-arterial extracorporeal membrane oxygenation. METHODS We conducted an observational, retrospective study of consecutive veno-arterial extracorporeal membrane oxygenation-treated patients between January 2012 and August 2018. The four types of model for end-stage liver disease scores-model for end-stage liver disease, international normalized ratio-excluded model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium-were calculated preoperatively. Veno-arterial extracorporeal membrane oxygenation was used based on the four clinical indications: primer graft failure after heart transplantation, weaning failure from cardiopulmonary bypass, acute myocardial infarction with refractory cardiogenic shock, and bridge to transplantation or bridge to candidacy. The primary endpoint of the study was overall mortality. The secondary endpoint was in-hospital mortality. We performed univariable and multivariable Cox regression analyses. RESULTS Data from 135 patients were analyzed. The median follow-up was 952 days (interquartile range = 417-1555 days). In-hospital mortality was 62.2%, and overall mortality was 71.1%. The multivariable Cox regression analysis is adjusted for indication, and the survival after veno-arterial extracorporeal membrane oxygenation score showed that the following scores were associated with overall mortality: model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01-1.07; p = 0.016), modified model for end-stage liver disease (hazard ratio = 1.04; 95% confidence interval = 1.01-1.06; p = 0.006), and model for end-stage liver disease with sodium (hazard ratio = 1.05; 95% confidence interval = 1.02-1.08; p = 0.001). CONCLUSION Model for end-stage liver disease, modified model for end-stage liver disease, and model for end-stage liver disease with sodium scores could be useful in the risk stratification of veno-arterial extracorporeal membrane oxygenation treatment in varying clinical indications.
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Affiliation(s)
- Ádám Nagy
- Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Enikő Holndonner-Kirst
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Csaba Eke
- Károly Rácz School of PhD Studies, Semmelweis University, Budapest, Hungary
| | - Miklós D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Levente Fazekas
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Kálmán Benke
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Miklós Pólos
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zoltán Szabolcs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | | | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
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Maiwall R, Kumar A, Bhadoria AS, Jindal A, Kumar G, Bhardwaj A, Maras JS, Sharma MK, Sharma BC, Sarin SK. Utility of N-acetylcysteine in ischemic hepatitis in cirrhotics with acute variceal bleed: a randomized controlled trial. Hepatol Int 2020; 14:577-586. [PMID: 32048131 DOI: 10.1007/s12072-020-10013-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Accepted: 01/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Ischemic hepatitis (IH) following acute variceal bleed (AVB) carries an ominous prognosis. N-Acetylcysteine (NAC), a potent anti-oxidant, may prevent IH by improving tissue oxygen delivery and improving hepatic hypoxia. METHODS Consecutive cirrhotics with AVB were prospectively randomized to receive either standard of care (SOC) plus NAC intravenously for 72 h(at 150 mg/kg/h for 1 h followed by 12.5 mg/kg/h for 4 h, followed by 6.25 mg/kg for 67 h) (Group A, n = 107) or SOC alone (Group B, n = 107). RESULTS Baseline characteristics were comparable. IH developed more frequently in Gr.B 25(23%) than A-15(14%); p = 0.08). Incidence of IH increased with severity of liver disease. Binary logistic regression analysis showed reduced incidence of IH in Gr.A than B [odds ratio (OR) 0.33, 0.11-0.93] patients after controlling for other significant factors. The incidence of acute kidney injury (AKI) was also reduced in Gr.A [OR 0.34, 0.15-0.75]. Development of IH was significantly associated with increased deaths due to liver failure at 6 weeks [subdistribution hazard ratio (SHR) 21.6, 7.4-62.8]. On multivariate competing risk analysis, significantly lower deaths due to liver failure (SHR 0.33, 0.11-0.97) were noted in Gr.A than B. CONCLUSIONS One in five patients with acute variceal bleed develops ischemic hepatitis which is associated with worse outcomes. NAC therapy averts deaths due to liver failure by preventing IH and reduces AKI and is, therefore, recommended for cirrhotics with acute variceal bleed. TRIAL REGISTRATION Clinicaltrials.gov no: NCT02015403.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
| | - Awinash Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
| | - Ajeet Singh Bhadoria
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
| | - Guresh Kumar
- Department of Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ankit Bhardwaj
- Department of Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
| | - Barjesh Chandra Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India.
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Andrade RJ, Robles-Díaz M. Diagnostic and prognostic assessment of suspected drug-induced liver injury in clinical practice. Liver Int 2020; 40:6-17. [PMID: 31578817 DOI: 10.1111/liv.14271] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 02/13/2023]
Abstract
Idiosyncratic drug-induced liver injury (DILI) is a challenging liver disorder because it can present with a range of phenotypes, mimicking almost every other hepatic disease, and lacks specific biomarkers for its diagnosis. Hence, a confident DILI diagnosis is seldom possible as it relies on the precise establishment of a temporal sequence between the exposure to a given prescription drug or sometimes hidden herbal product/over the counter medication as well as the exclusion of other aetiologies of liver disease. However, an accurate diagnosis is of most importance, as prompt withdrawal of the causative agent is essential in DILI management. Indeed, DILI can be severe and even fatal or in a fraction of cases evolve to chronic damage, but specific biomarkers for predicting mortality/liver transplantation or a chronic outcome in the very early phases of DILI are not yet available. In this article, we discuss the best diagnostic and prognostic approach of a DILI suspicion by judiciously choosing and interpreting the standard tests currently used in clinical practice.
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Affiliation(s)
- Raúl J Andrade
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Facultad de Medicina, Universidad de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Mercedes Robles-Díaz
- Unidad de Gestión Clínica de Aparato Digestivo, Instituto de Investigación Biomédica de Málaga-IBIMA, Hospital Universitario Virgen de la Victoria, Facultad de Medicina, Universidad de Málaga, Malaga, Spain.,Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
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50
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Abstract
Acute liver failure (ALF) is a rare syndrome resulting from an acute insult to the liver in patients without known underlying chronic liver disease. It is characterized by loss of synthetic function in the form of jaundice and coagulopathy and development of hepatic encephalopathy. Multiorgan failure (MOF) eventually develops, leading to death. Many different etiologies have been identified, with acetaminophen (APAP) overdose and viral hepatitis being the most common causes worldwide. The pathophysiology of ALF can be divided into cause-specific liver injury pathophysiologies and pathophysiology related to occurrence of secondary MOF. In terms of liver injury pathophysiology, APAP toxicity is the most well known. Secondary MOF is often a result of the initial massive proinflammatory response generating a systemic inflammatory response syndrome followed by a compensatory anti-inflammatory response leading to immune cell dysfunction and sepsis. As the liver is a tremendously important metabolic organ involved in energy metabolism, protein synthesis, fat metabolism, and glycemic control, multiple aspects of nutrition also need to be considered as part of the overall pathophysiology of ALF.
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Affiliation(s)
- Victor Dong
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada
| | - Rahul Nanchal
- Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin and the Medical Intensive Care Unit at Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada.,Department of Critical Care Medicine, University of Alberta, Edmonton, Canada
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