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Maiwall R, Kulkarni AV, Arab JP, Piano S. Acute liver failure. Lancet 2024; 404:789-802. [PMID: 39098320 DOI: 10.1016/s0140-6736(24)00693-7] [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] [Received: 09/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
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2
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Weiss N, Pflugrad H, Kandiah P. Altered Mental Status in the Solid-Organ Transplant Recipient. Semin Neurol 2024. [PMID: 39181120 DOI: 10.1055/s-0044-1789004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2024]
Abstract
Patients undergoing solid-organ transplantation (SOT) face a tumultuous journey. Prior to transplant, their medical course is characterized by organ dysfunction, diminished quality of life, and reliance on organ support, all of which are endured in hopes of reaching the haven of organ transplantation. Peritransplant altered mental status may indicate neurologic insults acquired during transplant and may have long-lasting consequences. Even years after transplant, these patients are at heightened risk for neurologic dysfunction from a myriad of metabolic, toxic, and infectious causes. This review provides a comprehensive examination of causes, diagnostic approaches, neuroimaging findings, and management strategies for altered mental status in SOT recipients. Given their complexity and the numerous etiologies for neurologic dysfunction, liver transplant patients are a chief focus in this review; however, we also review lesser-known contributors to neurological injury across various transplant types. From hepatic encephalopathy to cerebral edema, seizures, and infections, this review highlights the importance of recognizing and managing pre- and posttransplant neurological complications to optimize patient outcomes.
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Affiliation(s)
- Nicolas Weiss
- Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Neurological ICU, Paris, France
| | - Henning Pflugrad
- Department of Neurology, Agaplesion Ev. Klinikum Schaumburg, Obernkirchen, Germany
| | - Prem Kandiah
- Department of Neurology, Emory University Hospital, Atlanta, Georgia
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3
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Kabbani AR, Tergast TL, Manns MP, Maasoumy B. [Treatment strategies for acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2021; 116:3-16. [PMID: 31463674 PMCID: PMC7095250 DOI: 10.1007/s00063-019-00613-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 07/17/2019] [Accepted: 07/31/2019] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is a newly defined syndrome in patients with liver cirrhosis characterized by acute hepatic decompensation (jaundice, ascites, hepatic encephalopathy, bacterial infection and gastrointestinal bleeding), single or multiple organ failure and a high mortality (>15% within 28 days). The affected organ systems include not only the liver but also the circulation, lungs, kidneys, brain and/or coagulation. Pathophysiologically decisive is an uncontrolled inflammation that is induced by specific triggers and on the basis of previously (possibly not diagnosed) compensated as well as already decompensated liver cirrhosis leads to a severe systemic clinical syndrome, ACLF. The course during the first 72 h is decisive for the prognosis. In addition to treatment of the respective organ or system failure, the underlying triggers should be quickly identified and if necessary specifically treated. Often, however, these cannot (no longer) be determined with any certainty, in particular recent alcohol consumption as well as bacterial and viral infections play an important role. A specific treatment for the ACLF is (currently) not established. Some experimental approaches are currently being tested, including administration of granulocyte colony-stimulating factor (GCSF). Additionally, suitable patients should be presented to a liver transplantation center in a timely manner.
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Affiliation(s)
| | | | | | - B Maasoumy
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625, Hannover, Deutschland.
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4
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Rovegno M, Vera M, Ruiz A, Benítez C. Current concepts in acute liver failure. Ann Hepatol 2020; 18:543-552. [PMID: 31126880 DOI: 10.1016/j.aohep.2019.04.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 02/04/2023]
Abstract
Acute liver failure (ALF) is a severe condition secondary to a myriad of causes associated with poor outcomes. The prompt diagnosis and identification of the aetiology allow the administration of specific treatments plus supportive strategies and to define the overall prognosis, the probability of developing complications and the need for liver transplantation. Pivotal issues are adequate monitoring and the institution of prophylactic strategies to reduce the risk of complications, such as progressive liver failure, cerebral oedema, renal failure, coagulopathies or infections. In this article, we review the main aspects of ALF, including the definition, diagnosis and complications. Also, we describe the standard-of-care strategies and recent advances in the treatment of ALF. Finally, we include our experience of care patients with ALF.
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Affiliation(s)
- Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Alex Ruiz
- Unidad de Gastroenterología, Instituto de Medicina, Escuela de Medicina, Universidad Austral de Chile, Chile
| | - Carlos Benítez
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
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5
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Seetharam A. Intensive Care Management of Acute Liver Failure: Considerations While Awaiting Liver Transplantation. J Clin Transl Hepatol 2019; 7:384-391. [PMID: 31915608 PMCID: PMC6943205 DOI: 10.14218/jcth.2019.00032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 10/06/2019] [Accepted: 10/27/2019] [Indexed: 12/15/2022] Open
Abstract
Acute liver failure is a unique clinical phenomenon characterized by abrupt deterioration in liver function and altered mentation. The development of high-grade encephalopathy and multisystem organ dysfunction herald poor prognosis. Etiologic-specific treatments and supportive measures are routinely employed; however, liver transplantation remains the only chance for cure in those who do not spontaneously recover. The utility of artificial and bioartificial assist therapies as supportive care-to allow time for hepatic recovery or as a bridge to liver transplantation-has been examined but studies have been small, with mixed results. Given the severity of derangements, intensive critical care is needed to successfully bridge patients to transplant, and evaluation of candidates occurs rapidly in parallel with serial reassessments of operative fitness. Psychosocial assessment is often suboptimal and relative contraindications to transplant, such as ventilator-dependence may be overlooked. While often employed to guide evaluation, no single prognostic model discriminates those who will spontaneously recover and those who will require transplant. The purpose of this review will be to summarize approaches in critical care, prognostic modeling, and medical evaluation of the acute liver failure transplant candidate.
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Affiliation(s)
- Anil Seetharam
- Correspondence to: Anil Seetharam, Banner Transplant and Advanced Liver Disease, University of Arizona College of Medicine, 441 N. 12th Street, 2nd Floor, Phoenix, AZ 85006, USA. Tel: +1-602-521-5800; Fax: +1-602-521-5337, E-mail:
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6
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Sheikh MF, Unni N, Agarwal B. Neurological Monitoring in Acute Liver Failure. J Clin Exp Hepatol 2018; 8:441-447. [PMID: 30568346 PMCID: PMC6286879 DOI: 10.1016/j.jceh.2018.04.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 04/25/2018] [Indexed: 12/12/2022] Open
Abstract
Cerebral oedema and Intracranial Hypertension (ICH) are serious complications of acute liver failure affecting approximately 30% of patients, resulting in neurological injury or death. Multiple pathogenetic mechanisms contribute to the pathogenesis of HE including circulating neurotoxins such as ammonia, systemic and neuro-inflammation, infection and cerebral hyperaemia due to loss of cerebral vascular autoregulation. Early recognition and diagnosis is often difficult as clinical signs of elevated Intracranial Pressure (ICP) are not uniformly present and maybe masked by other organ support. ICP monitoring provides early diagnosis and monitoring of ICH, allowing targeted therapeutic interventions for prevention and treatment. ICP monitoring is the subject of much debate and there exists significant heterogeneity of clinical practice regarding its use. The procedure is associated with risks of haemorrhage but may be considered in highly selected patients such as those with highest risk for ICH awaiting transplant to allow for patient selection and optimisation. There is limited evidence that ICP monitoring confers a survival benefit which may explain why in the context of risk benefit analysis there is reduced utilisation in clinical practice. Less or non-invasive techniques of neurological monitoring such as measurement of jugular venous oxygen saturation to assess cerebral oxygen utilisation, and transcranial Doppler CNS to measure cerebral blood flow can provide important clinical information. They should be considered in combination as part of a multi-modal platform utilising specific roles of each system and incorporated within locally agreed algorithms. Other tools such as near-infrared spectrophotometry, optic nerve ultrasound and serum biomarkers of brain injury are being evaluated but are not used routinely in current practice.
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Affiliation(s)
- Mohammed F. Sheikh
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free Hospital, Rowland Hill Street, NW3 2PF London, UK
| | - Nazri Unni
- Intensive Care Unit, Royal Free Hospital, Rowland Hill Street, NW3 2PF London, UK
| | - Banwari Agarwal
- Liver Failure Group, UCL Institute for Liver and Digestive Health, Division of Medicine, UCL Medical School, Royal Free Hospital, Rowland Hill Street, NW3 2PF London, UK
- Intensive Care Unit, Royal Free Hospital, Rowland Hill Street, NW3 2PF London, UK
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7
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Montrief T, Koyfman A, Long B. Acute liver failure: A review for emergency physicians. Am J Emerg Med 2018; 37:329-337. [PMID: 30414744 DOI: 10.1016/j.ajem.2018.10.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Acute liver failure (ALF) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of ALF. DISCUSSION While ALF remains a rare clinical presentation, surveillance data suggest an overall incidence between 1 and 6 cases per million people every year, accounting for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the U.S. The definition of ALF includes neurologic dysfunction, an international normalized ratio ≥ 1.5, no prior evidence of liver disease, and a disease course of ≤26 weeks, and can be further divided into hyperacute, acute, and subacute presentations. There are many underlying etiologies, including acetaminophen toxicity, drug induced liver injury, and hepatitis. Emergency physicians will be faced with several complications, including encephalopathy, coagulopathy, infectious processes, renal injury, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the transplant team for appropriate patients improves patient outcomes. This review provides several guiding principles for management of acute complications. Using a pathophysiological-guided approach to the management of ALF associated complications is essential to optimizing patient care. CONCLUSIONS ALF remains a rare clinical presentation, but has significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with a transplantation center is imperative, as is identifying the underlying etiology and initiating symptomatic care.
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Affiliation(s)
- Tim Montrief
- University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Department of Emergency Medicine, 1611 N.W. 12th Avenue, Miami, FL 33136, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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8
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Jayakumar AR, Norenberg MD. Hyperammonemia in Hepatic Encephalopathy. J Clin Exp Hepatol 2018; 8:272-280. [PMID: 30302044 PMCID: PMC6175739 DOI: 10.1016/j.jceh.2018.06.007] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 06/10/2018] [Indexed: 12/12/2022] Open
Abstract
The precise mechanism underlying the neurotoxicity of Hepatic Encephalopathy (HE) is remains unclear. The dominant view has been that gut-derived nitrogenous toxins are not extracted by the diseased liver and thereby enter the brain. Among the various toxins proposed, the case for ammonia is most compelling. Events that lead to increased levels of blood or brain ammonia have been shown to worsen HE, whereas reducing blood ammonia levels alleviates HE. Clinical, pathological, and biochemical changes observed in HE can be reproduced by increasing blood or brain ammonia levels in experimental animals, while exposure of cultured astrocytes to ammonium salts reproduces the morphological and biochemical findings observed in HE. However, factors other than ammonia have recently been proposed to be involved in the development of HE, including cytokines and other blood and brain immune factors. Moreover, recent studies have questioned the critical role of ammonia in the pathogenesis of HE since blood ammonia levels do not always correlate with the level/severity of encephalopathy. This review summarizes the vital role of ammonia in the pathogenesis of HE in humans, as well as in experimental models of acute and chronic liver failure. It further emphasizes recent advances in the molecular mechanisms involved in the progression of neurological complications that occur in acute and chronic liver failure.
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Key Words
- AHE, Acute Hepatic Encephalopathy
- ALF, Acute Liver Failure
- CHE, Chronic Hepatic Encephalopathy
- CNS, Central Nervous System
- CSF, Cerebrospinal Fluid
- ECs, Endothelial Cells
- HE, Hepatic Encephalopathy
- IL, Interleukin
- LPS, Lipopolysaccharide
- MAPKs, Mitogen-Activated Protein Kinases
- NCX, Sodium-Calcium Exchanger
- NF-κB, Nuclear Factor-kappaB
- NHE, Sodium/Hydrogen Exchanger-1 or SLC9A1 (SoLute Carrier Family 9A1)
- SUR1, The Sulfonylurea Receptor 1
- TDP-43 and tau proteinopathies
- TDP-43, TAR DNA-Binding Protein, 43 kDa
- TLR, Toll-like Receptor
- TNF-α, Tumor Necrosis Factor-Alpha
- TSP-1, Thrombospondin-1
- ammonia
- hepatic encephalopathy
- inflammation
- matricellular proteins
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Affiliation(s)
- A R Jayakumar
- General Medical Research, Neuropathology Section, R&D Service, Veterans Affairs Medical Center, Miami, FL 33125, United States
- South Florida VA Foundation for Research and Education Inc., Veterans Affairs Medical Center, Miami, FL 33125, United States
| | - Michael D Norenberg
- Department of Pathology, University of Miami School of Medicine, Miami, FL 33125, United States
- Department of Biochemistry & Molecular Biology, University of Miami School of Medicine, Miami, FL 33125, United States
- Department of Neurology and Neurological Surgery, University of Miami School of Medicine, Miami, FL 33125, United States
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9
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Brain and the Liver: Cerebral Edema, Hepatic Encephalopathy and Beyond. HEPATIC CRITICAL CARE 2018. [PMCID: PMC7122599 DOI: 10.1007/978-3-319-66432-3_8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occurrence of brain dysfunction is common in both chronic liver disease as well as acute liver failure. While brain dysfunction most commonly manifests as hepatic encephalopathy is chronic liver disease; devastating complications of cerebral edema and brain herniation syndromes may occur with acute liver failure. Ammonia seems to play a central role in the pathogenesis of brain dysfunction in both chronic liver disease and acute liver failure. In this chapter we outline the pathophysiology and clinical management of brain dysfunction in the critically ill patients with liver disease.
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10
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Abstract
Hepatic encephalopathy occurs ubiquitously in all causes of advanced liver failure, however, its implications on mortality diverge and vary depending upon acuity and severity of liver failure. This associated mortality has decreased in subsets of liver failure over the last 20 years. Aside from liver transplantation, this improvement is not attributable to a single intervention but likely to a combination of practical advances in critical care management. Misconceptions surrounding many facets of hepatic encephalopathy exists due to heterogeneity in presentation, pathophysiology and outcome. This review is intended to highlight the important concepts, rationales and strategies for managing hepatic encephalopathy.
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Affiliation(s)
- Prem A Kandiah
- Division of Neuro Critical Care, Department of Neurosurgery, Co-appointment in Surgical Critical Care, Emory University Hospital, 1364 Clifton Road Northeast, 2nd Floor, 2D ICU-D264, Atlanta, GA 30322, USA.
| | - Gagan Kumar
- Department of Critical Care, Phoebe Putney Memorial Hospital, 417 Third Avenue, Albany, GA 31701, USA
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11
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Abstract
PURPOSE OF REVIEW The objective of this article is to review the latest developments related to the treatment of patients with acute liver failure (ALF). RECENT FINDINGS As the treatment of ALF has evolved, there is an increasing recognition regarding the risk of intracranial hypertension related to advanced hepatic encephalopathy. Therefore, there is an enhanced emphasis on neuromonitoring and therapies targeting intracranial hypertension. Also, new evidence implicates systemic proinflammatory cytokines as an etiology for the development of multiorgan system dysfunction in ALF; the recent finding of a survival benefit in ALF with high-volume plasmapheresis further supports this theory. SUMMARY Advances in the critical care management of ALF have translated to a substantial decrease in mortality related to this disease process. The extrapolation of therapies from general neurocritical care to the treatment of ALF-induced intracranial hypertension has resulted in improved neurologic outcomes. In addition, recognition of the systemic inflammatory response and multiorgan dysfunction in ALF has guided current treatment recommendations, and will provide avenues for future research endeavors. With respect to extracorporeal liver support systems, further randomized studies are required to assess their efficacy in ALF, with attention to nonsurvival end points such as bridging to liver transplantation.
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12
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Affiliation(s)
- Eelco F M Wijdicks
- From the Division of Critical Care Neurology, Mayo Clinic, Rochester, MN
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13
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Bernal W, Murphy N, Brown S, Whitehouse T, Bjerring PN, Hauerberg J, Frederiksen HJ, Auzinger G, Wendon J, Larsen FS. A multicentre randomized controlled trial of moderate hypothermia to prevent intracranial hypertension in acute liver failure. J Hepatol 2016; 65:273-9. [PMID: 26980000 DOI: 10.1016/j.jhep.2016.03.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 03/03/2016] [Accepted: 03/07/2016] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Animal models and human case series of acute liver failure (ALF) suggest moderate hypothermia (MH) to have protective effects against cerebral oedema (CO) development and intracranial hypertension (ICH). However, the optimum temperature for patient management is unknown. In a prospective randomized controlled trial we investigated if maintenance of MH prevented development of ICH in ALF patients at high risk of the complication. METHODS Patients with ALF, high-grade encephalopathy and intracranial pressure (ICP) monitoring in specialist intensive care units were randomized by sealed envelope to targeted temperature management (TTM) groups of 34°C (MH) or 36°C (control) for a period of 72h. Investigators were not blinded to group assignment. The primary outcome was a sustained elevation in ICP >25mmHg, with secondary outcomes the occurrence of predefined serious adverse effects, magnitude of ICP elevations and cerebral and all-cause hospital mortality (with or without transplantation). RESULTS Forty-six patients were randomized, of whom forty-three were studied. There was no significant difference between the TTM groups in the primary outcome during the study period (35% vs. 27%, p=0.56), for the MH (n=17) or control (n=26) groups respectively, relative risk 1.31 (95% CI 0.53-3.2). Groups had similar incidence of adverse events and overall mortality (41% vs. 46%, p=0.75). CONCLUSIONS In patients with ALF at high risk of ICH, MH at 33-34°C did not confer a benefit above management at 36°C in prevention of ICH or in overall survival. This study did not confirm advantage of its prophylactic use. (ISRCTN registration number 74268282; no funding.) LAY SUMMARY Studies in animals with acute liver failure (ALF) have suggested that cooling (hypothermia) could prevent or limit the development of brain swelling, a dangerous complication of the condition. There is limited data on its effects in humans. In a randomized controlled trial in severely ill patients with ALF we compared the effects of different temperatures and found no benefit on improving survival or preventing brain swelling by controlling temperature at 33-34°C against 36°C.
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Affiliation(s)
- William Bernal
- Liver Intensive Care Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Nicholas Murphy
- Department of Anaesthesia and Critical Care, University Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Sarah Brown
- Liver Intensive Care Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Tony Whitehouse
- Department of Anaesthesia and Critical Care, University Hospital Birmingham, Birmingham B15 2GW, United Kingdom
| | - Peter Nissen Bjerring
- Department of Hepatology, Rigshospitalet, University Hospital Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - John Hauerberg
- Department of Neurosurgery, Rigshospitalet, University Hospital Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Hans J Frederiksen
- Department of Anaesthesia, Rigshospitalet, University Hospital Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Georg Auzinger
- Liver Intensive Care Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Julia Wendon
- Liver Intensive Care Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom
| | - Fin Stolze Larsen
- Department of Hepatology, Rigshospitalet, University Hospital Copenhagen, Blegdamsvej 9, 2100 Copenhagen, Denmark
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Abstract
Acute liver failure is life threatening liver injury with coagulopathy and hepatic encephalopathy within 26 weeks and generally, in the absence of preexisting liver disease. Fulminant liver failure occurs when hepatic encephalopathy occurs within 8 weeks of jaundice. The majority of patients with ALF are women with the median age of 38 years. In the United States, drug induced liver injury including acetaminophen causes the majority of ALF cases. The etiology of ALF should be determined, if possible, because many causes have a specific treatment. The mainstay for ALF is supportive care and liver transplantation, if necessary. There are multiple prognostic criteria available. Prognosis can be poor and patients should be referred to a liver transplantation center as soon as possible.
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Affiliation(s)
- Carmi S Punzalan
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
| | - Curtis T Barry
- 1 Department of Medicine, Division of Gastroenterology, University of Massachusetts Memorial Medical Center, Worcester, MA, USA
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15
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Jones MC, Lasak-Myall T, Abdelhak TM, Varelas PN. Indomethacin for treatment of refractory intracranial hypertension secondary to acute liver failure. Am J Health Syst Pharm 2016; 72:1020-5. [PMID: 26025993 DOI: 10.2146/ajhp140539] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Successful use of i.v. indomethacin for urgent management of elevated intracranial pressure (ICP) due to acute liver failure is reported. SUMMARY A 42-year-old woman receiving intensive care for fulminant hepatic failure secondary to acetaminophen toxicity developed cerebral edema and intracranial hypertension refractory to standard pharmacotherapy and respiratory support measures. A computed tomography (CT) scan of the patient's head was ordered as part of an evaluation for liver transplantation, but the patient's severely elevated ICP precluded supine positioning for the CT study (throughout the hospital stay, the head of the patient's bed was kept at a 30° angle to optimize cerebral venous outflow). With administration of indomethacin 10 mg by i.v. injection, the ICP decreased from 29 to 13 mm Hg and remained at goal after the patient was placed in a fully supine position for a period long enough to permit the CT scan. Indomethacin was used a second time to facilitate CT imaging several days later. No adverse effects attributable to indomethacin use were documented. Although the patient underwent successful liver transplantation, her mental status and overall clinical status continued to deteriorate and she died on postoperative day 12. CONCLUSION Despite the poor overall patient outcome in this case, i.v. indomethacin was successfully used to decrease ICP in order to facilitate CT imaging as part of a transplantation eligibility workup.
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Affiliation(s)
- Mathew C Jones
- Mathew C. Jones, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Neurointensive Care, Department of Pharmacy, Henry Ford Hospital, Detroit, MI. Tracey Lasak-Myall, Pharm.D., BCPS, ATC, is Associate Medical Scientific Liaison, Allergan, Inc., Irvine, CA. Tamer M. Abdelhak, M.D., is Director of Neurocritical Care, Southern Illinois University School of Medicine, Springfield. Panayiotis N. Varelas, M.D., Ph.D., is Director, Neurosciences Intensive Care Unit, Henry Ford Hospital. At the time of writing, Drs. Lasak-Myall, Abdelhak, and Varelas worked at Henry Ford Hospital.
| | - Tracey Lasak-Myall
- Mathew C. Jones, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Neurointensive Care, Department of Pharmacy, Henry Ford Hospital, Detroit, MI. Tracey Lasak-Myall, Pharm.D., BCPS, ATC, is Associate Medical Scientific Liaison, Allergan, Inc., Irvine, CA. Tamer M. Abdelhak, M.D., is Director of Neurocritical Care, Southern Illinois University School of Medicine, Springfield. Panayiotis N. Varelas, M.D., Ph.D., is Director, Neurosciences Intensive Care Unit, Henry Ford Hospital. At the time of writing, Drs. Lasak-Myall, Abdelhak, and Varelas worked at Henry Ford Hospital
| | - Tamer M Abdelhak
- Mathew C. Jones, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Neurointensive Care, Department of Pharmacy, Henry Ford Hospital, Detroit, MI. Tracey Lasak-Myall, Pharm.D., BCPS, ATC, is Associate Medical Scientific Liaison, Allergan, Inc., Irvine, CA. Tamer M. Abdelhak, M.D., is Director of Neurocritical Care, Southern Illinois University School of Medicine, Springfield. Panayiotis N. Varelas, M.D., Ph.D., is Director, Neurosciences Intensive Care Unit, Henry Ford Hospital. At the time of writing, Drs. Lasak-Myall, Abdelhak, and Varelas worked at Henry Ford Hospital
| | - Panayiotis N Varelas
- Mathew C. Jones, Pharm.D., BCPS, is Clinical Pharmacy Specialist, Neurointensive Care, Department of Pharmacy, Henry Ford Hospital, Detroit, MI. Tracey Lasak-Myall, Pharm.D., BCPS, ATC, is Associate Medical Scientific Liaison, Allergan, Inc., Irvine, CA. Tamer M. Abdelhak, M.D., is Director of Neurocritical Care, Southern Illinois University School of Medicine, Springfield. Panayiotis N. Varelas, M.D., Ph.D., is Director, Neurosciences Intensive Care Unit, Henry Ford Hospital. At the time of writing, Drs. Lasak-Myall, Abdelhak, and Varelas worked at Henry Ford Hospital
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16
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Affiliation(s)
- William Bernal
- From the Liver Intensive Therapy Unit, Institute of Liver Studies, King's College London, London
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Cholongitas E, Theocharidou E, Vasianopoulou P, Betrosian A, Shaw S, Patch D, O'Beirne J, Agarwal B, Burroughs AK. Comparison of the sequential organ failure assessment score with the King's College Hospital criteria and the model for end-stage liver disease score for the prognosis of acetaminophen-induced acute liver failure. Liver Transpl 2012; 18:405-12. [PMID: 22213443 DOI: 10.1002/lt.23370] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Acetaminophen-induced acute liver failure (ALF) is a complex multiorgan illness. An assessment of the prognosis is essential for the accurate identification of patients for whom survival without liver transplantation (LT) is unlikely. The aims of this study were the comparison of prognostic models [King's College Hospital (KCH), Model for End-Stage Liver Disease, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II)] and the identification of independent prognostic indicators of outcome. We evaluated consecutive patients with severe acetaminophen-induced ALF who were admitted to the intensive care unit. At admission, demographic, clinical, and laboratory parameters were recorded. The discriminative ability of each prognostic score at the baseline was evaluated with the area under the receiver operating characteristic curve (AUC). In addition, using a multiple logistic regression, we assessed independent factors associated with outcome. In all, 125 consecutive patients with acetaminophen-induced ALF were evaluated: 67 patients (54%) survived with conservative medical management (group 1), and 58 patients (46%) either died without LT (28%) or underwent LT (18%; group 2). Group 1 patients had significantly lower median APACHE II (10 versus 14) and SOFA scores (9 versus 12) than group 2 patients (P < 0.001). The independent indicators associated with death or LT were a longer prothrombin time (P = 0.007), the inspiratory oxygen concentration (P = 0.005), and the lactate level at 12 hours (P < 0.001). The KCH criteria had the highest specificity (83%) but the lowest sensitivity (47%), and the SOFA score had the best discriminative ability (AUC = 0.79). In conclusion, for patients with acetaminophen-induced ALF, the SOFA score performed better than the other prognostic scores, and this reflected the presence of multiorgan dysfunction. A further evaluation of SOFA with the KCH criteria is warranted.
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Affiliation(s)
- Evangelos Cholongitas
- Fourth Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
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Voigt MD. Predicting death in patients with acetaminophen-induced acute liver failure: the King's College Hospital model is on the SOFA, not the mat. Liver Transpl 2012; 18:384-6. [PMID: 22253086 DOI: 10.1002/lt.23386] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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McPhail MJW, Bajaj JS, Thomas HC, Taylor-Robinson SD. Pathogenesis and diagnosis of hepatic encephalopathy. Expert Rev Gastroenterol Hepatol 2010; 4:365-78. [PMID: 20528123 DOI: 10.1586/egh.10.32] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Hepatic encephalopathy (HE) is a common and potentially devastating neuropsychiatric complication of acute liver failure and cirrhosis. Even in its mildest form, minimal HE (MHE), the syndrome significantly impacts daily living and heralds progression to overt HE. There is maturity in the scientific understanding of the cellular processes that lead to functional and structural abnormalities in astrocytes. Hyperammonemia and subsequent cell swelling is a key pathophysiological abnormality, but this aspect alone is insufficient to fully explain the complex neurotransmitter abnormalities that may be observable using sophisticated imaging techniques. Inflammatory cytokines, reactive oxygen species activation and the role of neurosteroids on neurotransmitter binding sites are emerging pathological lines of inquiry that have yielded important new information on the processes underlying HE and offer promise of future therapeutic targets. Overt HE remains a clinical diagnosis and the neurophysiological and imaging modalities used in research studies have not transferred successfully to the clinical situation. MHE is best characterized by psychometric evaluation, but these tests can be lengthy to perform and require specific expertise to interpret. Simpler computer-based tests are now available and perhaps offer an opportunity to screen, diagnose and monitor MHE in a clinical scenario, although large-scale studies comparing the different techniques have not been undertaken. There is a discrepancy between the depth of understanding of the pathophysiology of HE and the translation of this understanding to a simple, easily understood diagnostic and longitudinal marker of disease. This is a present area of focus for the management of HE.
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Affiliation(s)
- Mark J W McPhail
- Hepatology Section, Department of Medicine, 10th Floor QEQM Wing, St Mary's Hospital Campus, Imperial College London, South Wharf Street, London W2 1NY, UK
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