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Ravindranath A, Srivastava A, Yachha SK, Poddar U, Sarma MS, Mathias A. Prevalence and Precipitants of Hepatic Encephalopathy in Hospitalized Children With Chronic Liver Disease. J Clin Exp Hepatol 2024; 14:101452. [PMID: 39005950 PMCID: PMC11245966 DOI: 10.1016/j.jceh.2024.101452] [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: 01/10/2024] [Accepted: 05/25/2024] [Indexed: 07/16/2024] Open
Abstract
Objective Hepatic encephalopathy (HE) is a marker of poor prognosis in adults with chronic liver disease (CLD). We prospectively studied the prevalence and precipitants of HE in children with CLD as there is a paucity of literature on the same. Methods Children (1-18 years) admitted with CLD were examined daily for the presence and grading of HE (West Haven/Whittington grading). Precipitants were classified as infection, dyselectrolytemia, gastrointestinal bleeding, constipation and dehydration. Changes in grades of HE and outcome were noted. Results One hundred and sixty children (age 120 [84-168] months) were enrolled. HE was present in 50 (31.2%) patients with a total of 61 episodes. Maximum grade of HE was grade I (n = 16), II (n = 23), III (n = 11) and IV (n = 11). Forty-two cases had single and 8 had recurrent (2-5) episodes. Median duration of HE episodes was 96 (72-192) hours. Precipitants were identified in 55/61 (90.2%) episodes with infection (45/61, 73.7%) and dyselectrolytemia (33/61, 54%) being the most common. Lower albumin and sodium, higher INR and presence of infection were significantly associated with presence of HE. Overall, HE resolved in 33 (54%) episodes, while it progressed and persisted in 28 (45.9%) episodes. Patients with HE had a poorer outcome (25/50 vs 13/110; P < 0.01) with both higher in-hospital (11/50 vs 9/110; P = 0.02) and 1-month post discharge (14/39 vs 4/101; P < 0.01) mortality than those without HE. Conclusion One-third of admitted CLD children have HE, with identifiable precipitants in 90% of cases. Children with HE have poorer liver functions, higher rate of infections and worse outcome than those without HE.
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Affiliation(s)
- Aathira Ravindranath
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Surender K Yachha
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Moinak S Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Amrita Mathias
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
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Shi S, Zhang M, Chen X, Wang Z, Ding S, Chen Z, Yang Y, Zheng S. Liver transplantation for hepatitis B virus-related cirrhosis with acute-on-chronic liver failure and grade 3-4 hepatic encephalopathy: Survival and quality of life. Chin Med J (Engl) 2024; 137:2119-2121. [PMID: 38630917 PMCID: PMC11374271 DOI: 10.1097/cm9.0000000000003037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Indexed: 04/19/2024] Open
Affiliation(s)
- Shaohua Shi
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Minghui Zhang
- Department of General Surgery, The Sixth People's Hospital of Zhengzhou City, Zhengzhou, Henan 450015, China
| | - Xuliang Chen
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Zhuoyi Wang
- Department of Intensive Care Unit, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Songming Ding
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Zhitao Chen
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Yu Yang
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
| | - Shusen Zheng
- Department of Hepatobiliary and Pancreatic Surgery, Shulan (Hangzhou) Hospital Affiliated to Zhejiang Shuren University Shulan International Medical College, Hangzhou, Zhejiang 310003, China
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Kalo E, Read S, Baig A, Marshall K, Ma WS, Crowther H, Gofton C, Lynch KD, Sood S, Holmes J, Lubel J, Wigg A, McCaughan G, Roberts SK, Caraceni P, Ahlenstiel G, Majumdar A. Efficacy of albumin use in decompensated cirrhosis and real-world adoption in Australia. JGH Open 2024; 8:e70029. [PMID: 39301299 PMCID: PMC11410680 DOI: 10.1002/jgh3.70029] [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] [Received: 05/01/2024] [Revised: 08/26/2024] [Accepted: 09/03/2024] [Indexed: 09/22/2024]
Abstract
The current treatment approach to patients with liver cirrhosis relies on the individual management of complications. Consequently, there is an unmet need for an overall therapeutic strategy for primary and secondary prevention of complications. The clinical potential of long-term albumin infusions supported by recent clinical trials has expanded its indications and holds promise to transform the management and secondary prevention of cirrhosis-related complications. This renewed interest in albumin comes with inherent controversies, compounding challenges and pressing need for rigorous evaluation of its clinical potential to capitalize on its therapeutic breakthroughs. Australia is among a few countries worldwide to adopt outpatient human albumin infusion. Here, we summarize currently available evidence of the potential benefits of human albumin for the management of multiple liver cirrhosis-related complications and discuss key challenges for wide application of long-term albumin administration strategy in Australian clinical practice. Australian Gastroenterological week (AGW), organised by the Gastroenterological Society of Australia (GESA), was held between 9-11 September 2022. A panel of hepatologists, advanced liver nurses and one haematologist, were invited to a roundtable meeting to discuss the use of long-term albumin infusions for liver cirrhosis. management in Australia. In this review, we summarise the proceedings of this meeting in context of the current literature.
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Affiliation(s)
- Eric Kalo
- Blacktown Clinical School and Research Centre, School of Medicine Western Sydney University Blacktown New South Wales Australia
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
| | - Scott Read
- Blacktown Clinical School and Research Centre, School of Medicine Western Sydney University Blacktown New South Wales Australia
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
- Storr Liver Centre, The Westmead Institute for Medical Research University of Sydney Westmead New South Wales Australia
| | - Asma Baig
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
| | - Kate Marshall
- Royal Prince Alfred Hospital Sydney New South Wales Australia
| | - Wai-See Ma
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
| | - Helen Crowther
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
| | - Cameron Gofton
- Storr Liver Centre, The Westmead Institute for Medical Research University of Sydney Westmead New South Wales Australia
- Department of Gastroenterology and Hepatology Royal North Shore Hospital St Leonards New South Wales Australia
| | - Kate D Lynch
- Department of Gastroenterology and Hepatology Royal Adelaide Hospital, Central Adelaide Local Health Network Adelaide South Australia Australia
- Faculty of Health and Medical Sciences University of Adelaide Adelaide South Australia Australia
| | - Siddharth Sood
- Department of Gastroenterology Northern Health Melbourne Victoria Australia
- Department of Medicine The University of Melbourne Parkville Victoria Australia
| | - Jacinta Holmes
- Department of Medicine The University of Melbourne Parkville Victoria Australia
- Department of Gastroenterology St Vincent's Hospital Fitzroy Victoria Australia
| | - John Lubel
- Department of Gastroenterology Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Alan Wigg
- Hepatology and Liver Transplant Medicine Unit Southern Adelaide Local Health Network Adelaide South Australia Australia
- Flinders University of South Australia Adelaide South Australia Australia
| | - Geoff McCaughan
- A.W. Morrow Gastroenterology and Liver Centre Centenary Research Institute for Cancer Research and Cell Biology Camperdown New South Wales Australia
- Australian National Liver Transplant Unit Royal Prince Alfred Hospital Sydney New South Wales Australia
- Faculty of Medicine and Health University of Sydney Sydney New South Wales Australia
| | - Stuart K Roberts
- Department of Gastroenterology Alfred Health Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Paolo Caraceni
- Unit of Semeiotics, Liver and Alcohol-Related Diseases IRCCS Azienda-Ospedaliera Universitaria di Bologna, EMR Bologna Italy
- Department of Medical and Surgical Sciences University of Bologna, EMR Bologna Italy
| | - Golo Ahlenstiel
- Blacktown Clinical School and Research Centre, School of Medicine Western Sydney University Blacktown New South Wales Australia
- Blacktown Hospital, Western Sydney Local Health District Blacktown New South Wales Australia
- Storr Liver Centre, The Westmead Institute for Medical Research University of Sydney Westmead New South Wales Australia
| | - Avik Majumdar
- Department of Medicine The University of Melbourne Parkville Victoria Australia
- Victorian Liver transplant Unit Austin Health Heidelberg Victoria Australia
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Ntuli Y, Shawcross DL. Infection, inflammation and hepatic encephalopathy from a clinical perspective. Metab Brain Dis 2024:10.1007/s11011-024-01402-y. [PMID: 39212845 DOI: 10.1007/s11011-024-01402-y] [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: 04/11/2024] [Accepted: 07/23/2024] [Indexed: 09/04/2024]
Abstract
Hepatic encephalopathy (HE) is a syndrome that is associated with both acute and chronic liver injury. It manifests as a wide spectrum of neuropsychological abnormalities, ranging from subtle impairments in executive higher functions observed in cirrhosis, through to coma in acute liver failure. In acute liver failure, the central role of ammonia in the development of brain oedema has remained undisputed for 130 years. It latterly became apparent that infection and inflammation were profound determinants for the development of severe hepatic encephalopathy, associated with the development of cerebral oedema and intracranial hypertension. The relationship of the development of hepatic encephalopathy with blood ammonia levels in cirrhosis is less clear cut and the synergistic interplay of inflammation and infection with ammonia has been identified as being fundamental in the development and progression of hepatic encephalopathy. A perturbed gut microbiome and the presence of an impaired gut epithelial barrier that facilitates translocation of bacteria and bacterial degradation products into the systemic circulation, inducing systemic inflammation and innate and adaptive immune dysfunction, has now become the focus of therapies that treat hepatic encephalopathy in cirrhosis, and may explain why the prebiotic lactulose and rifaximin are efficacious. This review summarises the current clinical perspective on the roles of inflammation and infection in hepatic encephalopathy and presents the evidence base for existing therapies and those in development in the setting of acute and chronic liver failure.
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Affiliation(s)
- Yevedzo Ntuli
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, 125 Coldharbour Lane, London, SE5 9NU, UK
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, SE5 9RS, UK
| | - Debbie L Shawcross
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, 125 Coldharbour Lane, London, SE5 9NU, UK.
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, SE5 9RS, UK.
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Shi K, Bi Y, Wang X, Li Y, Zeng X, Feng Y, Wang X. Prognostic Value of High-Density Lipoprotein Cholesterol in Patients with Overt Hepatic Encephalopathy. Biomedicines 2024; 12:1783. [PMID: 39200247 PMCID: PMC11351328 DOI: 10.3390/biomedicines12081783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2024] [Revised: 07/26/2024] [Accepted: 08/05/2024] [Indexed: 09/02/2024] Open
Abstract
Overt hepatic encephalopathy (OHE), a serious complication of liver cirrhosis, is associated with alterations in lipid and lipoprotein metabolism. We evaluated the correlation between high-density lipoprotein cholesterol (HDL-C) levels and transplant-free (TF) mortality in patients with OHE. Patients with OHE admitted to Beijing Ditan Hospital between January 2010 and August 2016 (n = 821) and between September 2016 and December 2020 (n = 480) were included in the training and validation sets, respectively. Independent predictors were explored by a multivariate Cox regression analysis, and the area under the receiver operating characteristic curve (AUC) was used to assess the prognostic value of these factors. The prognostic value of HDL-C was good (AUC at 1 year: 0.745) and was equivalent to that of the Model for End-Stage Liver Disease (MELD) score (AUC at 1 year: 0.788). The optimal threshold values for HDL-C and MELD were 0.5 mmol/L and 17, respectively. The 1-year TF mortality rates in the low-risk (HDL-C ≥ 0.5 mmol/L and MELD < 17) and high-risk (HDL-C < 0.5 mmol/L and MELD ≥ 17) groups were 7.5% and 51.5% in the training set and 10.1% and 48.2% in the validation set, respectively. HDL-C level < 0.5 mmol/L and MELD score > 17 can facilitate the identification of high-risk patients and provide a basis for timely treatment.
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Affiliation(s)
| | | | | | | | | | - Ying Feng
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China; (K.S.); (Y.B.); (X.W.); (Y.L.); (X.Z.)
| | - Xianbo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing 100015, China; (K.S.); (Y.B.); (X.W.); (Y.L.); (X.Z.)
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Murtaza F, Mathew M, Fagbamila O, Subramani S, Nimal S, Nyshita VN, Priya V, Sany AT, Kumar Y, Cicani L, Ehsan M, Kandel K. Efficacy and safety of albumin for the treatment of hepatic encephalopathy: an updated systematic review and meta-analysis of randomized controlled trials. Ann Med Surg (Lond) 2024; 86:3416-3422. [PMID: 38846811 PMCID: PMC11152777 DOI: 10.1097/ms9.0000000000002039] [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: 10/14/2023] [Accepted: 03/30/2024] [Indexed: 06/09/2024] Open
Abstract
Background Albumin acts as a scavenger of reactive oxygen species and an inhibitor of inflammatory processes that underlie hepatic encephalopathy (HE). However, the role of albumin in hepatic encephalopathy is not well-established. The authors performed this meta-analysis to evaluate the efficacy and safety of albumin in the management of hepatic encephalopathy. Methods The authors carried out an extensive search across multiple databases, including MEDLINE (via PubMed), Embase, CENTRAL, and various trial registries, to identify randomized controlled trials (RCTs) evaluating the impact of albumin administration in HE. The authors used a random-effects model for analyses and presented dichotomous outcomes and continuous outcomes as relative risk and mean difference, along with corresponding 95% CIs, respectively. Heterogeneity was assessed using both the I2 index and χ2 test. Results Our meta-analysis included 4 RCTs involving 306 patients. Our primary outcomes, mortality, and persistence of HE were reported by all four studies. Albumin was found to significantly decrease mortality in patients with HE [risk ratio (RR) 0.52, 95% CI 0.32-0.83; I2 =0%]. Persistence of HE was found to be comparable between the two groups (RR 0.83, 95% CI 0.68-1.00; I2 =24%). There was no significant difference between the albumin and control groups regarding length of hospital stay (MD -1.55, 95% CI -3.5 to 0.14; I2 =41%), adverse events (RR 1.00, 95% CI 0.87-1.16; I2 =0%), and severe adverse events (RR 0.89, 95% CI 0.59-1.35). Conclusion Albumin administration in patients with hepatic encephalopathy decreases mortality but does not significantly impact the persistence of HE. Further high-quality, large-scale randomized controlled trials are needed to provide conclusive evidence.
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Affiliation(s)
| | - Midhun Mathew
- Department of Medicine, Pennsylvania Hospital, Philadelphia, PA
| | | | - Sachin Subramani
- Department of Medicine, ESIC Medical College and Hospital, Gulbarga
| | - Simran Nimal
- Department of Medicine, BJ Medical College, Pune
| | | | - Vishnu Priya
- Department of Medicine, Government Kilpauk Medical College, Chennai, India
| | - Abu Talha Sany
- Department of Medicine, Brahmanbaria Medical College & Hospital, Brahmanbaria, Bangladesh
| | - Yamanth Kumar
- Department of Medicine, Government Kilpauk Medical College, Chennai, India
| | - Laura Cicani
- Department of Medicine, International University of Health Sciences, Las Vegas, NV
| | - Muhammad Ehsan
- Department of Medicine, King Edward Medical University, Lahore, Pakistan
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Twohig PA, Peeraphatdit TB, Samson K, Schissel M, Smith L, Ashford A, Freese L, McCashland T. A Prospective Multimodal Education Intervention for Providers Does Not Increase Hepatic Encephalopathy Treatment Rates. Dig Dis Sci 2024; 69:1996-2007. [PMID: 38652390 DOI: 10.1007/s10620-024-08445-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 04/09/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Over 50% of hospitalizations from hepatic encephalopathy (HE) are preventable, but patients often do not receive medical treatment. AIMS To use a multimodal education intervention (MMEI) to increase HE treatment rates and to evaluate (1) trends in HE treatment, (2) predictors of receiving treatment, and (3) the impact of treatment on hospitalization outcomes. METHODS Prospective single-center cohort study of patients hospitalized with HE from April 1, 2020-September 30, 2022. The first 15 months were a control ("pre-MMEI"), the subsequent 15 months (MMEI) included three phases: (1) prior authorization resources, (2) electronic order set, and (3) in-person provider education. Treatment included receiving any drug (lactulose or rifaximin), or combination therapy. Treatment rates pre- vs. post-MMEI were compared using logistic regression. RESULTS 471 patients were included. There were lower odds of receiving any drug post-MMEI (p = 0.03). There was no difference in receiving combination therapy pre- or post-MMEI (p = 0.32). Predictors of receiving any drug included alcohol-related or cryptogenic cirrhosis (p's < 0.001), and the presence of ascites (p = 0.005) and/or portal hypertension (p = 0.003). The only significant predictor of not receiving any drug treatment was having autoimmune cirrhosis (p < 0.001). Patients seen by internal medicine (p = 0.01) or who were intoxicated (p = 0.02) were less likely to receive rifaximin. Any treatment was associated with higher 30-day liver disease-specific readmission (p < 0.001). CONCLUSION This MMEI did not increase HE treatment rates, suggesting that alternative strategies are needed to identify and address barriers to treatment.
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Affiliation(s)
- Patrick A Twohig
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA.
| | - Thoetchai Bee Peeraphatdit
- Division of Gastroenterology & Hepatology, University of Nebraska Medical Center, 982000 Medical Center Drive, Omaha, NE, 68198-2000, USA
| | - Kaeli Samson
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Makayla Schissel
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Lynette Smith
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Allison Ashford
- Departments of Internal Medicine & Hospital Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Laura Freese
- Departments of Internal Medicine & Hospital Medicine, University of Nebraska Medical Center, Omaha, NE, 68198, USA
| | - Timothy McCashland
- Department of Biostatistics, University of Nebraska Medical Center, 984375 Nebraska Medical Center, Omaha, NE, 68198, USA
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Erminelli D, Mangini C, Zarantonello L, Angeli P, Montagnese S. Overt Hepatic Encephalopathy: More Than Meets the Eye. Am J Gastroenterol 2024; 119:00000434-990000000-01105. [PMID: 38587287 PMCID: PMC11365597 DOI: 10.14309/ajg.0000000000002795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 03/13/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION We aimed to assess the reliability of a qualitative approach to overt hepatic encephalopathy (OHE) diagnosis compared with the semiquantitative, and recommended one. METHODS The above 2 methods were compared in 411 outpatients (71% males, 60 ± 10 years, model for end-stage liver disease 13.5 ± 5.0). RESULTS Of the 73 patients with OHE on quantitative assessment, 19 (26%) were missed on qualitative assessment, with no difference in the likelihood of the physician missing grades II or III. Sixty-eight (20%) of the 270 patients with no OHE on quantitative assessment were wrongly qualified as having OHE. DISCUSSION Qualitative clinical evaluation of OHE is not reliable, and recommendations should be followed.
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Affiliation(s)
| | - Chiara Mangini
- Department of Medicine, University of Padova, Padova, Italy
| | | | - Paolo Angeli
- Department of Medicine, University of Padova, Padova, Italy
| | - Sara Montagnese
- Department of Medicine, University of Padova, Padova, Italy
- Chronobiology Section, Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
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Louissaint J, Vargas HE. Picture Perfect: Artificial Intelligence in the Management of Hepatic Encephalopathy. Am J Gastroenterol 2024; 119:801-802. [PMID: 38363066 DOI: 10.14309/ajg.0000000000002659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Accepted: 01/11/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Jeremy Louissaint
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Hugo E Vargas
- Division of Gastroenterology and Hepatology, Transplant Center, Mayo Clinic Arizona, Phoenix, Arizona, USA
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Alukal JJ, Li F, Thuluvath PJ. Older Patients With Acute on Chronic Liver Failure Have a Higher Waitlist Mortality, but Acceptable Post Liver Transplantation Survival When Compared to Younger Patients. Clin Gastroenterol Hepatol 2024; 22:1014-1023.e6. [PMID: 38072285 DOI: 10.1016/j.cgh.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND & AIMS There is a paucity of studies on older patients (≥65 years) who develop acute on chronic liver failure (ACLF). The objectives of our study were to determine clinical characteristics and outcomes of older patients listed for liver transplantation (LT). METHODS Adults listed for LT with estimated ACLF (Est-ACLF) between 2005 and 2021 were identified using the United Network for Organ Sharing database and subdivided into older and younger age (18-64 years) groups. Kaplan-Meier survival analyses were used to evaluate survival, and a competing-risk model (Fine-Gray) was used to evaluate risk factors for survival on the waitlist. Logistic regression was done to evaluate risk factors. RESULTS A total of 4313 older (14%) and 26,628 younger (86%) patients were listed for LT, and 2142 (49.6%) and 16,931 (63.5%) were transplanted, respectively. Older patients had a higher 30-day waitlist mortality than younger patients (20.4% vs 16.7%; P < .0001); this was more pronounced in Est-ACLF-2 (23.7% vs 14.8%; P < .0001) and Est-ACLF-3 (43.3% vs 29.9%; P < .0001). One-year post-LT, patient survival in older patients with Est-ACLF grades 1, 2, and 3 were 86.4%, 85.5%, and 77% respectively; younger patients had better survival across all Est-ACLF grades. When adjusted for transplant eras, respiratory failure was the only independent risk factor for increased 1-year post-LT mortality in older patients. CONCLUSION Older patients with Est-CLF had significantly higher waitlist mortality than younger patients, but had acceptable 1-year post-LT survival including those with Est-ACLF-3; therefore, age alone should not be considered as a contraindication for LT. Older patients with respiratory failure should be carefully selected for LT.
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Affiliation(s)
- Joseph J Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland; Department of Medicine, University of California Riverside School of Medicine, Riverside, California
| | - Feng Li
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland; Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
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Mendez-Guerrero O, Carranza-Carrasco A, Chi-Cervera LA, Torre A, Navarro-Alvarez N. Optimizing nutrition in hepatic cirrhosis: A comprehensive assessment and care approach. World J Gastroenterol 2024; 30:1313-1328. [PMID: 38596498 PMCID: PMC11000076 DOI: 10.3748/wjg.v30.i10.1313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 02/25/2024] [Indexed: 03/14/2024] Open
Abstract
Cirrhosis is considered a growing cause of morbidity and mortality, which represents a significant public health problem. Currently, there is no effective treatment to reverse cirrhosis. Treatment primarily centers on addressing the underlying liver condition, monitoring, and managing portal hypertension-related complications, and evaluating the potential for liver transplantation in cases of decompensated cirrhosis, marked by rapid progression and the emergence of complications like variceal bleeding, hepatic encephalopathy, ascites, malnutrition, and more. Malnutrition, a prevalent complication across all disease stages, is often underdiagnosed in cirrhosis due to the complexities of nutritional assessment in patients with fluid retention and/or obesity, despite its crucial impact on prognosis. Increasing emphasis has been placed on the collaboration of nutritionists within hepatology and Liver transplant teams to deliver comprehensive care, a practice that has shown to improve outcomes. This review covers appropriate screening and assessment methods for evaluating the nutritional status of this population, diagnostic approaches for malnutrition, and context-specific nutrition treatments. It also discusses evidence-based recommendations for supplementation and physical exercise, both essential elements of the standard care provided to cirrhotic patients.
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Affiliation(s)
- Osvely Mendez-Guerrero
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Anaisa Carranza-Carrasco
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Luis Alberto Chi-Cervera
- Clínica de Especialidades Gastrointestinales y Hepáticas, Hospital Star Medica, Merida 97133, Yucatan, Mexico
| | - Aldo Torre
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Molecular Biology, Universidad Panamericana School of Medicine, Campus México, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
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Wang M, Yang X, Liu D, Dang P, Huang X, Zheng J, Ding F, Ding X, Wang X. Altered brain iron deposition in patients with minimal hepatic encephalopathy: an MRI quantitative susceptibility mapping study. Clin Radiol 2024; 79:e369-e375. [PMID: 38071103 DOI: 10.1016/j.crad.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 10/08/2023] [Accepted: 11/06/2023] [Indexed: 02/15/2024]
Abstract
AIM To explore the use of quantitative susceptibility mapping (QSM) in assessing changes in brain iron deposits and their association with cognitive function in patients with minimal hepatic encephalopathy (MHE). MATERIALS AND METHODS The study cohort comprised 27 cases with hepatitis B-associated cirrhosis with MHE (MHE group), 25 with hepatitis B-associated cirrhosis without MHE (NMHE group), and 25 healthy controls (HC group). Iron deposits in the bilateral frontal white matter, caudate nucleus (CN), putamen, globus pallidus, thalamus, red nucleus, substantia nigra (SN), hippocampus, and dentate nucleus were measured by QSM. The associations between iron deposition with the time taken to complete number connection tests A (NCT-A) and the score on digital-symbol test (DST) were analysed. RESULTS Susceptibility values differed significantly in the bilateral CN, left thalamus, right SN, and left hippocampus in the MHE group compared with the other groups and were positively associated with the times taken to complete the NCT-A in the bilateral CN, left thalamus, and right SN and negatively associated with DST scores in the bilateral CN, left TH, and left HP. CONCLUSION Reduced cognitive function in MHE patients was significantly associated with abnormally increased iron deposition in certain brain areas. The quantification of brain iron deposition by QSM may thus be an objective and accurate means of evaluating MHE.
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Affiliation(s)
- M Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - X Yang
- School of Clinical Medicine, Ningxia Medical University, Yinchuan 750004, China
| | - D Liu
- Department of Traditional Chinese Medicine Orthopedics and Traumatology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - P Dang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - X Huang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - J Zheng
- School of Clinical Medicine, Ningxia Medical University, Yinchuan 750004, China
| | - F Ding
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - X Ding
- Department of Infectious Diseases, General Hospital of Ningxia Medical University, Yinchuan 750004, China
| | - X Wang
- Department of Radiology, General Hospital of Ningxia Medical University, Yinchuan 750004, China.
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Ozturk NB, Jamil LH, Tapper EB. Diagnostic Performance of the ICD-10 Code K76.82 for Hepatic Encephalopathy in Patients With Cirrhosis. Am J Gastroenterol 2024; 119:364-366. [PMID: 37830544 DOI: 10.14309/ajg.0000000000002560] [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: 07/25/2023] [Accepted: 10/02/2023] [Indexed: 10/14/2023]
Abstract
INTRODUCTION Hepatic encephalopathy (HE) is prevalent and is associated with increased morbidity and mortality among patients with cirrhosis. On October 1, 2022, a new, specific International Classification of Diseases-10 code for HE, K76.82, was introduced. We aimed to analyze the diagnostic accuracy of K76.82. METHODS Diagnostic performance of K76.82 for HE (sensitivity, specificity, positive predictive ratio, and negative predictive ratio) was evaluated in 2 large health systems compared with lactulose, rifaximin, and K72.90. RESULTS A total of 2,483 patients were analyzed. The combination term "lactulose or rifaximin" showed the highest sensitivity of >98% while K76.82 demonstrated a specificity of >87% in all cohorts. DISCUSSION Although K76.82 is promising, the combination term "lactulose or rifaximin" identified patients with HE more accurately.
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Affiliation(s)
- Nazli Begum Ozturk
- Department of Internal Medicine, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan, USA
| | - Laith H Jamil
- Division of Gastroenterology and Hepatology, Corewell Health William Beaumont University Hospital, Royal Oak, Michigan, USA
- Oakland University William Beaumont School of Medicine, Rochester, Michigan, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
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14
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Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J Clin Med 2024; 13:506. [PMID: 38256640 PMCID: PMC10816826 DOI: 10.3390/jcm13020506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/07/2024] [Accepted: 01/14/2024] [Indexed: 01/24/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) refers to the deterioration of liver function in individuals who already have chronic liver disease. In the setting of ACLF, liver damage leads to the failure of other organs and is associated with increased short-term mortality. Optimal medical management of patients with ACLF requires implementing complex treatment strategies, often in an intensive care unit (ICU). Failure of organs other than the liver distinguishes ACLF from other critical illnesses. Although there is growing evidence supporting the current approach to ACLF management, the mortality associated with this condition remains unacceptably high. In this review, we discuss considerations for ICU care of patients with ACLF and highlight areas for further research.
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Affiliation(s)
- Fuat H. Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dimitri A. Raptis
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Saad A. Alghamdi
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Massimo M. Malagó
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dieter C. Broering
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh 12111, Saudi Arabia; (D.A.R.); (S.A.A.); (M.M.M.); (D.C.B.)
| | - Dmitri Bezinover
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA;
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15
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Torre A, Cisneros-Garza LE, Castillo-Barradas M, Navarro-Alvarez N, Sandoval-Salas R, González-Huezo MS, Pérez-Hernández JL, Méndez-Guerrero O, Ruiz-Manríquez JA, Trejo-Estrada R, Chavez-Tapia NC, Solís-Gasca LC, Moctezuma-Velázquez C, Aguirre-Valádez J, Flores-Calderón J, Higuera-de-la-Tijera F, García-Juárez I, Canedo-Castillo NA, Malé-Velázquez R, Montalvo-Gordon I, Vilatobá M, Márquez-Guillén E, Córdova-Gallardo J, Flores-García NC, Miranda-Zazueta G, Martínez-Saldívar BI, Páez-Zayas VM, Muñoz-Espinosa LE, Solís-Galindo FA. Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology. Ann Hepatol 2023; 28:101140. [PMID: 37482299 DOI: 10.1016/j.aohep.2023.101140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/26/2023] [Accepted: 05/31/2023] [Indexed: 07/25/2023]
Abstract
Acute-on chronic liver failure (ACLF) has been an intensively debated topic mainly due to the lack of a unified definition and diagnostic criteria. The growing number of publications describing the mechanisms of ACLF development, the progression of the disease, outcomes and treatment has contributed to a better understanding of the disease, however, it has also sparked the debate about this condition. As an attempt to provide medical professionals with a more uniform definition that could be applied to our population, the first Mexican consensus was performed by a panel of experts in the area of hepatology in Mexico. We used the most relevant and impactful publications along with the clinical and research experience of the consensus participants. The consensus was led by 4 coordinators who provided the most relevant bibliography by doing an exhaustive search on the topic. The entire bibliography was made available to the members of the consensus for consultation at any time during the process and six working groups were formed to develop the following sections: 1.- Generalities, definitions, and criteria, 2.- Pathophysiology of cirrhosis, 3.- Genetics in ACLF, 4.- Clinical manifestations, 5.- Liver transplantation in ACLF, 6.- Other treatments.
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Affiliation(s)
- Aldo Torre
- Metabolic Unit, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
| | - Laura Esthela Cisneros-Garza
- Gastroenterology and Hepatology Department, Hospital Christus Muguerza Alta Especialidad, Monterrey, Nuevo León, Mexico
| | | | - Nalu Navarro-Alvarez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Osvely Méndez-Guerrero
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | | | - Luis Carlos Solís-Gasca
- Gastroenterology Department, Hospital General de Zona #12 Benito Juárez del Instituto Mexicano del Seguro Social, Mérida, Yucatán, Mexico
| | - Carlos Moctezuma-Velázquez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Department of Medicine - Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | | | - Judith Flores-Calderón
- Pediatrics Department, Hospital de Pediatría, Centro Médico Nacional Siglo XXI, Mexico City, Mexico
| | | | - Ignacio García-Juárez
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Iaarah Montalvo-Gordon
- Clinic of Gastrointestinal and Hepatic Specialties, Hospital Faro del Mayab, Mérida, Yucatán, Mexico
| | - Mario Vilatobá
- Transplant Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Ernesto Márquez-Guillén
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico; Hospital Ángeles del Pedregal, Mexico City, Mexico
| | - Jacqueline Córdova-Gallardo
- Hepatology Department - General Surgery Service, Hospital General Dr. Manuel Gea González, Mexico City, Mexico
| | - Nayeli Cointa Flores-García
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Godolfino Miranda-Zazueta
- Gastroenterology Department, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | | | | | - Linda Elsa Muñoz-Espinosa
- Universidad Autónoma de Nuevo León. Liver Unit, Department of Internal Medicine, University Hospital 'Dr. José E. González', Monterrey, Nuevo León, Mexico
| | - Francisco Alfonso Solís-Galindo
- Gastroenterology Department, Unidad Médica de Alta Especialidad # 71 Instituto Mexicano del Seguro Social, Torreón, Coahuila, Mexico
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16
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Bloom PP, Tapper EB. Lactulose in cirrhosis: Current understanding of efficacy, mechanism, and practical considerations. Hepatol Commun 2023; 7:e0295. [PMID: 37820287 PMCID: PMC10578757 DOI: 10.1097/hc9.0000000000000295] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 09/04/2023] [Indexed: 10/13/2023] Open
Abstract
HE is a complication of cirrhosis characterized by neuropsychiatric and motor dysfunction, and results in decreased quality of life and increased mortality. Lactulose is a synthetic disaccharide used to treat HE since 1966, though many questions about its use remain unanswered. Lactulose reverses minimal HE, prevents overt HE, improves quality of life, increases the rate of recovery from overt HE, and improves survival rates. Lactulose's clinical effect appears to be derived from its impact on intestinal microbes, likely a result of its enteric acidifying effect, positive pressure on beneficial taxa, and improvement of gut barrier function. There are several practical considerations with lactulose including (1) a need to avoid excessive bowel movements and subsequent dehydration, (2) treatment titration protocols need further investigation, (3) baseline or treatment-induced gastrointestinal side effects limit adherence in some cases, and (4) the utility of monitoring stool consistency or pH remains unknown. Further research is needed to optimize our use of this effective treatment for HE.
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17
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Kulkarni AV, Vora M, Ramagundam R, Sharma M, Reddy DN, Rao P. Thyroxine Levels Predict the Development of Brain Failure in Patients With Cirrhosis in Indian Population. GASTRO HEP ADVANCES 2023; 3:55-57. [PMID: 39132184 PMCID: PMC11307603 DOI: 10.1016/j.gastha.2023.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 09/12/2023] [Indexed: 08/13/2024]
Affiliation(s)
| | - Moiz Vora
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | | | - P.N. Rao
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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18
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Gao J, Nie R, Chang H, Yang W, Ren Q. A meta-analysis of microbiome therapies for hepatic encephalopathy. Eur J Gastroenterol Hepatol 2023; 35:927-937. [PMID: 37505972 DOI: 10.1097/meg.0000000000002596] [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: 07/30/2023]
Abstract
Microbiome therapies may be reported to be effective in hepatic encephalopathy (HE). We thus did a meta-analysis of randomized controlled trials to assess the effect of microbiome therapies for HE. We systematically searched PubMed, Web of Science, EMBASE, and Cochrane Library for randomized controlled trials that compared the different treatments for HE including probiotics, symbiotics, and fecal microbiota transplant (FMT). Meta-analysis was performed to calculate pooled odds ratios (ORs) with corresponding 95% confidence intervals (CIs). Twenty-one studies met our inclusion criteria (N = 1746 participants). Probiotics, synbiotics and FMT significantly reversed minimal HE (MHE) (OR: 0.41, 95% CI: 0.19-0.90, P = 0.03), reduced overt HE (OHE) development (OR, 0.41; 95% CI: 0.28-0.61 P < 0.00001)and the frequency of serious adverse events(SAEs) (OR:0.14, 95% CI: 0.04-0.47, P = 0.001), meanwhile decreased ammonia levels (WMD: -9.26, 95% CI: -16.92 to -1.61; P = 0.02), NCT level (MD = -4.41, 95% CI: -0.87 to -0.22, P = 0.04) and hospitalization rates (OR, 0.38; 95% CI: 0.19-0.79, P = 0.009) compared with placebo/no treatment. Finally, we conclude that microbiome therapies were more effective in improving MHE and preventing progression to OHE, reducing the frequency of SAEs, and decreasing ammonia levels, NCT level, and hospitalization rates when compared to placebo/no treatment.
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Affiliation(s)
- Jie Gao
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Rui Nie
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Hong Chang
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
| | - Wei Yang
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
- Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China
| | - Qian Ren
- Lanzhou University
- Department of Gastroenterology, the First Hospital of Lanzhou University
- Key Laboratory for Gastrointestinal Diseases of Gansu Province, Lanzhou University, Lanzhou, China
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19
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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20
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Badal BD, Bajaj JS. Hepatic Encephalopathy in Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:691-702. [PMID: 37380292 DOI: 10.1016/j.cld.2023.03.012] [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
Acute-on-chronic liver failure (ACLF) is characterized by the presence of chronic liver disease and extrahepatic organ failure and is associated with a high rate of short-term mortality. International societies have sought to define the criteria for ACLF and differ on definitions. Encephalopathy is an important organ failure in ACLF cases and is included as a marker of ACLF across society definitions. Both brain failure and ACLF commonly occur in the presence of a triggering event and in the setting of the large amount of inflammation that ensues. The presence of encephalopathy as a part of ACLF not only increases the chances of mortality but also provides unique challenges in that the patient will be limited in conversations around major decisions such as need for advanced level of care, liver transplant, or even end-of-life decisions. Many decisions need to be made quickly and occur in parallel in the care of patients with encephalopathy and ACLF and include stabilizing the patient, identifying precipitants or alternative diagnoses, and medical management. Infections has emerged as a major trigger for both ACLF and encephalopathy, and special attention should be given to identifying and treating infections as they occur.
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Affiliation(s)
- Bryan D Badal
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, 1201 Broad Rock Boulevard, Richmond, VA, USA
| | - Jasmohan S Bajaj
- Division of Gastroenterology, Hepatology and Nutrition, Virginia Commonwealth University and Central Virginia Veterans Healthcare System, 1201 Broad Rock Boulevard, Richmond, VA, USA.
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21
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Marginean CM, Pirscoveanu D, Popescu M, Vasile CM, Docea AO, Mitruț R, Mărginean IC, Iacob GA, Firu DM, Mitruț P. Challenges in Diagnosis and Therapeutic Approach of Acute on Chronic Liver Failure-A Review of Current Evidence. Biomedicines 2023; 11:1840. [PMID: 37509478 PMCID: PMC10376368 DOI: 10.3390/biomedicines11071840] [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: 05/29/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute and severe decompensation of chronic liver disease (CLD) correlated with multiple organ failure, poor prognosis, and increased mortality. In 40-50% of ACLF cases, the trigger is not recognized; for many of these patients, bacterial translocation associated with systemic inflammation is thought to be the determining factor; in the other 50% of patients, sepsis, alcohol consumption, and reactivation of chronic viral hepatitis are the most frequently described trigger factors. Other conditions considered precipitating factors are less common, including acute alcoholic hepatitis, major surgery, TIPS insertion, or inadequate paracentesis without albumin substitution. Host response is likely the primary factor predicting ACLF severity and prognosis, the host immune response having a particular significance in this syndrome, together with the inflammatory cascade. The management of ACLF includes both the prevention of the precipitating factors that lead to acute liver decompensation and the support of vital functions, the prevention and management of complications, the estimation of prognosis, and the opportunity for liver transplantation.
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Affiliation(s)
- Cristina Maria Marginean
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Denisa Pirscoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Corina Maria Vasile
- Department of Pediatric Cardiology, "Marie Curie" Emergency Children's Hospital, 041451 Bucharest, Romania
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Radu Mitruț
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania
| | | | - George Alexandru Iacob
- Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Mihai Firu
- Ph.D. School Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Paul Mitruț
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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22
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Wang Q, Chen C, Zuo S, Cao K, Li H. Integrative analysis of the gut microbiota and faecal and serum short-chain fatty acids and tryptophan metabolites in patients with cirrhosis and hepatic encephalopathy. J Transl Med 2023; 21:395. [PMID: 37330571 PMCID: PMC10276405 DOI: 10.1186/s12967-023-04262-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/09/2023] [Indexed: 06/19/2023] Open
Abstract
OBJECTIVE The purpose of this study was to describe the changes in the gut microbiome of patients with cirrhosis and hepatic encephalopathy (HE), as well as quantify the variations in short-chain fatty acid (SCFA) and tryptophan metabolite levels in serum and faeces. METHODS Fresh faeces and serum were collected from 20 healthy volunteers (NC group), 30 cirrhosis patients (Cir group), and 30 HE patients (HE group). Then, 16S rRNA sequencing and metabolite measurements were performed using the faeces. Gas chromatography‒mass spectrometry and ultrahigh-performance liquid chromatography-tandem mass spectrometry were used to measure SCFA and tryptophan levels, respectively. The results were analysed by SIMCA16.0.2 software. Differences in species were identified using MetaStat and t tests. The correlations among the levels of gut microbes and metabolites and clinical parameters were determined using Spearman correlation analysis. RESULTS Patients with cirrhosis and HE had lower microbial species richness and diversity in faeces than healthy volunteers; these patients also had altered β-diversity. Serum valeric acid levels were significantly higher in the HE group than in the Cir group. Serum SCFA levels did not differ between the Cir and NC groups. Serum melatonin and 5-HTOL levels were significantly higher in the HE group than in the Cir group. The Cir and NC groups had significant differences in the levels of eight serum tryptophan metabolites. Furthermore, the levels of faecal SCFAs did not differ between the HE and Cir groups. Faecal IAA-Ala levels were significantly lower in the HE group than in the Cir group. There were significant differences in the levels of 6 faecal SCFAs and 7 faecal tryptophan metabolites between the Cir and NC groups. Certain gut microbes were associated with serum and faecal metabolites, and some metabolites were associated with certain clinical parameters. CONCLUSION Reduced microbial species richness and diversity were observed in patients with HE and cirrhosis. In both serum and faeces, the levels of different SCFAs and tryptophan metabolites showed varying patterns of change. In HE patients, the levels of some serum tryptophan metabolites, and not SCFAs, were correlated with liver function and systemic inflammation. Systemic inflammation in patients with cirrhosis was correlated with faecal acetic acid levels. In summary, this study identified metabolites important for HE and cirrhosis.
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Affiliation(s)
- Qiang Wang
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, People's Republic of China
- School of Clinical Medicine, Guizhou Medical University, Guiyang, Guizhou, People's Republic of China
| | - Chengxin Chen
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, People's Republic of China
| | - Shi Zuo
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, People's Republic of China
| | - Kun Cao
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, People's Republic of China.
| | - Haiyang Li
- Department of Hepatobiliary Surgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, People's Republic of China.
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23
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Chow KW, Ibrahim BM, Yum JJ, Dang A, Dang L, Chen KT, Jackson NJ, Saab S. Barriers to Lactulose Adherence in Patients with Cirrhosis and Hepatic Encephalopathy. Dig Dis Sci 2023; 68:2389-2397. [PMID: 37119376 PMCID: PMC11380462 DOI: 10.1007/s10620-023-07935-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 03/18/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND Hepatic encephalopathy (HE) is a major cause of mortality and morbidity in patients with cirrhosis. Lactulose non-adherence is one of the most frequently reported precipitants of hospital admission for HE. AIMS We aimed to identify which factors contribute most to lactulose non-adherence and propose strategies to promote greater adherence and utilization of lactulose. METHODS Participants in this study consisted of patients with cirrhosis who were taking lactulose for prevention of HE. Subjects were administered the Morisky Adherence Scale 8 (MAS-8) and a customized 16-question survey that assessed barriers to lactulose adherence. Results from the MAS-8 were used to stratify subjects into "adherent" and "non-adherent" groups. Survey responses were compared between groups. RESULTS We enrolled 129 patients in our study, of whom 45 were categorized as "adherent and 72 were categorized as "non-adherent." Barriers to adherence included large volumes of lactulose, high frequency of dosing, difficulty remembering to take the medication, unpleasant taste, and medication side-effects. Most patients (97%) expressed understanding of the importance of lactulose, and 71% of patients felt that lactulose was working to manage their HE. Hospital admission rates for HE was higher in non-adherent patients, although this difference was not statistically significant. CONCLUSION We identified several factors that contribute to lactulose non-adherence among patients treated for HE. Many of these factors are potentially modifiable. Patient and care-giver education are critical to assure adherence. Pharmacists and nurses are an essential but underutilized aspect of education regarding proper medication use.
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Affiliation(s)
- Kenneth W Chow
- Department of Medicine, Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Brittney M Ibrahim
- Department of Medicine, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA
| | - Jung J Yum
- Department of Medicine, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA
- Department of Surgery, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA
| | - An Dang
- Department of Medicine, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA
| | - Long Dang
- Department of Medicine, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA
| | - Kuan-Ting Chen
- University of California at Los Angeles, Los Angeles, CA, USA
| | | | - Sammy Saab
- Department of Medicine, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
- Department of Surgery, Pfleger Liver Institute, UCLA Medical Center, 200 Medical Plaza, Suite 214, Los Angeles, CA, 90095, USA.
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Riggio O, Celsa C, Calvaruso V, Merli M, Caraceni P, Montagnese S, Mora V, Milana M, Saracco GM, Raimondo G, Benedetti A, Burra P, Sacco R, Persico M, Schepis F, Villa E, Colecchia A, Fagiuoli S, Pirisi M, Barone M, Azzaroli F, Soardo G, Russello M, Morisco F, Labanca S, Fracanzani AL, Pietrangelo A, Di Maria G, Nardelli S, Ridola L, Gasbarrini A, Cammà C. Hepatic encephalopathy increases the risk for mortality and hospital readmission in decompensated cirrhotic patients: a prospective multicenter study. Front Med (Lausanne) 2023; 10:1184860. [PMID: 37305121 PMCID: PMC10248517 DOI: 10.3389/fmed.2023.1184860] [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] [Received: 03/12/2023] [Accepted: 04/28/2023] [Indexed: 06/13/2023] Open
Abstract
Introduction Hepatic encephalopathy (HE) affects the survival and quality of life of patients with cirrhosis. However, longitudinal data on the clinical course after hospitalization for HE are lacking. The aim was to estimate mortality and risk for hospital readmission of cirrhotic patients hospitalized for HE. Methods We prospectively enrolled 112 consecutive cirrhotic patients hospitalized for HE (HE group) at 25 Italian referral centers. A cohort of 256 patients hospitalized for decompensated cirrhosis without HE served as controls (no HE group). After hospitalization for HE, patients were followed-up for 12 months until death or liver transplant (LT). Results During follow-up, 34 patients (30.4%) died and 15 patients (13.4%) underwent LT in the HE group, while 60 patients (23.4%) died and 50 patients (19.5%) underwent LT in the no HE group. In the whole cohort, age (HR 1.03, 95% CI 1.01-1.06), HE (HR 1.67, 95% CI 1.08-2.56), ascites (HR 2.56, 95% CI 1.55-4.23), and sodium levels (HR 0.94, 95% CI 0.90-0.99) were significant risk factors for mortality. In the HE group, ascites (HR 5.07, 95% CI 1.39-18.49) and BMI (HR 0.86, 95% CI 0.75-0.98) were risk factors for mortality, and HE recurrence was the first cause of hospital readmission. Conclusion In patients hospitalized for decompensated cirrhosis, HE is an independent risk factor for mortality and the most common cause of hospital readmission compared with other decompensation events. Patients hospitalized for HE should be evaluated as candidates for LT.
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Affiliation(s)
- Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
- Department of Gastroenterology, “Santa Maria Goretti” Hospital, “Sapienza” Polo Pontino, Latina, Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
- Department of Surgical, Oncological and Oral Sciences (Di.Chir.On.S.), University of Palermo, Palermo, Italy
| | - Vincenza Calvaruso
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Paolo Caraceni
- Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliera-Universitaria di Bologna, Bologna, Italy
- Department of Medical and Surgical Sciences, Center for Biomedical Applied Research, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | | | - Vincenzina Mora
- Medicina Interna e Gastroenterologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Martina Milana
- Hepatology and Liver Transplant Unit, University of Tor Vergata, Rome, Italy
| | - Giorgio Maria Saracco
- Division of Gastroenterology, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Giovanni Raimondo
- Division of Medicine and Hepatology, University Hospital of Messina, Messina, Italy
| | - Antonio Benedetti
- Department of Gastroenterology and Hepatology, Università Politecnica delle Marche, Ancona, Italy
| | - Patrizia Burra
- Gastroenterology/Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Rodolfo Sacco
- Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | - Marcello Persico
- Internal Medicine and Hepatology Unit, Department of Medicine, Surgery and Dentistry, “Scuola Medica Salernitana”, University of Salerno, Salerno, Italy
| | - Filippo Schepis
- Gastroenterology Unit, Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Gastroenterology Unit, Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
| | - Antonio Colecchia
- Gastroenterology Unit, Department of Medical Specialities, University Hospital of Modena, University of Modena and Reggio Emilia, Modena, Italy
- Unit of Gastroenterology, Borgo Trento University Hospital, Verona, Italy
| | - Stefano Fagiuoli
- Gastroentyerology, University of Milan Bicocca, Milan, Italy
- Gastroenterology, Hepatology and Transplantation Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mario Pirisi
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
- Internal Medicine Unit, Azienda Ospedaliera Universitaria (AOU) Maggiore della Carità Hospital, Novara, Italy
| | - Michele Barone
- Section of Gastroenterology, Department of Emergency and Organ Transplantation, University “Aldo Moro” of Bari, Bari, Italy
| | - Francesco Azzaroli
- Gastroenterology Unit, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, Department of Surgical and Medical Sciences, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Giorgio Soardo
- Clinic of Internal Medicine-Liver Unit, Department of Medical Area (DAME), University of Udine, Udine, Italy
- Italian Liver Foundation, Area Science Park, Trieste, Italy
| | - Maurizio Russello
- Liver Unit, Azienda di Rilievo Nazionale ed Alta Specializzazione (ARNAS) Garibaldi-Nesima, Catania, Italy
| | - Filomena Morisco
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine and Surgery, University of Naples “Federico II”, Naples, Italy
| | - Sara Labanca
- Gastroenterology Unit, Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Anna Ludovica Fracanzani
- Department of Pathophysiology and Transplantation, Università degli Studi di Milano, Milan, Italy
- General Medicine and Metabolic Diseases, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonello Pietrangelo
- Department of Internal and Emergency Medicine, University Hospital of Modena, Modena, Italy
| | - Gabriele Di Maria
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Antonio Gasbarrini
- Medicina Interna e Gastroenterologia, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario Gemelli Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), Rome, Italy
| | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
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Bajaj JS, Tandon P, O'Leary JG, Reddy KR, Garcia-Tsao G, Thuluvath P, Lai JC, Subramanian RM, Vargas HE, Wong F, Fagan A, McGeorge S, Thacker LR, Kamath PS. Admission Serum Metabolites and Thyroxine Predict Advanced Hepatic Encephalopathy in a Multicenter Inpatient Cirrhosis Cohort. Clin Gastroenterol Hepatol 2023; 21:1031-1040.e3. [PMID: 35436625 PMCID: PMC11000256 DOI: 10.1016/j.cgh.2022.03.046] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/07/2022] [Accepted: 03/24/2022] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Grades 3 to 4 hepatic encephalopathy (advanced HE), also termed brain failure, is an organ failure that defines acute-on-chronic liver failure. It is associated with poor outcomes in cirrhosis but cannot be predicted accurately. We aimed to determine the admission metabolomic biomarkers able to predict the development of advanced HE with subsequent validation. METHODS Prospective inpatient cirrhosis cohorts (multicenter and 2-center validation) without brain failure underwent admission serum collection and inpatient follow-up evaluation. Serum metabolomics were analyzed to predict brain failure on random forest analysis and logistic regression. A separate validation cohort also was recruited. RESULTS The multicenter cohort included 602 patients, of whom 144 developed brain failure (105 only brain failure) 3 days after admission. Unadjusted random forest analysis showed that higher admission microbially derived metabolites and lower isoleucine, thyroxine, and lysophospholipids were associated with brain failure development (area under the curve, 0.87 all; 0.90 brain failure only). Logistic regression area under the curve with only clinical variables significantly improved with metabolites (95% CI 0.65-0.75; P = .005). Four metabolites that significantly added to brain failure prediction were low thyroxine and maltose and high methyl-4-hydroxybenzoate sulfate and 3-4 dihydroxy butyrate. Thyroxine alone also significantly added to the model (P = .05). The validation cohort including 81 prospectively enrolled patients, of whom 11 developed brain failure. Admission hospital laboratory thyroxine levels predicted brain failure development despite controlling for clinical variables with high specificity. CONCLUSIONS In a multicenter inpatient cohort, admission serum metabolites, including thyroxine, predicted advanced HE development independent of clinical factors. Admission low local laboratory thyroxine levels were validated as a predictor of advanced HE development in a separate cohort.
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Affiliation(s)
- Jasmohan S Bajaj
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia.
| | - Puneeta Tandon
- Department of Medicine, University of Alberta, Edmonton, Canada
| | | | - K Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | | | - Paul Thuluvath
- Department of Medicine, Mercy Medical Center, Baltimore, Maryland
| | - Jennifer C Lai
- Department of Medicine, University of California San Francisco, San Francisco, California
| | - Ram M Subramanian
- Department of Medicine, Emory University Medical Center, Atlanta, Georgia
| | - Hugo E Vargas
- Department of Medicine, Mayo Clinic Arizona, Phoenix, Arizona
| | - Florence Wong
- Department of Medicine, University of Toronto, Toronto, Canada
| | - Andrew Fagan
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Sara McGeorge
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Leroy R Thacker
- Department of Medicine, Virginia Commonwealth University, Richmond Veterans Affairs Medical Center, Richmond, Virginia
| | - Patrick S Kamath
- Department of Medicine, Mayo Clinic Rochester, Rochester, Minnesota
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26
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Chauhan M, Zhang T, Thuluvath PJ. Combined effects of hyponatremia and hepatic encephalopathy on inpatient mortality. Ann Hepatol 2023; 28:101084. [PMID: 36878465 DOI: 10.1016/j.aohep.2023.101084] [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: 11/26/2022] [Revised: 01/15/2023] [Accepted: 02/05/2023] [Indexed: 03/08/2023]
Abstract
INTRODUCTION AND OBJECTIVES Although hyponatremia and hepatic encephalopathy (HE) are known independent predictors of mortality, their combined effect is unknown. We investigated whether the inpatient mortality differed among patients with both hyponatremia and HE compared to those with either hyponatremia or HE alone. MATERIALS AND METHODS In this retrospective study, data were extracted from the National Inpatient Sample (NIS) to identify US adults (aged ≥18 years) with cirrhosis between January 1st, 2016, and December 31st, 2017. We analyzed the effects of hyponatremia, HE, or a combination of hyponatremia and HE on inpatient mortality using logistic regression. RESULTS Among 309,841 cirrhosis-related admissions, 22,870 (7%) patients died during hospitalization. Those with a combination of hyponatremia and HE had higher mortality (14%) than those with HE only (11%), hyponatremia only (9%), and neither hyponatremia nor HE (6%) (p<0.001). When compared to patients without hyponatremia or HE, patients with both hyponatremia and HE had the highest odds (adjusted odds ratio or aOR) of inpatient mortality (aOR 1.90, 95% CI: 1.79 - 2.01) followed by patients with HE only (aOR 1.75, 95% CI: 1.69 - 1.82) and patients with hyponatremia only (aOR 1.17, 95% CI: 1.12 - 1.22). Patients with HE only had 50% higher odds of inpatient mortality when compared to those with hyponatremia only (aOR: 1.50, 95% CI: 1.43 - 1.57). CONCLUSIONS In this nationwide study, the presence of both hyponatremia and HE was associated with higher inpatient mortality than either hyponatremia or HE alone.
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Affiliation(s)
- Mahak Chauhan
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
| | - Talan Zhang
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, MD, United States; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD. United States.
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27
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Ngu NLY, Flanagan E, Bell S, Le ST. Acute-on-chronic liver failure: Controversies and consensus. World J Gastroenterol 2023; 29:232-240. [PMID: 36687118 PMCID: PMC9846945 DOI: 10.3748/wjg.v29.i2.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.
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Affiliation(s)
- Natalie L Y Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Eliza Flanagan
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
| | - Suong T Le
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
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28
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Moon AM, Kim HP, Cook S, Blanchard RT, Haley KL, Jacks A, Shafer JS, Fried MW. Speech patterns and enunciation for encephalopathy determination-A prospective study of hepatic encephalopathy. Hepatol Commun 2022; 6:2876-2885. [PMID: 35861546 PMCID: PMC9512449 DOI: 10.1002/hep4.2054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 06/01/2022] [Accepted: 06/22/2022] [Indexed: 01/05/2023] Open
Abstract
Hepatic encephalopathy (HE) is a complication of cirrhosis that benefits from early diagnosis and treatment. We aimed to characterize speech patterns of individuals with HE to investigate its potential to diagnose and monitor HE. This was a single-center prospective cohort study that included participants with cirrhosis with HE (minimal HE [MHE] and overt HE [OHE]), cirrhosis without HE, and participants without liver disease. Audio recordings of reading, sentence repetition, and picture description tasks were obtained from these groups. Two certified speech-language pathologists assessed speech rate (words per minute) and articulatory precision. An overall severity metric was derived from these measures. Cross-sectional analyses were performed using nonparametric Wilcoxon statistics to evaluate group differences. Change over time in speech measures was analyzed descriptively for individuals with HE. The study included 43 total participants. Speech results differed by task, but the overall pattern showed slower speech rate and less precise articulation in participants with OHE compared to other groups. When speech rate and precision ratings were combined into a single speech severity metric, the impairment of participants with OHE was more severe than all other groups, and MHE had greater speech impairment than non-liver disease controls. As OHE improved clinically, participants showed notable improvement in speech rate. Participants with OHE demonstrated impaired speech rate, precision, and speech severity compared with non-liver disease and non-HE cirrhosis. Participants with MHE had less pronounced impairments. Speech parameters improved as HE clinically improved. Conclusion: These data identify speech patterns that could improve HE diagnosis, grading, and remote monitoring.
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Affiliation(s)
- Andrew M. Moon
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Hannah P. Kim
- Division of Gastroenterology, Hepatology, and NutritionDepartment of MedicineVanderbilt University Medical CenterNashvilleTennesseeUSA
| | - Sarah Cook
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Renee T. Blanchard
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Katarina L. Haley
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Adam Jacks
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Jennifer S. Shafer
- Division of Speech and Hearing SciencesDepartment of Allied Health SciencesUniversity of North Carolina School of MedicineChapel HillNorth CarolinaUSA
| | - Michael W. Fried
- Division of Gastroenterology and HepatologyDepartment of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
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29
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Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care 2022; 26:289. [PMID: 36163253 PMCID: PMC9511746 DOI: 10.1186/s13054-022-04163-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/10/2022] [Indexed: 01/11/2023] Open
Abstract
AbstractOrgan dysfunction or overt failure is a commonplace event in the critically ill affecting up to 70% of patients during their stay in the ICU. The outcome depends on the resolution of impaired organ function, while a domino-like deterioration of organs other than the primarily affected ones paves the way for increased mortality. “Acute Liver Failure” was defined in the 1970s as a rare and potentially reversible severe liver injury in the absence of prior liver disease with hepatic encephalopathy occurring within 8 weeks. Dysfunction of the liver in general reflects a critical event in “Multiple Organ Dysfunction Syndrome” due to immunologic, regulatory and metabolic functions of liver parenchymal and non-parenchymal cells. Dysregulation of the inflammatory response, persistent microcirculatory (hypoxic) impairment or drug-induced liver injury are leading problems that result in “secondary liver failure,” i.e., acquired liver injury without underlying liver disease or deterioration of preexisting (chronic) liver disease (“Acute-on-Chronic Liver Failure”). Conventional laboratory markers, such as transaminases or bilirubin, are limited to provide insight into the complex facets of metabolic and immunologic liver dysfunction. Furthermore, inhomogeneous definitions of these entities lead to widely ranging estimates of incidence. In the present work, we review the different definitions to improve the understanding of liver dysfunction as a perpetrator (and therapeutic target) of multiple organ dysfunction syndrome in critical care.
Graphic Abstract
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30
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Shaw J, Beyers L, Bajaj JS. Inadequate practices for hepatic encephalopathy management in the inpatient setting. J Hosp Med 2022; 17 Suppl 1:S8-S16. [PMID: 35972037 PMCID: PMC9542542 DOI: 10.1002/jhm.12897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 05/23/2022] [Accepted: 05/27/2022] [Indexed: 11/18/2022]
Abstract
Hepatic encephalopathy (HE) is an important complication of decompensated liver disease. Hospital admission for episodes of HE are very common, with these patients being managed by the hospitalists. These admissions are costly and burdensome to the health-care system. Diagnosis of HE at times is not straightforward, particularly in patients who are altered and unable to provide any history. Precipitants leading to episodes of HE, should be actively sought and effectively tackled along with the overall management. This mandates timely diagnostics, appropriate initiation of pharmacological treatment, and supportive care. Infections are the most important precipitants leading to HE and should be aggressively managed. Lactulose is the front-line medication for primary treatment of HE episodes and for prevention of subsequent recurrence. However, careful titration in the hospital setting along with the appropriate route of administration should be established and supervised by the hospitalist. Rifaximin has established its role as an add-on medication, in those cases where lactulose alone is not working. Overall effective management of HE calls for attention to guideline-directed nutritional requirements, functional assessment, medication reconciliation, patient education/counseling, and proper discharge planning. This will potentially help to reduce readmissions, which are all too common for HE patients. Early specialty consultation may be warranted in certain conditions. Numerous challenges exist to optimal care of hospitalized OHE patients. However, hospitalists if equipped with knowledge about a systematic approach to taking care of these frail patients are in an ideal position to ensure good inpatient and transition of care outcomes.
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Affiliation(s)
- Jawaid Shaw
- Department of Internal Medicine, Division of Hospital MedicineVirginia Commonwealth UniversityRichmondVirginiaUSA
| | - Lisa Beyers
- Department of Internal Medicine, Strong Memorial HospitalUniversity of RochesterRochesterNew YorkUSA
| | - Jasmohan S. Bajaj
- Division of Gastroenterology, Hepatology and NutritionVirginia Commonwealth University and Central Virginia Veterans Healthcare SystemRichmondVirginiaUSA
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31
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Bloom PP, Donlan J, Torres Soto M, Daidone M, Hohmann E, Chung RT. Fecal microbiota transplant improves cognition in hepatic encephalopathy and its effect varies by donor and recipient. Hepatol Commun 2022; 6:2079-2089. [PMID: 35384391 PMCID: PMC9315114 DOI: 10.1002/hep4.1950] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/23/2022] [Accepted: 03/12/2022] [Indexed: 01/25/2023] Open
Abstract
Early data suggest fecal microbiota transplant (FMT) may treat hepatic encephalopathy (HE). Optimal FMT donor and recipient characteristics are unknown. We assessed the safety and efficacy of FMT in patients with prior overt HE, comparing five FMT donors. We performed an open-label study of FMT capsules, administered 5 times over 3 weeks. Primary outcomes were change in psychometric HE score (PHES) and serious adverse events (SAEs). Serial stool samples underwent shallow shotgun metagenomic sequencing. Ten patients completed FMT administration and 6-month follow-up. Model for End-Stage Liver Disease (MELD) score did not change after FMT (14 versus 14, p = 0.51). Thirteen minor adverse events and three serious adverse events (two unrelated to FMT) were reported. One SAE was extended-spectrum beta-lactamase Escherichia coli bacteremia. The PHES improved after three doses of FMT (+2.1, p < 0.05), after five doses of FMT (+2.9, p = 0.007), and 4 weeks after the fifth dose of FMT (+3.1, p = 0.02). Mean change in the PHES ranged from -1 to +6 by donor. Two taxa were identified by random forest analysis and confirmed by linear regression to predict the PHES- Bifidobacterium adolescentis (adjusted R2 = 0.27) and B. angulatum (adjusted R2 = 0.25)-both short-chain fatty acid (SCFA) producers. Patients who responded to FMT had higher levels of Bifidobacterium as well as other known beneficial taxa at baseline and throughout the study. The FMT donor with poorest cognitive outcomes in recipients had the lowest fecal SCFA levels. Conclusion: FMT capsules improved cognition in HE, with an effect varying by donor and recipient factors (NCT03420482).
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Affiliation(s)
- Patricia P. Bloom
- Division of GastroenterologyUniversity of MichiganAnn ArborMichiganUSA
| | - John Donlan
- Harvard Medical SchoolBostonMassachusettsUSA
| | | | - Michael Daidone
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Elizabeth Hohmann
- Division of Infectious DiseaseMassachusetts General HospitalBostonMassachusettsUSA
| | - Raymond T. Chung
- Division of GastroenterologyMassachusetts General HospitalBostonMassachusettsUSA
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Risk factors for underlying comorbidities and complications in patients with hepatitis B virus-related acute-on-chronic liver failure. Epidemiol Infect 2022; 150:e147. [PMID: 35788251 PMCID: PMC9354478 DOI: 10.1017/s0950268822001169] [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] [Indexed: 11/30/2022] Open
Abstract
Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a severe and life-threatening complication, characterised by multi-organ failure and high short-term mortality. However, there is limited information on the impact of various comorbidities on HBV-ACLF in a large population. This study aimed to investigate the relationship between comorbidities, complications and mortality. In this retrospective observational study, we identified 2166 cases of HBV-ACLF hospitalised from January 2010 to March 2018. Demographic data from the patients, medical history, treatment, laboratory indices, comorbidities and complications were collected. The mortality rate in our study group was 47.37%. Type 2 diabetes mellitus was the most common comorbidity, followed by alcoholic liver disease. Spontaneous bacterial peritonitis, pneumonia and hepatic encephalopathy (HE) were common in these patients. Diabetes mellitus and hyperthyroidism are risk factors for death within 90 days, together with gastrointestinal bleeding and HE at admission, HE and hepatorenal syndrome during hospitalisation. Knowledge of risk factors can help identify HBV-ACLF patients with a poor prognosis for HBV-ACLF with comorbidities and complications.
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Kulkarni AV, Rabiee A, Mohanty A. Management of Portal Hypertension. J Clin Exp Hepatol 2022; 12:1184-1199. [PMID: 35814519 PMCID: PMC9257868 DOI: 10.1016/j.jceh.2022.03.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/07/2022] [Indexed: 12/12/2022] Open
Abstract
Portal hypertension is the cause of the clinical complications associated with cirrhosis. The primary complications of portal hypertension are ascites, acute variceal bleed, and hepatic encephalopathy. Hepatic venous pressure gradient measurement remains the gold standard test for diagnosing cirrhosis-related portal hypertension. Hepatic venous pressure gradient more than 10 mmHg is associated with an increased risk of complications and is termed clinically significant portal hypertension (CSPH). Clinical, laboratory, and imaging methods can also aid in diagnosing CSPH non-invasively. Recently, deep learning methods have been demonstrated to diagnose CSPH effectively. The management of portal hypertension is always individualized and is dependent on the etiology, the availability of therapies, and the degree of portal hypertension complications. In this review, we discuss the diagnosis and management of cirrhosis-related portal hypertension in detail. Also, we highlight the history of portal hypertension and future research areas in portal hypertension.
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Key Words
- ACLF, acute-on-chronic liver failure
- AKI, acute kidney injury
- APRI, AST to platelet ratio
- AST, aspartate transaminase
- BB, Beta blocker
- BRTO, balloon occluded retrograde transvenous obliteration
- CKD, chronic kidney disease
- CSPH, clinically significant portal hypertension
- CT, computed tomography
- GFR, glomerular filtration rate
- GOV, gastrpoesopahegal varices
- HE, hepatic encephalopathy
- HRS, hepatorenal syndrome
- HVPG, hepatic venous pressure gradient
- ICG, indocyanine green
- LOLA, l-ornithine l-aspartate
- NAFLD, Non-alcoholic fatty liver disease
- SBP, spontaneous bacterial peritonitis
- SGLT2I, sodium glucose co-transporter 2 inhibitors
- SSM, splenic stiffness measurement
- TE, transient elastography
- TIPS, transjugular intrahepatic portosystemic shunt
- VITRO, von Willebrand factor to platelet counts
- acute kidney injury
- ascites
- hemodynamics
- history
- vasoconstrictors
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Affiliation(s)
| | | | - Arpan Mohanty
- Boston University School of Medicine, Boston, MA, USA
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Vaz K, Little R, Majeed A, Kemp W, Roberts SK. Determinants of Short- and Long-Term Outcomes of an Australian Cohort of Patients Admitted with Alcoholic Hepatitis. Dig Dis Sci 2022; 67:3356-3365. [PMID: 34231100 DOI: 10.1007/s10620-021-07140-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 06/26/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Alcoholic hepatitis is a common condition with high mortality. This study aimed to firstly describe the presentation, treatment, and short- and long-term outcomes of an Australian cohort of patients admitted to hospital with alcoholic hepatitis and secondly to validate existing prognostic models. METHODS This is a retrospective study of consecutive patients admitted with alcoholic hepatitis to a major academic liver center in Melbourne, Australia, between January 1, 2010, and December 31, 2019. Cases were identified through appropriate International Classification of Diseases version 10 coding as well as review of non-coded patients with compatible biochemistry. Baseline demographic data, alcohol consumption, laboratory values, treatment, and outcomes at 30 days, 90 days, and 12 months post-diagnosis were collected from electronic medical records. Mortality data were extracted from an independent state government death registry. RESULTS In total, 126 patients (72 males [57%], median age 51 years) were included in the final analysis. Ninety-five (75%) were cirrhotic at diagnosis, 81 (64%) met criteria for severe alcoholic hepatitis, and 41 (33%) had an infection during their index admission. 54% of eligible patients were treated with corticosteroids. 30-day and 12-month mortality rates were 8.7% and 27.1%, respectively, with hepatic encephalopathy (hazard ratio 5.45) and neutrophil-to-lymphocyte ratio (hazard ratio 1.09) independent markers for 12-month mortality on Cox regression analysis. Glasgow alcoholic hepatitis score outperformed other major prognostic models for short-term mortality. CONCLUSIONS The 12-month mortality rate of 27% following alcoholic hepatitis is lower than previously reported studies, with hepatic encephalopathy and neutrophil-to-lymphocyte ratio predictive of long-term outcome.
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Affiliation(s)
- Karl Vaz
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, Australia.
- Department of Gastroenterology and Hepatology, Austin Health, 145 Studley Rd, Heidelberg, VIC, 3084, Australia.
| | - Robert Little
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, Australia
| | - Ammar Majeed
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne, Australia
- Central Clinical School, Monash University, Melbourne, Australia
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Amarasena S, Clark PJ, Gordon LG, Toombs M, Pratt G, Hartel G, Bernardes CM, Powell EE, Valery PC. Differences in the pattern and cost of hospital care between Indigenous and non-Indigenous Australians with cirrhosis: an exploratory study. Intern Med J 2022. [PMID: 35717648 DOI: 10.1111/imj.15854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 06/09/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Liver diseases are important contributors to the mortality gap between Indigenous and non-Indigenous Australians. AIMS This cohort study examined factors associated with hospital admissions and healthcare outcomes among Indigenous Australians with cirrhosis. METHODS Patient-reported outcomes were obtained by face-to-face interview (Chronic Liver Disease Questionnaire and Short Form 36 (SF-36)). Clinical data were extracted from medical records and through data linkage for 534 patients (25 indigenous). Cumulative overall survival (Kaplan-Meier), rates of hospital admissions and emergency presentations, and costs were assessed by indigenous status. Incidence rate ratios (IRR; Poisson regression) were reported. RESULTS Indigenous Australians admitted to hospital with cirrhosis had lower educational status compared with non-indigenous patients (79.2% vs 43.4%; P < 0.001). The two groups had, in general, similar clinical characteristics including disease severity (P = 0.78), presence of cirrhosis complications (P = 0.67), comorbidities (P = 0.62), rates of cirrhosis-related admissions (P = 0.86) and 5-year survival (P = 0.30). However, indigenous patients had a lower score in the SF-36 domain related to bodily pain (P = 0.037), more cirrhosis admissions via the emergency department (IRR = 1.42, 95% confidence interval (CI) 1.10-1.83) and fewer planned cirrhosis admissions (IRR = 0.32, 95% CI 0.14-0.72). The total cost for cirrhosis-related hospital admissions for 534 patients over 6 years (July 2012 to June 2018) was A$13.7 million. The cost of cirrhosis-related hospital admissions was double for indigenous patients (cost ratio = 2.04, 95% CI 2.04-2.05). CONCLUSIONS Our data highlight the disparities in health service use and patient-reported outcomes, despite having similar clinical profiles. Integration between primary care, Aboriginal Community Controlled Health Organisations and liver specialists is critical for appropriate health service delivery and effective use of resources. Chronic liver disease costs the community dearly.
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Affiliation(s)
- Samath Amarasena
- Department of Gastroenterology and Hepatology, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Paul J Clark
- Department of Gastroenterology and Hepatology, Mater Hospitals, Brisbane, Queensland, Australia.,Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Louisa G Gordon
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Maree Toombs
- Rural Clinical School, Faculty of Medicine, University of Queensland, Toowoomba, Queensland, Australia
| | - Greg Pratt
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Gunter Hartel
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Christina M Bernardes
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
| | - Elizabeth E Powell
- Department of Gastroenterology and Hepatology, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,Centre for Liver Disease Research, Translational Research Institute, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Patricia C Valery
- Population Health Department, QIMR Berghofer Medical Research Institute, Brisbane, Queensland, Australia
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36
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A dynamic nomogram to predict transplant-free mortality in patients with hepatitis B-related cirrhosis and overt hepatic encephalopathy. Int Immunopharmacol 2022; 108:108879. [PMID: 35623289 DOI: 10.1016/j.intimp.2022.108879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 05/16/2022] [Accepted: 05/17/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND Overt hepatic encephalopathy (OHE) is a serious complication of liver disease. We aimed to develop a dynamic nomogram for estimating the probability of 30-day transplant-free mortality in patients with OHE and hepatitis B-related cirrhosis (HBC). METHODS We identified 402 patients with OHE and HBC at the Beijing Ditan Hospital between January 2011 and July 2016. Independent risk factors were determined using multivariate Cox proportional hazards regression analysis. A dynamic nomogram was established to predict the probability of 30-day transplant-free mortality. The discrimination and clinical usefulness of the nomogram were estimated using the area under the receiver operating characteristic (AUC) and calibration curves, and decision curve analysis. A prospective cohort of 208 patients was enrolled for validation. RESULTS The model for end-stage liver disease (MELD) score and neutrophil-to-lymphocyte ratio (NLR) were independently associated with the 30-day transplant-free mortality. The AUC values of the nomogram were 0.881 and 0.879 in the derivation and validation cohorts, respectively, and the discrimination ability was superior to that of the established models. The calibration plot fitted the predicted survival and observed probabilities well. The incidence of mortality was 2.0% (3/151) in patients with MELD scores < 23 and NLR < 4, and 55.4% (41/92) in those with MELD scores ≥ 23 and NLR ≥ 4. CONCLUSIONS The dynamic nomogram can predict the risk of 30-day transplant-free mortality in patients with OHE and HBC. Patients with MELD scores ≥ 23 and NLR ≥ 4 have a high mortality rate and should be admitted to intensive care.
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Neutrophil-lymphocyte ratio and the risk of 30-day mortality in patients with overt hepatic encephalopathy. Eur J Gastroenterol Hepatol 2022; 34:529-536. [PMID: 35352702 DOI: 10.1097/meg.0000000000002368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
AIM Patients with overt hepatic encephalopathy (OHE) have an increased risk of adverse outcomes. However, the relationship between neutrophil to lymphocyte ratio (NLR) and the 30-day risk of death in patients with OHE has not been well evaluated. METHODS We retrospectively analyzed 1301 patients with OHE at Beijing Ditan Hospital between August 2008 and December 2018. After adjustment for major risk factors, Cox regression analysis and restricted cubic splines were used to analyze the relation between NLR and 30-day mortality. The 30-day survival was calculated by Kaplan-Meier method. RESULTS All patients were divided into four subgroups on the basis of the quartiles of the baseline NLR distribution (< 2.5, 2.5-4.3, 4.3-7.5, >7.5). The 30-day mortality rates were 7.8%, 12.7%, 19.5% and 34.1%, respectively (P < 0.001). Compared with the lowest quartile, the increase in the NLR was associated with an increase risk of 30-day mortality after multivariable adjustment (NLR 2.5-4.3: adjusted hazard ratio [AHR], 1.17 (95% confidence interval [CI], 0.70-1.95); NLR 4.3-7.5: AHR, 1.58 (95% CI, 1.01-2.47); NLR > 7.5: AHR, 2.32 (95% CI, 1.50-3.57). A nonlinear association between NLR and the adjusted probability of 30-day mortality was observed. Elevated NLR was correlated with increased 30-day mortality in patients with OHE across different subgroups (HR >1.0). CONCLUSION An elevated NLR is independently associated with a higher risk of 30-day mortality in patients with OHE.
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38
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Elhence A, Shalimar. Liver dysfunction in Barcelona Clinic Liver Cancer-2022 update: Clear as day or still in fog? J Hepatol 2022; 76:1236-1237. [PMID: 34954248 DOI: 10.1016/j.jhep.2021.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 12/09/2021] [Accepted: 12/17/2021] [Indexed: 12/15/2022]
Affiliation(s)
- Anshuman Elhence
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Abstract
In patients with cirrhosis and chronic liver disease, acute-on-chronic liver failure is emerging as a major cause of mortality. These guidelines indicate the preferred approach to the management of patients with acute-on-chronic liver failure and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence for these guidelines was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation process. In instances where the evidence was not appropriate for Grading of Recommendations, Assessment, Development, and Evaluation, but there was consensus of significant clinical merit, key concept statements were developed using expert consensus. These guidelines are meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.
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40
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Méndez-Guerrero O, Calle-Rodas DA, Cervantes-Alvarez E, Alatorre-Arenas E, Pérez-Escobar J, Navarro-Alvarez N, Torre A. Renal and brain failure predict mortality of patients with acute-on-chronic liver failure admitted to the intensive care unit. Ann Hepatol 2021; 22:100270. [PMID: 33091594 DOI: 10.1016/j.aohep.2020.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/20/2020] [Accepted: 09/21/2020] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES Acute on Chronic Liver Failure (ACLF) is characterized by organ failure and high 28-day mortality. Identifying clinical predictors associated with early mortality could have implications for the treatment of patients with ACLF. PATIENTS AND METHODS Patients diagnosed with chronic liver failure that developed ACLF based on the EASL-CLIF Consortium definition admitted to the Intensive care unit of a tertiary hospital between 2012-2018 were included. Bivariate and multivariate Cox regression analyses were performed to identify factors associated with mortality. RESULTS 148 patients (55% female) were diagnosed with ACLF of which 55% (n = 82) had ACLF grade 3, 28% (n = 41) grade 2 and 17% (n = 25) grade 1. The median age was 54 years (41-63). Hepatitis C virus (HCV) was the most frequent etiology in 29.8% (n = 44) of the patients with bacterial infection being the most predominant precipitant factor in 58.1% (n = 86). Ninety-day global cumulative survival was only 18%. When divided by grade, mortality reached to 10% in ACLF 3. Moreover, in the multivariate Cox regression analysis, renal failure (HR 3.26, 95% CI (2.13-4.99), brain failure (HR 1.37, 95% CI 1.09-2.04) and male sex (HR 1.62, 95% CI 1.10-2.40) were independent predictors of 28- and 90-day mortality. CONCLUSIONS ACLF is a frequent syndrome among chronic liver disease patients. Brain and renal failure are significantly associated with higher mortality and are independent predictors of 28 and 90-day mortality.
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Affiliation(s)
- Osvely Méndez-Guerrero
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico
| | - Daniel A Calle-Rodas
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico
| | - Eduardo Cervantes-Alvarez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico; PECEM, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Elisa Alatorre-Arenas
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico
| | - Juanita Pérez-Escobar
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico
| | - Nalu Navarro-Alvarez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico; Universidad Panamericana School of Medicine, Campus México, Mexico City, Mexico; Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO, United States.
| | - Aldo Torre
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Department of Gastroenterology, Mexico City, Mexico.
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Morega S, Cătălin B, Simionescu CE, Sapalidis K, Rogoveanu I. Cerebrolysin Prevents Brain Injury in a Mouse Model of Liver Damage. Brain Sci 2021; 11:brainsci11121622. [PMID: 34942925 PMCID: PMC8699728 DOI: 10.3390/brainsci11121622] [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: 11/04/2021] [Revised: 11/26/2021] [Accepted: 12/06/2021] [Indexed: 11/16/2022] Open
Abstract
Liver damage can lead to secondary organ damage by toxic substances and catabolic products accumulation which can increase the permeability of blood-brain barrier, leading to cognitive impairment. The only real treatment for end stage liver failure is grafting. With some, but not all, neurological symptoms subsiding after transplantation, the presence of brain damage can impair both the short and long-term outcome. We tested if Cerebrolysin can prevent brain injury in an experimental model of non-viral liver damage in mice. Behavior, abdominal ultrasound evaluation and immunohistochemistry were used to evaluate the animals. No ultrasound or behavior differences were found between the control and treated animals, with both groups displaying more anxiety and no short-term memory benefit compared to sham mice. Cerebrolysin treatment was able to maintain a normal level of cortical NeuN+ cells and induced an increase in the area occupied by BrdU+ cells. Surprisingly, no difference was observed when investigating Iba1+ cells. With neurological complications of end-stage liver disease impacting the rehabilitation of patients receiving liver grafts, a neuroprotective treatment of patients on the waiting lists might improve their rehabilitation outcome by ensuring a minimal cerebral damage.
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Affiliation(s)
- Shandiz Morega
- U.M.F. Doctoral School Craiova, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Bogdan Cătălin
- Experimental Research Centre for Normal and Pathological Aging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (B.C.); (C.E.S.)
| | - Cristiana Eugenia Simionescu
- Department of Pathology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
- Correspondence: (B.C.); (C.E.S.)
| | - Konstantinos Sapalidis
- 3rd Department of Surgery, AHEPA University Hospital, Medical School, Aristotle University of Thessaloniki, 54124 Thessaloniki, Greece;
| | - Ion Rogoveanu
- Gastroenterology Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
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Wang Y, Dong F, Sun S, Wang X, Zheng X, Huang Y, Li B, Gao Y, Qian Z, Liu F, Lu X, Liu J, Ren H, Zheng Y, Yan H, Deng G, Qiao L, Zhang Y, Gu W, Xiang X, Zhou Y, Xu B, Hou Y, Zhang Q, Xiong Y, Zou C, Chen J, Huang Z, Jiang X, Qi T, Luo S, Chen Y, Gao N, Liu C, Yuan W, Mei X, Li J, Li T, Zheng R, Zhou X, Zhang W, Li H, Meng Z. Increased INR Values Predict Accelerating Deterioration and High Short-Term Mortality Among Patients Hospitalized With Cirrhosis or Advanced Fibrosis. Front Med (Lausanne) 2021; 8:762291. [PMID: 34869468 PMCID: PMC8637055 DOI: 10.3389/fmed.2021.762291] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Accepted: 10/18/2021] [Indexed: 12/12/2022] Open
Abstract
Background and Objective: An increase in the international normalized ratio (INR) is associated with increased mortality in patients with cirrhosis and other chronic liver diseases, while little is known about the quantitative relationship. This study aimed to investigate the quantitative relationship between the INR and short-term prognosis among patients hospitalized with cirrhosis or advanced fibrosis and to evaluate the role of the INR as a risk factor for short-term liver transplant (LT)-free mortality in these patients. Patients and Methods: This study prospectively analyzed multicenter cohorts established by the Chinese Acute-on-Chronic Liver Failure (CATCH-LIFE) study. Cox regression was used to describe the relationship between the INR and independent risk factors for short-term LT-free mortality. Forest plots were used in the subgroup analysis. Generalized additive models (GAMs) and splines were used to illustrate the quantitative curve relationship between the INR and the outcome and inflection point on the curve. Results: A total of 2,567 patients with cirrhosis and 924 patients with advanced fibrosis were included in the study. The 90-day LT-free mortality of patients with cirrhosis and advanced fibrosis was 16.7% (428/2,567) and 7.5% (69/924), respectively. In the multivariable Cox regression analysis, the increase in the INR was independently associated with the risk of 90-day LT-free mortality both in patients with cirrhosis (HR, 1.06; 95% CI, 1.04–1.07, p < 0.001) and in patients with advanced fibrosis (HR, 1.09; 95% CI, 1.06–1.12, p < 0.001). An INR of 1.6/1.7 was found to be the starting point of coagulation dysfunction with a rapid increase in mortality in patients with cirrhosis or in patients with advanced fibrosis, respectively. A 28-day LT-free mortality of 15% was associated with an INR value of 2.1 in both cirrhosis and advanced fibrosis patients. Conclusions: This study was the first to quantitatively describe the relationship between the INR and short-term LT-free mortality in patients with cirrhosis or advanced fibrosis. The starting points of INR indicating the rapid increase in mortality and the unified cutoff value of coagulation failure in cirrhosis and advanced fibrosis, will help clinicians accurately recognize early disease deterioration.
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Affiliation(s)
- Ying Wang
- Department of Infectious Disease, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Chinese Chronic Liver Failure Consortium, China
| | - Fuchen Dong
- Chinese Chronic Liver Failure Consortium, China.,Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Shuning Sun
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xianbo Wang
- Chinese Chronic Liver Failure Consortium, China.,Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xin Zheng
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Tongji Medical College, Institute of Infection and Immunology, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Yan Huang
- Chinese Chronic Liver Failure Consortium, China.,Hunan Key Laboratory of Viral Hepatitis, Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China
| | - Beiling Li
- Chinese Chronic Liver Failure Consortium, China.,Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Yanhang Gao
- Chinese Chronic Liver Failure Consortium, China.,Department of Hepatology, The First Hospital of Jilin University, Jilin, China
| | - Zhiping Qian
- Chinese Chronic Liver Failure Consortium, China.,Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Feng Liu
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Xiaobo Lu
- Chinese Chronic Liver Failure Consortium, China.,Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Junping Liu
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Henan Provincial People's Hospital, Henan, China
| | - Haotang Ren
- Chinese Chronic Liver Failure Consortium, China.,State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yubao Zheng
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huadong Yan
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Hwamei Hospital, Ningbo No. 2 Hospital, University of Chinese Academy of Sciences, Ningbo, China
| | - Guohong Deng
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Liang Qiao
- Chinese Chronic Liver Failure Consortium, China.,Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Zhang
- Chinese Chronic Liver Failure Consortium, China.,Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Wenyi Gu
- Chinese Chronic Liver Failure Consortium, China.,Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaomei Xiang
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yi Zhou
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Baoyan Xu
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yixin Hou
- Chinese Chronic Liver Failure Consortium, China.,Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qun Zhang
- Chinese Chronic Liver Failure Consortium, China.,Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yan Xiong
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Tongji Medical College, Institute of Infection and Immunology, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Congcong Zou
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases, Tongji Medical College, Institute of Infection and Immunology, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jun Chen
- Chinese Chronic Liver Failure Consortium, China.,Hunan Key Laboratory of Viral Hepatitis, Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China
| | - Zebing Huang
- Chinese Chronic Liver Failure Consortium, China.,Hunan Key Laboratory of Viral Hepatitis, Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha, China
| | - Xiuhua Jiang
- Chinese Chronic Liver Failure Consortium, China.,Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Tingting Qi
- Chinese Chronic Liver Failure Consortium, China.,Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sen Luo
- Department of Infectious Disease, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Chinese Chronic Liver Failure Consortium, China
| | - Yuanyuan Chen
- Department of Infectious Disease, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Chinese Chronic Liver Failure Consortium, China
| | - Na Gao
- Chinese Chronic Liver Failure Consortium, China.,Department of Hepatology, The First Hospital of Jilin University, Jilin, China
| | - Chunyan Liu
- Chinese Chronic Liver Failure Consortium, China.,Department of Hepatology, The First Hospital of Jilin University, Jilin, China
| | - Wei Yuan
- Chinese Chronic Liver Failure Consortium, China.,Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Xue Mei
- Chinese Chronic Liver Failure Consortium, China.,Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Jing Li
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Tao Li
- Chinese Chronic Liver Failure Consortium, China.,Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Rongjiong Zheng
- Chinese Chronic Liver Failure Consortium, China.,Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Xinyi Zhou
- Chinese Chronic Liver Failure Consortium, China.,Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Weituo Zhang
- Chinese Chronic Liver Failure Consortium, China.,Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hai Li
- Chinese Chronic Liver Failure Consortium, China.,Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Zhongji Meng
- Department of Infectious Disease, Hubei Clinical Research Center for Precise Diagnosis and Treatment of Liver Cancer, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Chinese Chronic Liver Failure Consortium, China
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43
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Bloom PP, Tapper EB, Young VB, Lok AS. Microbiome therapeutics for hepatic encephalopathy. J Hepatol 2021; 75:1452-1464. [PMID: 34453966 PMCID: PMC10471317 DOI: 10.1016/j.jhep.2021.08.004] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/20/2021] [Accepted: 08/02/2021] [Indexed: 12/13/2022]
Abstract
Hepatic encephalopathy (HE) is a complication of cirrhosis characterised by neuropsychiatric and motor dysfunction. Microbiota-host interactions play an important role in HE pathogenesis. Therapies targeting microbial community composition and function have been explored for the treatment of HE. Prebiotics, probiotics and faecal microbiota transplant (FMT) have been used with the aim of increasing the abundance of potentially beneficial taxa, while antibiotics have been used to decrease the abundance of potentially harmful taxa. Other microbiome therapeutics, including postbiotics and absorbents, have been used to target microbial products. Microbiome-targeted therapies for HE have had some success, notably lactulose and rifaximin, with probiotics and FMT also showing promise. However, there remain several challenges to the effective application of microbiome therapeutics in HE, including the resilience of the microbiome to sustainable change and unpredictable clinical outcomes from microbiota alterations. Future work in this space should focus on rigorous trial design, microbiome therapy selection, and a personalised approach to HE.
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Affiliation(s)
- Patricia P Bloom
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA.
| | - Elliot B Tapper
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA
| | - Vincent B Young
- Department of Internal Medicine, Division of Infectious Disease, University of Michigan, USA; Department of Microbiology and Immunology, University of Michigan, USA
| | - Anna S Lok
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, University of Michigan, USA
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44
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A Trial of Ornithine Phenylacetate and the Arc of Ammonia's History in the Management of Overt Hepatic Encephalopathy. Clin Gastroenterol Hepatol 2021; 19:2493-2495. [PMID: 33157316 DOI: 10.1016/j.cgh.2020.11.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 11/01/2020] [Indexed: 02/07/2023]
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45
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Acute on Chronic Liver Failure: Factors Associated With Transplantation. Transplant Direct 2021; 7:e788. [PMID: 34805490 PMCID: PMC8601355 DOI: 10.1097/txd.0000000000001245] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Revised: 08/16/2021] [Accepted: 08/18/2021] [Indexed: 12/15/2022] Open
Abstract
Acute on chronic liver failure (ACLF) carries a poor prognosis unless liver transplantation is offered. We present risk factors associated with proceeding with liver transplantation in patients with ACLF.
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46
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Rahimi RS, Brown KA, Flamm SL, Brown RS. Overt Hepatic Encephalopathy: Current Pharmacologic Treatments and Improving Clinical Outcomes. Am J Med 2021; 134:1330-1338. [PMID: 34242619 DOI: 10.1016/j.amjmed.2021.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 06/11/2021] [Accepted: 06/14/2021] [Indexed: 02/07/2023]
Abstract
Overt hepatic encephalopathy is a generally reversible neurologic complication of cirrhosis. Overt hepatic encephalopathy has been associated with poor hospitalization- and mortality-related outcomes, which is important given increasing hepatic encephalopathy-related hospitalizations over time. The aim of this narrative review is to provide an overview of hospital- and mortality-related outcomes in patients with overt hepatic encephalopathy and the pharmacologic therapies that may improve these outcomes. Guideline-recommended prophylaxis with lactulose (first-line therapy) or secondary prophylaxis with rifaximin plus lactulose decreases hospital admissions and mortality rates. Rifaximin or lactulose treatment was beneficial for reducing the hospitalization rate in patients with hepatic encephalopathy compared with no treatment. Further, retrospective studies have shown that rifaximin with or without lactulose was effective for decreasing the number of hepatic encephalopathy episodes, hepatic encephalopathy-related hospitalizations, and duration of hospitalization. Ornithine phenylacetate, an ammonia-reducing agent currently in development, is also being investigated in hospitalized patients with hepatic encephalopathy. Overall, data support that prophylaxis for the prevention of hepatic encephalopathy recurrence improves outcomes in patients with cirrhosis and a history of hepatic encephalopathy.
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Affiliation(s)
- Robert S Rahimi
- Baylor Scott and White Hospital, Baylor University Medical Center, Dallas, Tex.
| | - Kimberly A Brown
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Mich
| | - Steven L Flamm
- Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Robert S Brown
- Weill Cornell Medicine, Center for Liver Disease, New York, NY
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47
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Trivedi PS, Jensen AM, Brown MA, Morgan RL, Lindrooth RC, Ryu RK, Ho PM, Kriss MS. High Prevalence of Transjugular Intrahepatic Portosystemic Shunt Creation Without Prior Endoscopy During Acute Variceal Bleeding Hospitalization in the United States. Hepatol Commun 2021; 5:1784-1790. [PMID: 34558832 PMCID: PMC8485889 DOI: 10.1002/hep4.1756] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 04/07/2021] [Accepted: 05/06/2021] [Indexed: 11/06/2022] Open
Abstract
Current clinical guidelines by both American Association for the Study of Liver Disease and European Association for the Study of the Liver recommend endoscopy in all patients admitted with acute variceal bleeding within 12 hours of admission. Transjugular intrahepatic portosystemic shunt (TIPS) creation may be considered in patients at high risk if hemorrhage cannot be controlled endoscopically. We conducted a cross-sectional observational study to assess how frequently TIPS is created for acute variceal bleeding in the United States without preceding endoscopy. Adult patients undergoing TIPS creation for acute variceal bleeding in the United States (n = 6,297) were identified in the last 10 available years (2007-2016) of the National Inpatient Sample. Hierarchical logistic regression was used to examine the relationship between endoscopy nonutilization and hospital characteristics, controlling for patient demographics, income level, insurance type, and disease severity. Of 6,297 discharges following TIPS creation for acute variceal bleeding in the United States, 31% (n = 1,924) did not receive first-line endoscopy during the same encounter. Rates of "no endoscopy" decreased with increasing population density of the hospital county (nonmicropolitan counties 43%, n = 114; mid-size metropolitan county 35%, n = 513; and central county with >1 million population 23%, n = 527) but not by hospital teaching status (n = 1,465, 32% teaching vs. n = 430, 26% nonteaching; P = 0.10). Higher disease mortality risk (odds ratio, 0.42; 95% confidence interval, 0.22-0.80; P = 0.02) was associated with lower odds of noncompliance. Conclusion: One third of all patients undergoing TIPS creation for acute variceal bleeding in the United States do not receive first-line endoscopy during the same encounter. Patients admitted to urban hospitals are more likely to receive guideline-concordant care.
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Affiliation(s)
- Premal S Trivedi
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Matthew A Brown
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | - Rustain L Morgan
- Department of Radiology, Division of Interventional RadiologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
| | | | - Robert K Ryu
- University of Southern California Keck School of MedicineLos AngelesCAUSA
| | - P Michael Ho
- Veterans Affairs Eastern Colorado Health SystemAuroraCOUSA
| | - Michael S Kriss
- Division of Gastroenterology and HepatologyUniversity of Colorado Anschutz Medical CampusAuroraCOUSA
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48
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Long L, Li H, Deng G, Wang X, Lu S, Li B, Meng Z, Gao Y, Qian Z, Liu F, Lu X, Ren H, Shang J, Li H, Wang S, Zheng Y, Yan H, Yin S, Tan W, Zhang Q, Zheng X, Chen J, Luo S, Zhao J, Yuan W, Li T, Zheng R, Liu J, Liu X, Gu W, Li S, Mei X, Chen R, Huang Y. Impact of Hepatic Encephalopathy on Clinical Characteristics and Adverse Outcomes in Prospective and Multicenter Cohorts of Patients With Acute-on-Chronic Liver Diseases. Front Med (Lausanne) 2021; 8:709884. [PMID: 34409052 PMCID: PMC8365160 DOI: 10.3389/fmed.2021.709884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 07/07/2021] [Indexed: 12/18/2022] Open
Abstract
Importance: Hepatic encephalopathy is a severe complication, and its contribution to clinical adverse outcomes in patients with acute-on-chronic liver diseases from the East is unclear. Objective: We aimed to investigate the impact of hepatic encephalopathy on clinical characteristics and adverse outcomes in prospective and multicenter cohorts of patients with acute-on-chronic liver diseases. Design: We conducted a cohort study of two multicenter prospective cohorts. Setting: China. Participants: Acute-on-chronic liver disease patients with various etiologies. Exposure: The diagnosis and severity of hepatic encephalopathy were assessed using the West Haven scale. Main Outcome Measure: The correlation between clinical adverse outcomes and varying hepatic encephalopathy grades was analyzed in the target patients. Results: A total of 3,949 patients were included, and 340 of them had hepatic encephalopathy. The incidence of hepatic encephalopathy was higher in patients with alcohol consumption (9.90%) than in those with hepatitis B virus infection (6.17%). The incidence of 28- and 90-day adverse outcomes increased progressively from hepatic encephalopathy grades 1–4. Logistic regression analysis revealed that hepatic encephalopathy grades 3 and 4 were independent risk factors for the 28- and 90-day adverse outcome in the fully adjusted model IV. Stratified analyses showed similar results in the different subgroups. Compared to grades 1–2 and patients without hepatic encephalopathy, those with grade 3 hepatic encephalopathy had a significant increase in clinical adverse outcomes, independent of other organ failures. Conclusions and Relevance: Hepatic encephalopathy grades 3–4 were independent risk factors for 28- and 90-day adverse outcomes. Hepatic encephalopathy grade 3 could be used as an indicator of brain failure in patients with acute-on-chronic liver disease.
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Affiliation(s)
- Liyuan Long
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, China
| | - Hai Li
- Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China.,Key Laboratory of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Chinese Ministry of Health (Shanghai Jiao Tong University), Shanghai, China.,Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China
| | - Guohong Deng
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xianbo Wang
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Sihong Lu
- Department of Infectious Diseases, Institute of Infection and Immunology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Beiling Li
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Zhongji Meng
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Yanhang Gao
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Zhiping Qian
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Feng Liu
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Hepatology, Tianjin Institute of Hepatology, Nankai University Second People's Hospital, Tianjin, China.,Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Xiaobo Lu
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Haotang Ren
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, China
| | - Hai Li
- Department of Infectious Diseases, Affiliated Hospital of Logistics University of People's Armed Police Force, Tianjin, China
| | - Shaoyang Wang
- Department of Infectious Diseases, Fuzhou General Hospital of Nanjing Military Command, Fuzhou, China
| | - Yubao Zheng
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Huadong Yan
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Hepatology, Ningbo No. 2 Hospital, Ningbo, China
| | - Shan Yin
- Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China.,Key Laboratory of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Chinese Ministry of Health (Shanghai Jiao Tong University), Shanghai, China
| | - Wenting Tan
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xin Zheng
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Department of Infectious Diseases, Institute of Infection and Immunology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Jinjun Chen
- Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China.,Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Sen Luo
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jinming Zhao
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Wei Yuan
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Tao Li
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, China
| | - Rongjiong Zheng
- Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Ürümqi, China
| | - Junping Liu
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, China
| | - Xiaoxiao Liu
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, China
| | - Wenyi Gu
- Department of Gastroenterology, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China.,Key Laboratory of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Chinese Ministry of Health (Shanghai Jiao Tong University), Shanghai, China
| | - Sumeng Li
- Department of Infectious Diseases, Institute of Infection and Immunology, Tongji Medical College, Union Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Xue Mei
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Ruochan Chen
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, China
| | - Yan Huang
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, China.,Chinese Chronic Liver Failure (CLIF) Consortium, Shanghai, China
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49
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Jalan R, D'Amico G, Trebicka J, Moreau R, Angeli P, Arroyo V. New clinical and pathophysiological perspectives defining the trajectory of cirrhosis. J Hepatol 2021; 75 Suppl 1:S14-S26. [PMID: 34039485 DOI: 10.1016/j.jhep.2021.01.018] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 01/08/2021] [Accepted: 01/11/2021] [Indexed: 02/06/2023]
Abstract
Traditionally, the complications of cirrhosis, namely variceal bleeding, ascites and hepatic encephalopathy, were thought to result predominantly from circulatory dysfunction and altered organ perfusion arising as a result of portal hypertension. Over the past 20 years, large, international prospective studies have indicated the importance of systemic inflammation and organ immunopathology as additional determinants of organ dysfunction in cirrhosis, which not only manifests in the liver, brain, circulation and the kidneys, but also the immune system, gut, muscles, adrenal glands, reproductive organs, heart and lungs. This review provides an overview of the traditional and emerging concepts around the initiation and maintenance of organ dysfunction in cirrhosis and proposes a new paradigm based upon a better understanding of acute decompensation of cirrhosis. The interaction between the traditional concepts and the emerging perspectives remains a matter of great interest and the basis for future research.
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Affiliation(s)
- Rajiv Jalan
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom.
| | - Gennaro D'Amico
- Gastroenterology Unit, Ospedale Cervello and University of Palermo, Italy
| | - Jonel Trebicka
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; JW Goethe University Hospital, Frankfurt, Germany
| | - Richard Moreau
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; APHP, Hôpital Beaujon, Service d'Hépatologie, Clichy, France; Inserm, Université de Paris, Centre de Recherche sur L'Inflammation, Paris, France
| | - Paolo Angeli
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; University of Padova, Padova, Italy
| | - Vicente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
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50
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Bernal W, Karvellas C, Saliba F, Saner FH, Meersseman P. Intensive care management of acute-on-chronic liver failure. J Hepatol 2021; 75 Suppl 1:S163-S177. [PMID: 34039487 DOI: 10.1016/j.jhep.2020.10.024] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/20/2020] [Accepted: 10/21/2020] [Indexed: 02/07/2023]
Abstract
The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, United Kingdom.
| | - Constantine Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Canada
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Université Paris SACLAY, INSERM Unit 1193, Villejuif, France
| | - Fuat H Saner
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie Universitätsklinikum Essen Hufelandstr. 55 45 147, Essen, Germany
| | - Philippe Meersseman
- Medical Intensive Care Unit, Department of General Internal Medicine, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium
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