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Kulkarni AV, Gustot T, Reddy KR. Liver transplantation for acute liver failure and acute-on-chronic liver failure. Am J Transplant 2024:S1600-6135(24)00435-0. [PMID: 39094950 DOI: 10.1016/j.ajt.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver (ACLF) are distinct phenotypes of liver failure and, thus, need to be compared and contrasted for appropriate management. There has been a significant improvement in the outcomes of these patients undergoing liver transplantation (LT). Survival post-LT for ALF and ACLF ranges between 90% and 95% and 80% and 90% at 1 year, futility criteria have been described in both ALF and ACLF where organ failures define survival. Plasma exchange and continuous renal replacement therapy may serve as bridging therapies. Identifying the futility of LT is as necessary as the utility of LT in patients with ALF and ACLF. The role of regenerative therapies such as granulocyte colony-stimulating factors in ACLF and hepatocyte and xenotransplantation in both conditions remains uncertain. Measures to increase the donor pool through increasing deceased donor transplants in Asian countries, living donations in Western countries, auxiliary liver transplants, and ABO-incompatible liver transplants are necessary to improve the survival of these patients. In this review, we discuss the similarities and differences in clinical characteristics and the timing and outcomes of LT for ALF and ACLF, briefly highlighting the role of bridging therapies and providing an overview of recent advances in the management of ALF and ACLF.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, HUB Hôpital Erasme, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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Fernandes EDSM, Corrêa RR, Furtado RLL, Brüggenwirth IMA, Yang C, de Mello FPT, de Oliveira Andrade R, Pimentel LMS, Girão CL, César C, Siqueira MAP, Braga EP, Carvalho ACG, Porte RJ, Bouskela E. Oxygenated versus non-oxygenated flush out during deceased donor liver procurement: The first proof-of-concept study in humans. Artif Organs 2024. [PMID: 38949484 DOI: 10.1111/aor.14815] [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: 02/12/2024] [Revised: 05/24/2024] [Accepted: 06/11/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Liver transplantation is used for treating end-stage liver disease, fulminant hepatitis, and oncological malignancies and organ shortage is a major limiting factor worldwide. The use of grafts based on extended donor criteria have become internationally accepted. Oxygenated machine perfusion technologies are the most recent advances in organ transplantation; however, it is only applied after a period of cold ischemia. Due to its high cost, we aimed to use a novel device, OxyFlush®, based on oxygenation of the preservation solution, applied during liver procurement targeting the maintenance of ATP during static cold storage (SCS). METHODS Twenty patients were randomly assigned to the OxyFlush or control group based on a 1:1 ratio. In the OxyFlush group, the perfusion solution was oxygenated with OxyFlush® device while the control group received a non-oxygenated solution. Liver and the common bile duct (CBD) biopsies were obtained at three different time points. The first was at the beginning of the procedure, the second during organ preparation, and the third after total liver reperfusion. Biopsies were analyzed, and adenosine triphosphate (ATP) levels and histological scores of the liver parenchyma and CBD were assessed. Postoperative laboratory tests were performed. RESULTS OxyFlush® was able to maintain ATP levels during SCS and improved the damage caused by the lack of oxygen in the CBD. However, OxyFlush® did not affect laboratory test results and histological findings of the parenchyma. CONCLUSION We present a novel low-cost device that is feasible and could represent a valuable tool in organ preservation during SCS.
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Affiliation(s)
- Eduardo de Souza Martins Fernandes
- Laboratory for Clinical and Experimental Research on Vascular Biology (Biovasc), Department of Physiological Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Clementino Fraga Filho University Hospital, UFRJ, Rio de Janeiro, Brazil
| | - Raphael Rodrigues Corrêa
- Department of Surgery, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | | | - Isabel M A Brüggenwirth
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Cindy Yang
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
| | - Felipe Pedreira Tavares de Mello
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | - Ronaldo de Oliveira Andrade
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | - Leandro Moreira Savattone Pimentel
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | - Camila Liberato Girão
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | - Camilla César
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | - Munique Ana Pimentel Siqueira
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, DASA São Lucas Hospital, Rio de Janeiro, Brazil
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, Adventista Silvestre Hospital, Rio de Janeiro, Brazil
- Liver Transplant, São Francisco de Assis Hospital, Rio de Janeiro, Brazil
| | | | | | - Robert J Porte
- Department of Surgery, Section of Hepatobiliary Surgery and Liver Transplantation, University Medical Center Groningen, Groningen, The Netherlands
- Department of Surgery, Section Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Eliete Bouskela
- Laboratory for Clinical and Experimental Research on Vascular Biology (Biovasc), Department of Physiological Sciences, Rio de Janeiro State University, Rio de Janeiro, Brazil
- Obesity Unit, Centro de Pesquisas Clínicas Multiusuário (CePeM), Hospital Universitário Pedro Ernesto (HUPE), State University of Rio de Janeiro, Rio de Janeiro, Brazil
- Postgraduate Program in Clinical and Experimental Physiopathology (Fisclinex), Faculty of Medical Sciences, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [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: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Kulkarni AV, Avadhanam M, Karandikar P, Rakam K, Gupta A, Simhadri V, Premkumar M, Zuberi AA, Gujjarlapudi D, Narendran R, Shaik S, Sharma M, Iyengar S, Alla M, Venishetty S, Reddy DN, Rao PN. Antibiotics With or Without Rifaximin for Acute Hepatic Encephalopathy in Critically Ill Patients With Cirrhosis: A Double-Blind, Randomized Controlled (ARiE) Trial. Am J Gastroenterol 2024; 119:864-874. [PMID: 37942950 DOI: 10.14309/ajg.0000000000002575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 10/10/2023] [Indexed: 11/10/2023]
Abstract
INTRODUCTION Critically ill patients with cirrhosis admitted to the intensive care unit (ICU) are usually on broad-spectrum antibiotics because of suspected infection or as a hospital protocol. It is unclear if additional rifaximin has any synergistic effect with broad-spectrum antibiotics in ICU patients with acute overt hepatic encephalopathy (HE). METHODS In this double-blind trial, patients with overt HE admitted to ICU were randomized to receive antibiotics (ab) alone or antibiotics with rifaximin (ab + r). Resolution (or 2 grade reduction) of HE, time to resolution of HE, in-hospital mortality, nosocomial infection, and changes in endotoxin levels were compared between the 2 groups. A subgroup analysis of patients with decompensated cirrhosis and acute-on-chronic liver failure was performed. RESULTS Baseline characteristics and severity scores were similar among both groups (92 in each group). Carbapenems and cephalosporin with beta-lactamase inhibitors were the most commonly used ab. On Kaplan-Meier analysis, 44.6% (41/92; 95% confidence interval [CI], 32-70.5) in ab-only arm and 46.7% (43/92; 95% CI, 33.8-63) in ab + r arm achieved the primary objective ( P = 0.84).Time to achieve the primary objective (3.65 ± 1.82 days and 4.11 ± 2.01 days; P = 0.27) and in-hospital mortality were similar among both groups (62% vs 50%; P = 0.13). Seven percent and 13% in the ab and ab + r groups developed nosocomial infections ( P = 0.21). Endotoxin levels were unaffected by rifaximin. Rifaximin led to lower in-hospital mortality (hazard ratio: 0.39 [95% CI, 0.2-0.76]) in patients with decompensated cirrhosis but not in patients with acute-on-chronic liver failure (hazard ratio: 0.99 [95% CI, 0.6-1.63]) because of reduced nosocomial infections. DISCUSSION Reversal of overt HE in those on ab was comparable with those on ab + r.
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Affiliation(s)
| | | | | | - Kalyan Rakam
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, India
| | - Anand Gupta
- Department of Critical Care Medicine, AIG Hospitals, Hyderabad, India
| | - Venu Simhadri
- Department of Basic Sciences, Asian Healthcare Foundation, Hyderabad, India
| | | | | | | | | | - Sameer Shaik
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Mithun Sharma
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Sowmya Iyengar
- Department of Hepatology, AIG Hospitals, Hyderabad, India
| | - Manasa Alla
- Department of Hepatology, AIG Hospitals, Hyderabad, India
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Yang Y, Zhang JY, Ma ZJ, Wang SC, He P, Tang XQ, Yang CF, Luo X, Yang X, Li L, Zhang MC, Li Y, Yu JH. Visualization of therapeutic intervention for acute liver injury using low-intensity pulsed ultrasound-responsive phase variant nanoparticles. Biomater Sci 2024; 12:1281-1293. [PMID: 38252410 DOI: 10.1039/d3bm01423a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
Acute liver injury (ALI) is a highly fatal condition characterized by sudden massive necrosis of liver cells, inflammation, and impaired coagulation function. Currently, the primary clinical approach for managing ALI involves symptom management based on the underlying causes. The association between excessive reactive oxygen species originating from macrophages and acute liver injury is noteworthy. Therefore, we designed a novel nanoscale phase variant contrast agent, denoted as PFP@CeO2@Lips, which effectively scavenges reactive oxygen species, and enables visualization through low intensity pulsed ultrasound activation. The efficacy of the nanoparticles in scavenging excess reactive oxygen species from RAW264.7 and protective AML12 cells has been demonstrated through in vitro and in vivo experiments. Additionally, these nanoparticles have shown a protective effect against LPS/D-GalN attack in C57BL/6J mice. Furthermore, when exposed to LIPUS irritation, the nanoparticles undergo liquid-gas phase transition and enable ultrasound imaging.
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Affiliation(s)
- You Yang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Ju-Ying Zhang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Zi-Jun Ma
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Shi-Chun Wang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Ping He
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Xiao-Qing Tang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Chao-Feng Yang
- Department of Radiology, Affifiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Xia Luo
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Xing Yang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Ling Li
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Mao-Chun Zhang
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
| | - Yang Li
- Department of Ultrasound, Yuechi People's Hospital, Guangan, 638300, Sichuan, China
- Department of Radiology, Affifiliated Hospital of North Sichuan Medical College, Nanchong, 637000, Sichuan, China
| | - Jin-Hong Yu
- Department of Ultrasound, Affifiliated Hospital of North Sichuan Medical College, Innovation Centre for Science and Technology of North Sichuan Medical College, Nanchong, 637000, Sichuan, China.
- Department of Ultrasound, Yuechi People's Hospital, Guangan, 638300, Sichuan, China
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