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Rolfes PS, Sundaram SS, Sokol RJ, Taylor SA. Establishing Neonate-specific Prognostic Markers in Acute Liver Failure: Admission Alpha Fetoprotein and Novel Neonatal Acute Liver Failure Scores Predict Patient Outcomes. J Pediatr 2024; 272:114080. [PMID: 38692563 DOI: 10.1016/j.jpeds.2024.114080] [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: 02/12/2024] [Revised: 03/18/2024] [Accepted: 04/23/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE To develop neonate-specific prediction models for survival with native liver (SNL) in neonatal acute liver failure (ALF) and to determine if these prediction models have superior accuracy to existing models for older children with ALF. STUDY DESIGN A single-center, retrospective chart review was conducted on neonates ≤ 30 days of life between 2005 and 2022 with ALF (international normalized ratio ≥ 2 or prothrombin time ≥ 20s and liver dysfunction). Statistical analysis included comparison of patients by outcome of SNL and generalized linear modeling to derive prediction models. The predictive accuracy of variables was evaluated by receiver operating characteristic (ROC) analysis and Kaplan-Meier survival analysis. RESULTS A total of 51 patients met inclusion criteria. The most common causes of neonatal ALF included ischemia (22%), infection (20%), and gestational alloimmune liver disease (16%). Overall SNL rate was 43% (n = 22). Alpha fetoprotein levels were higher in SNL patients (P = .034) and differed more significantly by SNL status among nongestational alloimmune liver disease patients (n = 21, P = .001). An alpha fetoprotein < 4775 ng/mL had 75% sensitivity and 100% specificity to predict death or transplant in nongestational alloimmune liver disease patients with an area under the ROC curve of 0.81. A neonate-specific admission model (international normalized ratio and ammonia) and peak model (prothrombin time and ammonia) also predicted SNL with good accuracy (area under the ROC curve = 0.73 and 0.82, respectively). CONCLUSIONS We identified neonate-specific prognostic variables for SNL in ALF. Findings from our study may help early risk stratification to guide medical decision-making and consideration for liver transplantation.
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Affiliation(s)
- Priya S Rolfes
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO.
| | - Shikha S Sundaram
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Ronald J Sokol
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
| | - Sarah A Taylor
- Department of Pediatrics, Pediatric Liver Center, Digestive Health Institute and Section of Pediatric Gastroenterology, Hepatology & Nutrition, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO
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Samanta A, Poddar U. Pediatric acute liver failure: Current perspective in etiology and management. Indian J Gastroenterol 2024; 43:349-360. [PMID: 38466551 DOI: 10.1007/s12664-024-01520-6] [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: 10/17/2023] [Accepted: 12/28/2023] [Indexed: 03/13/2024]
Abstract
Pediatric acute liver failure (PALF) is a catastrophic clinical condition with very high morbidity and mortality without early detection and intervention. It is characterized by the acute onset of massive hepatocellular injury that releases circulating inflammatory mediators, resulting in metabolic disturbances, coagulopathy, hepatic encephalopathy and multi-organ failure. The etiological spectrum is dominated by hepatotropic viruses, drug-induced liver injury, metabolic and genetic disorders and immune-mediated diseases. Unlike adults, indeterminate causes for acute liver failure constitute a considerable proportion of cases of acute liver failure in children in the west. The heterogeneity of age and etiology in PALF has led to difficulties in developing prognostic scoring. The recent guidelines emphasize prompt identification of PALF, age-appropriate evaluation for hepatic encephalopathy and laboratory evaluation with careful monitoring. Current therapy focuses on supporting the failing liver and other organs, pending either spontaneous recovery or liver transplantation. Targeted therapy is available for a select group of etiologies. Liver transplantation can be lifesaving and a plan for the same should be organized, whenever indicated. The aim of this review is to define PALF, understand its etiopathogenesis, address the challenges encountered during the management and update the latest advances in liver transplantation and non-transplant treatment options in PALF.
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Affiliation(s)
- Arghya Samanta
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India
| | - Ujjal Poddar
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raebareli Road, Lucknow, 226 014, India.
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Poyekar S, Nagral A. Prediction of mortality from hepatitis A virus-related acute liver failure in children-Do we have the perfect prognostic model? Indian J Gastroenterol 2024; 43:292-295. [PMID: 38630419 DOI: 10.1007/s12664-024-01574-6] [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] [Indexed: 05/28/2024]
Affiliation(s)
- Samriddhi Poyekar
- Department of Gastroenterology, Jagjivan Ram Hospital, Mumbai, 400 008, India
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Centre, Mumbai, 400 026, India.
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Ascher Bartlett JM, Bangerth S, Jordan S, Weaver C, Barhouma S, Etesami K, Kohli R, Emamaullee J. CHALF Score: A Novel Tool to Rapidly Risk Stratify Children in Need of Liver Transplant Evaluation During Acute Liver Failure. Transplantation 2024; 108:930-939. [PMID: 37867246 PMCID: PMC10963165 DOI: 10.1097/tp.0000000000004845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
BACKGROUND Pediatric acute liver failure (PALF) can require emergent liver transplantation (LT, >25%) or lead to death (~15%). Existing models cannot predict clinical trajectory or survival with native liver (SNL). We aimed to create a predictive model for PALF clinical outcomes based on admission variables. METHODS A retrospective, single-center PALF cohort (April 2003 to January 2022) was identified using International Classification of Disease codes, selected using National Institutes of Health PALF Study Group (PALFSG) criteria, and grouped by clinical outcome (SNL, LT, or death). Significant admission variables were advanced for feature selection using least absolute shrinkage and selection operator regression with bootstrapping (5000×). A predictive model of SNL versus LT or death was created using logistic regression and validated using PALFSG data. RESULTS Our single-center cohort included 147 patients (58% SNL, 32% LT, 10% expired), while the PALFSG validation cohort included 492 patients (50% SNL, 35% LT, 15% expired). Admission variables associated with SNL included albumin (odds ratio [OR], 16; P < 0.01), ammonia (OR, 2.37; P < 0.01), and total bilirubin (OR, 2.25; P < 0.001). A model using these variables predicted SNL versus LT or death with high accuracy (accuracy [0.75 training, 0.70 validation], area under the curve [0.83 training, 0.78 validation]). A scaled score (CHLA-acute liver failure score) was created that predicted SNL versus LT or death with greater accuracy (C statistic 0.83) than Pediatric End-Stage Liver Disease (C statistic 0.76) and admission liver injury unit (C statistic 0.76) scores. CONCLUSIONS The CHLA-acute liver failure score predicts SNL versus LT or mortality in PALF using admission laboratories with high accuracy. This novel, externally validated model offers an objective guide for urgent referral to a pediatric LT center.
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Affiliation(s)
- Johanna M. Ascher Bartlett
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics; Children’s Hospital Los Angeles, Los Angeles, California, USA
- University of Southern California, Los Angeles, California, USA
| | - Sarah Bangerth
- University of Southern California, Los Angeles, California, USA
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Shannon Jordan
- University of Southern California, Los Angeles, California, USA
| | - Carly Weaver
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics; Children’s Hospital Los Angeles, Los Angeles, California, USA
| | - Sarah Barhouma
- University of Southern California, Los Angeles, California, USA
| | - Kambiz Etesami
- University of Southern California, Los Angeles, California, USA
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Rohit Kohli
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics; Children’s Hospital Los Angeles, Los Angeles, California, USA
- University of Southern California, Los Angeles, California, USA
| | - Juliet Emamaullee
- University of Southern California, Los Angeles, California, USA
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of Surgery, University of Southern California, Los Angeles, California, USA
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Verma SK, Upadhyay P, Shukla S, Jain A, Shukla S, Patwa AK. Prognostic markers in hepatitis A-related pediatric acute liver failure and validation of the Peds-hepatitis A virus prognostic model. Indian J Gastroenterol 2024; 43:459-467. [PMID: 38568354 DOI: 10.1007/s12664-024-01551-z] [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: 01/05/2024] [Accepted: 02/01/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVES Hepatitis A virus (HAV) is the commonest cause for pediatric acute liver failure (PALF) in India. The objective of the study was to identify the predictors of mortality and to evaluate the utility of Peds-HAV model in a cohort of non-LT HAV-PALF. METHODS The study included HAV-related PALF from two non-transplant centers. The predictors of outcome were identified by univariate analysis followed by Cox regression analysis. The prognostic accuracy of Peds-HAV model, King's College Hospital (KCH) criteria and pediatric end-stage liver disease score (PELD) were evaluated. RESULTS As many as 140 children with PALF were included, of whom 96 (68.6%) children had HAV-PALF. On Cox regression analysis, international normalized ratio (INR) (p < 0.001), jaundice to encephalopathy (JE) interval (p < 0.001) and hepatic encephalopathy (HE) grade 3/4 (p = 0.01) were independent predictors of mortality. The mortality rates were 0% (0/42), 14.3% (3/21), 60% (9/15) and 94.4% (17/18) when none, 1, 2 or 3 criteria of the Peds-HAV were met, respectively. Peds-HAV model at a listing cut-off of ≥ 2 criteria predicted death with 89.7% sensitivity and 89.6% specificity. In contrast, KCH criteria had a lower sensitivity of 62.1%. PELD score had a sensitivity of 89.7% and specificity of 85.1% at a cut-off of 30. The overall prognostic accuracy of Peds-HAV model (89.6%) was higher than those of KCH (83.3%) and PELD (86.5%). CONCLUSION INR, HE grade and JE interval were independent predictors of mortality. The study provides an external validation of Peds-HAV model as a prognostic score in HAV-PALF. CLINICAL TRIAL REGISTRY NUMBER Not applicable as this is a retrospective study.
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Affiliation(s)
- Sanjeev Kumar Verma
- Department of Pediatrics, King George Medical University, Lucknow, 226 003, India.
| | - Piyush Upadhyay
- Department of Pediatrics, Ram Manohar Lohiya Institute of Medical Sciences, Lucknow, 226 010, India
| | - Stuti Shukla
- Department of Pediatrics, King George Medical University, Lucknow, 226 003, India
| | - Amita Jain
- Department of Microbiology, King George Medical University, Lucknow, 226 003, India
| | - Suruchi Shukla
- Department of Microbiology, King George Medical University, Lucknow, 226 003, India
| | - Ajay Kumar Patwa
- Department of Medicine, King George Medical University, Lucknow, 226 003, India
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Li R, Wang J, Zhang C, Squires JE, Belle SH, Ning J, Cai J, Squires RH. Improved mortality prediction for pediatric acute liver failure using dynamic prediction strategy. J Pediatr Gastroenterol Nutr 2024; 78:320-327. [PMID: 38374548 PMCID: PMC10879686 DOI: 10.1002/jpn3.12094] [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: 05/14/2023] [Revised: 09/10/2023] [Accepted: 09/23/2023] [Indexed: 02/21/2024]
Abstract
OBJECTIVES To develop and validate a prediction tool for pediatric acute liver failure (PALF) mortality risks that captures the rapid and heterogeneous clinical course for accurate and updated prediction. METHODS Data included 1144 participants with PALF enrolled during three phases of the PALF registry study over 15 years. Using joint modeling, we built a dynamic prediction tool for mortality by combining longitudinal trajectories of multiple laboratory and clinical variables. The predictive performance for 7-day and 21-day mortality was assessed using the area under curve (AUC) through cross-validation and split-by-time validation. RESULTS We constructed a prognostic joint model that combines the temporal trajectories of international normalized ratio, total bilirubin, hepatic encephalopathy, platelet count, and serum creatinine. Dynamic prediction using updated information improved predictive performance over static prediction using the information at enrollment (Day 0) only. In cross-validation, AUC increased from 0.784 to 0.887 when measurements obtained between Days 1 and 2 were incorporated. AUC remained similar when we used the earlier subset of the sample for training and the later subset for testing. CONCLUSIONS Serial measurements of five variables in the first few days of PALF capture the dynamic clinical course of the disease and improve risk prediction for mortality. Continuous disease monitoring and updating risk prognosis are beneficial for timely and judicious medical decisions.
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Affiliation(s)
- Ruosha Li
- Department of Biostatistics and Data Sciences, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Jingyan Wang
- Department of Biostatistics and Data Sciences, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Cuihong Zhang
- Department of Biostatistics and Data Sciences, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - James E. Squires
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Steven H. Belle
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jianwen Cai
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Robert H. Squires
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Özgör B, Gungor S, Aladağ M, Varol FI, Aslan M, Yilmaz S, Gungor S. The Value of Electroencephalogram (EEG) Findings in the Evaluation and Treatment Management of Pediatric Acute Liver Failure. Cureus 2024; 16:e54300. [PMID: 38496192 PMCID: PMC10944321 DOI: 10.7759/cureus.54300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 03/19/2024] Open
Abstract
Background Pediatric acute liver failure (PALF) is still life-threatening and requires urgent care. The presence of encephalopathy is a clinical diagnosis, but it is more difficult to diagnose in children than in adults, and an electroencephalogram (EEG) can be invaluable. The role of EEG in managing the treatment of patients with PALF, other than the identification of encephalopathy, is unknown. This study aimed to investigate patients' EEGs, which may guide in choosing the most appropriate treatment in encephalopathy children. A further aim was to investigate a new score method, based on the laboratory results, which might indicate the presence of encephalopathy in cases with PALF. Methods Medical data of 33 PALF patients followed in our clinic were reviewed retrospectively. This study included 33 patients, whose EEG recording was taken on the first day of supportive treatment due to liver failure in the pediatric intensive care unit (PICU). The EEG findings were categorized into three classes: normal, epileptic and non-epileptic paroxysmal, and background encephalopathic patterns including widespread slowing and voltage suppression. Result This retrospective study included 13 male and 20 female patients with a mean age at presentation of 4.82±4.81 months whose EEG was performed on the first day of supportive therapy for liver failure in the PICU. The EEG findings were categorized into three groups: normal, epileptic and non-epileptic paroxysms, and encephalopathic patterns including diffuse background slowing and voltage suppression. Comparing EEG findings and treatments, we found that the normal EEG group responded well to liver-supporting therapy and the rate of plasmapheresis treatment was significantly higher in the diffuse slowing group. Patients with diffuse slowing of the EEG were 9.6 times more likely to receive plasmapheresis. We found that above a cut-off of ≥7.5 for the TAI (total bilirubin, albumin, and international normalized ratio (INR)) score used in our study, the risk of developing encephalopathy increased 14.4-fold. Conclusions In PALF, EEG findings can provide findings that will help clinicians in determining treatment selection and prognosis, as well as detecting epileptic focus and encephalopathy. The TAI score can be used to assess the risk of encephalopathy in cases of PALF, when it is challenging to identify encephalopathy or when an EEG is not possible.
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Affiliation(s)
- Bilge Özgör
- Pediatric Neurology, İnönü University, Malatya, TUR
| | - Sukru Gungor
- Pediatric Gastroenterology, İnönü University, Malatya, TUR
| | - Merve Aladağ
- Pediatric Medicine, Nurdağı State Hospital, Gaziantep, TUR
| | - Fatma I Varol
- Pediatric Gastroenterology, İnönü University, Malatya, TUR
| | - Mahmut Aslan
- Pediatric Neurology, Mersin City Hospital, Mersin, TUR
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Zhang C, Ning J, Cai J, Squires JE, Belle SH, Li R. Dynamic risk score modeling for multiple longitudinal risk factors and survival. Comput Stat Data Anal 2024; 189:107837. [PMID: 37720873 PMCID: PMC10501111 DOI: 10.1016/j.csda.2023.107837] [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] [Indexed: 09/19/2023]
Abstract
Modeling disease risk and survival using longitudinal risk factor trajectories is of interest in various clinical scenarios. The capacity to build a prognostic model using the trajectories of multiple longitudinal risk factors, in the presence of potential dependent censoring, would enable more informed, personalized decision making. A dynamic risk score modeling framework is proposed for multiple longitudinal risk factors and survival in the presence of dependent censoring, where both events depend on participants' post-baseline clinical progression and form a competing risks structure. The model requires relatively few random effects regardless of the number of longitudinal risk factors and can therefore accommodate multiple longitudinal risk factors in a parsimonious manner. The proposed method performed satisfactorily in extensive simulation studies. It is further applied to the motivating registry study on pediatric acute liver failure to model death using the trajectories of multiple clinical and biochemical markers. Once established, the model yields an easily calculable longitudinal risk score that can be used for disease monitoring among future patients.
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Affiliation(s)
- Cuihong Zhang
- Department of Biostatistics & Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Jing Ning
- Department of Biostatistics, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jianwen Cai
- Department of Biostatistics, The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - James E. Squires
- Division of Gastroenterology, Hepatology, and Nutrition, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Steven H. Belle
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ruosha Li
- Department of Biostatistics & Data Science, The University of Texas Health Science Center at Houston, Houston, TX, USA
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Pediatric acute liver failure in Saudi Arabia: prognostic indicators, outcomes and the role of genetic testing. Eur J Gastroenterol Hepatol 2023; 35:420-430. [PMID: 36574286 DOI: 10.1097/meg.0000000000002499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE The objective of this study was to determine the etiologies, outcomes, prognostic indicators and the role of genetic testing in children with acute liver failure (ALF). METHODS This retrospective study included 46 patients with pediatric acute liver failure (PALF) according to the PALF study group definition, admitted to King Fahad Specialist Hospital-Dammam, Saudi Arabia, between January 2014 and December 2021. Patients who survived with supportive therapy were designated as the recovery group, whereas those who died or underwent liver transplantation were designated as the death/transplant group. RESULTS There were 26 (56.5%) patients in the recovery group and 20 (43.5%) patients in the death/transplant group. Four patients (8.7%) underwent liver transplantation. After indeterminate causes (45.6%), genetic-metabolic diseases and drug-induced liver injury (DILI) were the most common cause with 15.2 and 13%, respectively. Genetic testing had a high yield of (6/31) in identifying monogenic disease associated with ALF. Younger age, lower Glasgow Coma Scale and higher international normalized ratio (INR) on admission were predictors for poor prognosis. The death/transplant group had longer intensive care unit stay ( P < 0.001), and on admission they had more advanced hepatic encephalopathy ( P < 0.005), more prolonged prothrombin time ( P < 0.001), higher lactate ( P < 0.006), higher total and direct bilirubin ( P < 0.008) and ( P < 0.001), respectively. CONCLUSION Genetic, metabolic and DILI causes constituted the most common cause of PALF after indeterminate causes. The use of genetic testing can improve diagnostic rates in special cases, but we could not assess the effect of genetic testing on prognosis. The overall survival rate in our study was 65.2%. Younger age, higher admission INR and lower Glasgow coma scale were indicators of poor prognosis.
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Long-Term Survival Outcomes beyond the First Year after Liver Transplantation in Pediatric Acute Liver Failure Compared with Biliary Atresia: A Large-Volume Living Donor Liver Transplantation Single-Center Study. J Clin Med 2022; 11:jcm11247480. [PMID: 36556096 PMCID: PMC9780885 DOI: 10.3390/jcm11247480] [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: 11/06/2022] [Revised: 12/12/2022] [Accepted: 12/15/2022] [Indexed: 12/23/2022] Open
Abstract
Pediatric acute liver failure (PALF) is a common cause of liver transplantation (LT) but showed poor post-LT outcomes. We reviewed 36 PALF patients and 120 BA patients who underwent LT in our institution. The cause of PALF was unknown in 66.7%. PALF patients were older (6.2 vs. 2.9 years) with higher PELD scores (31.5 vs. 24.4) and shorter waitlist time (15.7 vs. 256.1 days) (p < 0.01). PALF patients showed higher rates of post-transplant renal replacement therapy (RRT) (13.9% vs. 4.2%) and hepatic artery complications (13.9% vs. 0.8%), while portal vein complications rates were lower (0% vs. 10.8%), (p < 0.05). Although PALF patients showed lower 5-year survival rates (77.8% vs. 95.0 %, p < 0.01), the 5-year survival rates of patients who lived beyond the first year were comparable (96.6% vs. 98.3%, p = 0.516). The most common cause of deaths within one year was graft failure (75.0%) in PALF patients, but infection (67.7%) in BA patients. In multivariate analysis, lower body weight, hepatic artery complications and post-transplant RRT were associated with worse survival outcomes (p < 0.05). In conclusion, physicians should be alert to monitor the immediate postoperative graft dysfunction and hepatic artery complications and patients on post-transplant RRT in order to improve survival outcomes in PALF patients.
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Gong K, Xu X, Yao J, Ye S, Yu X, Tu H, Lan Y, Fan YC, Shi Y. Acute hepatitis of unknown origin in children: A combination of factors. Front Pharmacol 2022; 13:1056385. [PMID: 36438816 PMCID: PMC9698116 DOI: 10.3389/fphar.2022.1056385] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 10/31/2022] [Indexed: 08/16/2023] Open
Abstract
On 5 April 2022, the World Health Organization was notified of 10 cases of severe acute hepatitis of unknown etiology in children under 10 years of age in the United Kingdom. Although the exact cause of a proportion of pediatric acute hepatitis and acute liver failure cases was unclear, the above event has caused widespread concern worldwide. As of 14 September 2022, approximately 1,296 probable cases of acute hepatitis of unknown etiology have been reported from 37 countries/regions, of which approximately 55 required or received liver transplantation and 29 died. Although the etiology of acute hepatitis of unknown origin in children remains unclear, many hypotheses have been proposed about the disease. Instead of individual factors such as "adenovirus infection," "SARS-CoV-2 related," and "Adeno-associated virus 2 with helper virus coinfection," it is more likely due to a combination of factors. Accordingly, there is an urgent need for more data and research to clarify the disease etiology. This review aims to provide a historical perspective of acute hepatitis of unknown etiology in children in the past decades and summarize the current hypothesis and evidence on this emerging disease.
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Affiliation(s)
- Kai Gong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xianbin Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Junjie Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Shaoheng Ye
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Xia Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Huilan Tu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yan Lan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Yu-chen Fan
- Department of Hepatology, Qilu Hospital, Cheeloo College of Medicine, Shandong University, Jinan, Shandong, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
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Ascher Bartlett JM, Yanni G, Kwon Y, Emamaullee J. Pediatric acute liver failure: Reexamining key clinical features, current management, and research prospects. Liver Transpl 2022; 28:1776-1784. [PMID: 35557028 PMCID: PMC9588650 DOI: 10.1002/lt.26500] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 04/13/2022] [Accepted: 05/04/2022] [Indexed: 01/01/2023]
Abstract
This review aims to synthesize the most updated research, outcomes, and trends in the field of pediatric liver transplantation (LT), specifically focusing on children who have suffered from acute liver failure. Pediatric acute liver failure is a dynamic, life-threatening condition that can either self-resolve or lead to death. LT is a lifesaving intervention. With the introduction of technical variant grafts and recent immunosuppression modifications, overall patient survival, graft survival, and waitlist mortality have improved. Furthermore, recent advances in the knowledge of immunologic mediators of acute liver failure offer the possibility of more detailed understanding of the pathophysiology and new areas for research. Given the success of living donor LT for pediatric patients with acute liver failure, this option should continue to be actively considered as an alternative treatment option for patients who are listed for transplantation and are managed at a multidisciplinary tertiary care transplant center.
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Affiliation(s)
- Johanna M. Ascher Bartlett
- Division of Gastroenterology, Hepatology and Nutrition, Department of PediatricsChildren's Hospital Los AngelesCaliforniaLos AngelesUSA
| | - George Yanni
- Division of Gastroenterology, Hepatology and Nutrition, Department of PediatricsChildren's Hospital Los AngelesCaliforniaLos AngelesUSA
| | - Yong Kwon
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaCaliforniaLos AngelesUSA
| | - Juliet Emamaullee
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Department of SurgeryUniversity of Southern CaliforniaCaliforniaLos AngelesUSA
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Jagadisan B, Dhawan A. Emergencies in paediatric hepatology. J Hepatol 2022; 76:1199-1214. [PMID: 34990749 DOI: 10.1016/j.jhep.2021.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022]
Abstract
The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.
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Affiliation(s)
- Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK.
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Choi HJ, Kim I, Lee HJ, Oh HJ, Ahn MK, Baek WI, Kim YE, Oh SH, Lee BS, Namgoong JM, Kim DY, Lee EJ, Shim JO, Ko JS, Kim KM. Clinical characteristics of neonatal cholestasis in a tertiary hospital and the development of a novel prediction model for mortality. EBioMedicine 2022; 77:103890. [PMID: 35220043 PMCID: PMC8889106 DOI: 10.1016/j.ebiom.2022.103890] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/24/2021] [Accepted: 02/04/2022] [Indexed: 11/05/2022] Open
Abstract
Background Few studies have described the aetiologies of neonatal cholestasis, and the overall neonatal cholestasis-related mortality (NCM) rate is unclear. We investigated the aetiology and outcome of neonatal cholestasis in a tertiary hospital and developed an NCM prediction model for these patients. Methods Patients aged <100 days with serum direct bilirubin (DB) levels of >1.0 mg/dL were retrospectively screened. Diagnostic and laboratory data during the 8-week follow-up period after enrolment between 2005 and 2020 were extracted digitally, and medical charts were reviewed manually by clinicians. Logistic regression was used to derive a prediction model for the 1-year mortality outcome of neonatal cholestasis, and performance evaluation and external validation were conducted for the NCM prediction model. Findings We enrolled 4028 neonates with DB of >1.0 mg/dL at least once. Prematurity and birth injury (35.4%), complex heart anomalies (18.6%), liver diseases (11.4%), and gastrointestinal anomalies (9.2%) were the most common aetiologies; 398 (9.9%) patients died before one year of age. The peak value of DB was positively correlated to the 1-year mortality rate. In the multivariate analysis, simple laboratory indices, including platelet, prothrombin time, aspartate aminotransferase, albumin, direct bilirubin, creatinine, and C-reactive protein, were independent predictors of 1-year mortality outcome of complete-case subjects. Using these laboratory indices, a logistic regression-based NCM prediction model was constructed. It showed acceptable performances on discrimination (area under the curve, 0.916), calibration (slope, 1.04) and Brier scoring (0.072). The external validation of the sample (n = 920) from two other centres also revealed similar performance profiles of the NCM model. Interpretation Various aetiologies of neonatal cholestasis were identified in a tertiary hospital, resulting in unfavourable outcomes of a large proportion. The NCM prediction model may have the potential to help clinicians to be aware of high-risk neonatal cholestasis.
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Amatya P, Kapalavai SK, Deep A, Sankaranarayanan S, Krupanandan R, Sadasivam K, Ramachandran B. Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings. Front Pediatr 2022; 10:956699. [PMID: 36120651 PMCID: PMC9478462 DOI: 10.3389/fped.2022.956699] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure. MATERIALS AND METHODS This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled. RESULTS Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation. CONCLUSION Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.
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Affiliation(s)
- Puja Amatya
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Sudeep Kumar Kapalavai
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Akash Deep
- Department of Pediatric Critical Care, King's College Hospital, London, United Kingdom
| | | | - Ravikumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Kalaimaran Sadasivam
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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Ribas GS, Lopes FF, Deon M, Vargas CR. Hyperammonemia in Inherited Metabolic Diseases. Cell Mol Neurobiol 2021; 42:2593-2610. [PMID: 34665389 DOI: 10.1007/s10571-021-01156-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/10/2021] [Indexed: 12/13/2022]
Abstract
Ammonia is a neurotoxic compound which is detoxified through liver enzymes from urea cycle. Several inherited or acquired conditions can elevate ammonia concentrations in blood, causing severe damage to the central nervous system due to the toxic effects exerted by ammonia on the astrocytes. Therefore, hyperammonemic patients present potentially life-threatening neuropsychiatric symptoms, whose severity is related with the hyperammonemia magnitude and duration, as well as the brain maturation stage. Inherited metabolic diseases caused by enzymatic defects that compromise directly or indirectly the urea cycle activity are the main cause of hyperammonemia in the neonatal period. These diseases are mainly represented by the congenital defects of urea cycle, classical organic acidurias, and the defects of mitochondrial fatty acids oxidation, with hyperammonemia being more severe and frequent in the first two groups mentioned. An effective and rapid treatment of hyperammonemia is crucial to prevent irreversible neurological damage and it depends on the understanding of the pathophysiology of the diseases, as well as of the available therapeutic approaches. In this review, the mechanisms underlying the hyperammonemia and neurological dysfunction in urea cycle disorders, organic acidurias, and fatty acids oxidation defects, as well as the therapeutic strategies for the ammonia control will be discussed.
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Affiliation(s)
- Graziela Schmitt Ribas
- Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil.
| | - Franciele Fátima Lopes
- Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil
| | - Marion Deon
- Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil
| | - Carmen Regla Vargas
- Departamento de Análises Clínicas, Faculdade de Farmácia, Universidade Federal do Rio Grande do Sul, Porto Alegre, RS, Brazil. .,Serviço de Genética Médica, Hospital de Clíınicas de Porto Alegre, Ramiro Barcelos, 2350, Porto Alegre, RS, CEP 90035-003, Brazil.
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Abstract
The authors have analyzed the indications and outcomes after ALPPS procedure considering modern literature data devoted to this surgery in pediatric patients. No data on post-resection liver failure, as well as unclear future liver remnant function make it possible to question the feasibility of such procedures in children.
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Affiliation(s)
- D G Akhaladze
- Dmitry Rogachev National Medical Research Center of Pediatric Hematology,Oncology and Immunology, Moscow, Russian Federation
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Ahmad AH, Mahadeo KM. Perspective: A Framework to Screen Pediatric and Adolescent Hematopoietic Cellular Therapy Patients for Organ Dysfunction: Time for a Multi-Disciplinary and Longitudinal Approach. Front Oncol 2021; 11:622630. [PMID: 33718184 PMCID: PMC7943835 DOI: 10.3389/fonc.2021.622630] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 01/05/2021] [Indexed: 12/23/2022] Open
Abstract
Hematopoietic Cell Transplantation (HCT) is a potentially curative therapy for children and adolescent/young adults (AYA) with high-risk malignancies as well as some non-malignant genetic diseases. However, HCT may be associated with endotheliopathies and/or organ dysfunction that may progress to pediatric multi-organ dysfunction syndrome (pMODS) and require critical care intervention. Discipline specific scoring systems may be used to characterize individual organ dysfunction, but the extent to which they are used to prospectively monitor HCT patients with mild dysfunction is unknown. Further, separate scoring systems may be used to define risk of mortality and inform prognostication among those who require critical care support. Our understanding of the epidemiology, risk factors, morbidity, mortality, required monitoring, optimal prevention strategies and appropriate management of children undergoing HCT who develop organ dysfunction, endotheliopathies and/or progress to pMODS is poor. Discipline-specific registries and clinical studies have described improving outcomes for children undergoing HCT, including those who require critical care support; however, longitudinal studies/prospective registries that capture common data elements among HCT patients with and without organ dysfunction, endotheliopathies and pMODS are needed to facilitate inter-disciplinary collaboration and optimally characterize the risk profiles, define screening and prophylaxis regimens and mitigate toxicity.
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Affiliation(s)
- Ali H Ahmad
- Pediatric Critical Care Medicine, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
| | - Kris M Mahadeo
- Pediatric Stem Cell Transplantation and Cellular Therapy and CARTOX Program, University of Texas at MD Anderson Cancer Center, Houston, TX, United States
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Acute Liver Failure in a Pediatric Patient with Tetralogy of Fallot following Cardiac Catheterization. Case Rep Anesthesiol 2020; 2020:7537902. [PMID: 32774928 PMCID: PMC7399743 DOI: 10.1155/2020/7537902] [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: 03/26/2020] [Revised: 06/09/2020] [Accepted: 07/13/2020] [Indexed: 11/17/2022] Open
Abstract
A 4-month-old female with Tetralogy of Fallot (TOF) developed acute liver failure (ALF) following a cardiac catheterization procedure to correct severe stenosis of her right ventricular outflow tract (RVOT) conduit via balloon angioplasty. Cardiac history included TOF, heterotaxy syndrome, ipsilateral pulmonary veins, interrupted inferior vena cava (IVC) with azygos continuation, patent ductus arteriosus (PDA), and pulmonary atresia that was repaired with a right ventricle (RV) to pulmonary artery (PA) conduit. This is the first case described of its kind to our knowledge. Consent was obtained from the patient's family to publish this case report.
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20
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Development of a Prognostic Score to Predict Mortality in Patients With Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2020; 70:777-782. [PMID: 32443030 DOI: 10.1097/mpg.0000000000002625] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study aims to develop a new prognostic score based on changes in serial laboratory data from patients with pediatric acute liver failure (PALF). METHODS We retrospectively reviewed data on 146 patients with PALF at the Seoul National University Children Hospital (SNUCH) and the Asan Medical Center (AMC). Daily morning laboratory records were obtained for up to 7 days after diagnosis of PALF: total bilirubin (TB) (mg/dL), international normalized ratio for prothrombin time (INR) at enrolment; peak TB, peak INR, peak ammonia (μmol/L); the difference between the peak TB and TB at enrollment (ie, Δpeak TB), the difference between the peak INR and INR at enrollment (ie, Δpeak INR), the maximum change in serial TB (ie, Δdaily TB), the maximum change in serial INR level (ie, Δdaily INR). We assigned nontransplanted patients in SNUCH and AMC to derivation and validation cohorts, respectively. RESULTS Δpeak TB, Δdaily TB, Δpeak INR, and Δdaily INR were significantly higher in the nonsurvival group. We developed a new score that can predict mortality in nontransplanted patients (derivation cohort n = 42, validation cohort n = 33). PALF-Delta score (PALF-Ds) = [0.232 × Δpeak TB (mg/dL)] + [2.263 × Δdaily INR] + [0.013 × peak ammonia (μmol/L)] - 4.498. The score yielded AUC 0.918 in the derivation cohort (sensitivity 81%, specificity 91%) and AUC 0.947 in the validation cohort (sensitivity 100%, specificity 89%). CONCLUSION A prognostic scoring system using the change of TB/INR may be useful for predicting mortality in patients with PALF.
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Lal BB, Sood V, Snehavardhan P, Khanna R, Pasupuleti SSR, Siloliya M, Kumar G, Alam S. A novel, bedside, etiology specific prognostic model (Peds-HAV) in hepatitis A induced pediatric acute liver failure. Hepatol Int 2020; 14:483-490. [PMID: 32372333 DOI: 10.1007/s12072-020-10050-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/18/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND Hepatitis A virus (HAV) is the commonest cause of pediatric acute liver failure (PALF) in developing countries. Our objective was to develop and validate a HAV-etiology specific prognostic model in PALF. METHODS All children with HAV induced PALF (IgM HAV reactive) were included. Outcome was defined at day 28. Only those with death or native liver survival were included. The model (Peds-HAV) was derived using the independent predictors of outcome and validated in a prospective independent cohort. RESULTS Hepatitis A accounted for 131 (45.9%) of total 285 PALF. After excluding 11 children who underwent liver transplant, 120 children (74 survivors and 46 death) were included. The first 75 patients formed the derivation cohort and the next 45 patients formed the prospective validation cohort. In the derivation cohort, INR: OR 2.208, (95% CI 1.321-3.690), p = 0.003, grade of hepatic encephalopathy (HE): OR 3.078, (95% CI 1.017-9.312), p = 0.047 and jaundice-to-HE interval: OR 1.171, (95% CI 1.044-1.314), p = 0.007 were independent predictors of death. The final model comprised three criteria: (1) presence of grade 3-4 HE, (2) INR greater than 3.1, and (3) jaundice to HE interval more than 10 days. Presence of 2 or more of these criteria predicted death with 90% sensitivity, 81.4% specificity and 84.9% accuracy. Peds-HAV model was superior to existing prognostic models. In the validation cohort, Peds-HAV model predicted death with 83.3% sensitivity and 92.6% specificity. CONCLUSION Peds-HAV model is a simple, bedside, dynamic, etiology (HAV) specific prognostic model based on 3 objective parameters with optimum sensitivity and specificity, hence should be used as liver transplant listing criteria in HAV induced PALF.
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Affiliation(s)
- Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Pandey Snehavardhan
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | | | - Manish Siloliya
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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Mendizabal M, Dip M, Demirdjian E, Lauferman L, Lopez S, Minetto J, Costaguta A, Rumbo C, Malla I, Sanchez MC, Halac E, Cervio G, Cuarterolo M, Galoppo M, Imventarza O, Bisgniano L, D'Agostino D, Rubinstein F. Changing Etiologies and Prognostic Factors in Pediatric Acute Liver Failure. Liver Transpl 2020; 26:268-275. [PMID: 31606931 DOI: 10.1002/lt.25658] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Accepted: 09/29/2019] [Indexed: 02/07/2023]
Abstract
After the implementation of universal hepatitis A virus vaccination in Argentina, the outcome of pediatric acute liver failure (PALF) remains unknown. We aimed to identify variables associated with the risk of liver transplantation (LT) or death and to determine the causes and short-term outcomes of PALF in Argentina. We retrospectively included 135 patients with PALF listed for LT between 2007 and 2016. Patients with autoimmune hepatitis (AIH), Wilson's disease (WD), or inborn errors of metabolism (IEM) were classified as PALF-chronic liver disease (CLD), and others were classified as "pure" PALF. A logistic regression model was developed to identify factors independently associated with death or need of LT and risk stratification. The most common etiologies were indeterminate (52%), AIH (23%), WD (6%), and IEM (6%). Overall, transplant-free survival was 35%, whereas 50% of the patients underwent LT and 15% died on the waiting list. The 3-month risk of LT or death was significantly higher among patients with pure PALF compared with PALF-CLD (76.5% versus 42.5%; relative risk, 1.8 [1.3-2.5]; P < 0.001), and 3 risk factors were independently associated with worse outcome: international normalized ratio (INR) ≥3.5 (odds ratio [OR], 3.1; 95% confidence interval [CI], 1.3-7.2]), bilirubin ≥17 mg/dL (OR, 4.4; 95% CI, 1.9-10.3]), and pure PALF (OR, 3.8; 95% CI, 1.6-8.9). Patients were identified by the number of risk factors: Patients with 0, 1, or ≥2 risk factors presented a 3-month risk of worse outcome of 17.6%, 36.6%, and 82%, respectively. In conclusion, although lacking external validation, this simple risk-staging model might help stratify patients with different transplant-free survival rates and may contribute to establishing the optimal timing for LT.
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Affiliation(s)
- Manuel Mendizabal
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina
| | | | | | | | | | | | | | | | - Ivone Malla
- Hepatology and Liver Transplant Unit, Hospital Universitario Austral, Pilar, Argentina.,Hospital Garrahan, Buenos Aires, Argentina
| | - María Camila Sanchez
- Pediatric Gastroenterology and Hepatology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | | | | | - Marcela Galoppo
- Hospital de Niños Dr. Ricardo Gutiérrez, Buenos Aires, Argentina
| | | | - Liliana Bisgniano
- Instituto Nacional Central Unico Coordinador de Ablación e Implante, Buenos Aires, Argentina
| | - Daniel D'Agostino
- Pediatric Gastroenterology and Hepatology Division, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
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Mahadeo KM, Bajwa R, Abdel-Azim H, Lehmann LE, Duncan C, Zantek N, Vittorio J, Angelo J, McArthur J, Schadler K, Chan S, Tewari P, Khazal S, Auletta JJ, Choi SW, Shoberu B, Kalwak K, Harden A, Kebriaei P, Abe JI, Li S, Moffet JR, Abraham S, Tambaro FP, Kleinschmidt K, Richardson PG, Corbacioglu S. Diagnosis, grading, and treatment recommendations for children, adolescents, and young adults with sinusoidal obstructive syndrome: an international expert position statement. Lancet Haematol 2020; 7:e61-e72. [PMID: 31818728 DOI: 10.1016/s2352-3026(19)30201-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/03/2023]
Abstract
Sinusoidal obstructive syndrome, also known as hepatic veno-occlusive disease, is a potentially life-threatening complication that occurs in children undergoing haemopoietic stem-cell transplantation (HSCT). Differences in the incidence of genetic predisposition and clinical presentation of sinusoidal obstructive syndrome between children and adults have rendered the historical Baltimore and Seattle diagnostic criteria insufficient for children. In 2017, the European Society for Blood and Marrow Transplantation (EBMT) proposed the first paediatric diagnostic and severity grading guidelines for sinusoidal obstructive syndrome, intended for implementation across European centres. However, universally accepted paediatric criteria are needed to ensure prompt diagnosis, definitive treatment, and improved outcomes for children, adolescents, and young adults with sinusoidal obstructive syndrome, and to facilitate international clinical research collaboration. We convened an international panel of multidisciplinary experts including physicians with expertise in HSCT, paediatric intensive care, nephrology, hepatology, radiology, pathology, and transfusion medicine; HSCT advanced-practice providers and medical trainees; pharmacists; and translational and basic science researchers from the Pediatric Acute Lung Injury and Sepsis Investigators Network, the EBMT, the Pediatric Blood and Marrow Transplant Consortia, and several other institutions with extensive experience in sinusoidal obstructive syndrome. Panellists convened at The University of Texas, MD Anderson Cancer Center (Houston, TX, USA) in February, 2019, to evaluate the available evidence. In this expert position statement paper, we provide consensus recommendations for the international implementation of guidelines for the diagnosis, severity grading, and treatment of sinusoidal obstructive syndrome among children, adolescents, and young adults. We endorse universal adoption of paediatric diagnostic guidelines for sinusoidal obstruction syndrome as proposed by the EBMT, and provide implementation guidance for standardisation across centres; we have further proposed adjunctive use of age-appropriate organ-specific toxicity criteria for severity grading and provided prophylaxis and treatment considerations among children and adolescent and young adult patients. Key recommendations include: (1) liver biopsy, portal venous wedge pressure, and reversal of portal venous flow on Doppler ultrasonography should not be used for the routine diagnosis of sinusoidal obstructive syndrome in children, adolescents, and young adults; (2) platelet refractoriness can be defined as a corrected count increment of less than 5000-7500 following at least two sequential ABO-compatible fresh platelet transfusions; (3) hepatomegaly is best defined as an absolute increase of at least 1 cm in liver length at the midclavicular line; and if a baseline measurement is not available, hepatomegaly can be defined as greater than 2 SDs above normal for age; and (4) the presence and volume of ascites can be categorised as mild (minimal fluid by liver, spleen, or pelvis), moderate (<1 cm fluid), or severe (fluid in all three regions with >1 cm fluid in at least two regions).
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Affiliation(s)
- Kris M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | - Rajinder Bajwa
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Blood and Marrow Transplantation Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Leslie E Lehmann
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Christine Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Nicole Zantek
- Department of Laboratory Medicine and Pathology, University of Minnesota Medical School. University of Minnesota Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - Jennifer Vittorio
- Department of Pediatrics, Division of Pediatric Transplant Hepatology, New York-Presbyterian Morgan Stanley Children's Hospital, Columbia University Irving Medical Center, New York, NY, USA
| | - Joseph Angelo
- Department of Pediatrics, Renal Division, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care, St Jude's Children's Research Hospital, Memphis, TN, USA
| | - Keri Schadler
- Department of Pediatrics, Division of Pediatric Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sherwin Chan
- Department of Radiology, Division of Pediatric Radiology, Children's Mercy Hospital, University of Missouri Kansas City School of Medicine, Kansas City, MO, USA
| | - Priti Tewari
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Sajad Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeffery J Auletta
- Department of Hematology/Oncology/BMT and Infectious Diseases, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Sung Won Choi
- Department of Pediatrics, Division of Hematology/Oncology and Bone Marrow Transplant, University of Michigan, Ann Arbor, MI, USA
| | - Basirat Shoberu
- Department of Pharmacy, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Krzysztof Kalwak
- Department of Paediatrics, Division of Immunology and Transplantology, Medical University Wroclaw, Wroclaw, Poland
| | - Avis Harden
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Partow Kebriaei
- Department of Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun-Ichi Abe
- Department of Cardiology, Division of Internal Medicine/Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shulin Li
- Department of Pediatrics, Division of Pediatric Research, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jerelyn Roberson Moffet
- Department of Pediatrics, Division of Blood and Marrow Transplant, Duke Children's Hospital, Duke University, Durham, NC, USA
| | - Susan Abraham
- Department of Pathology, Division of Pathology and Laboratory Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Francesco Paolo Tambaro
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, University of Texas MD Anderson Cancer Center, Houston, TX, USA; UOC SIT-TMO AORN Santobono-Pausilipon-Napoli, Italy
| | - Katharina Kleinschmidt
- Department of Pediatrics, Division of Pediatric Oncology, Stem Cell Transplant, University Hospital of Regensburg, Regensburg, Germany
| | - Paul G Richardson
- Department of Medical Oncology, Division of Hematologic Oncology, Jerome Lipper Multiple Myeloma Center, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Selim Corbacioglu
- Department of Pediatrics, Division of Pediatric Oncology, Stem Cell Transplant, University Hospital of Regensburg, Regensburg, Germany
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Chien MM, Chang MH, Chang KC, Lu FT, Chiu YC, Chen HL, Ni YH, Hsu HY, Wu JF. Prognostic parameters of pediatric acute liver failure and the role of plasma exchange. Pediatr Neonatol 2019; 60:389-395. [PMID: 30361144 DOI: 10.1016/j.pedneo.2018.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 05/23/2018] [Accepted: 09/19/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND This study investigated the prognostic parameters and beneficial effects of repeat plasma exchange in children with acute liver failure (ALF). METHODS Twenty-three patients under 18 years of age admitted to National Taiwan University Hospital due to ALF from 2003 to 2016 were included in this retrospective analysis. RESULTS Among the patients, 11 (48%) had native liver recovery (NLR), 9 (39.1%) died without liver transplant, and 3 (12.9%) received liver transplantation. The NLR group showed a lower proportion of idiopathic cases, lower peak ammonia level, higher peak alpha fetoprotein (AFP) level, and they had plasma exchange fewer times than the other groups. Receiver operating characteristic curve analyses yielded optimal cutoff values of plasma exchange (≤6 times), peak ammonia level (<190 μmol/L), and peak AFP level for predicting NLR in children with ALF. CONCLUSION Pediatric ALF with idiopathic etiology, high peak ammonia level, and low peak AFP level are associated with fewer cases of NLR. Plasma exchange for more than six times probably offers little benefit with regard to patient survival if liver transplantation is not performed promptly.
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Affiliation(s)
- Mu-Ming Chien
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Hwei Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Kai-Chi Chang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Fang-Ting Lu
- Department of Pediatrics, Changhua Christian Hospital, Changhua, Taiwan
| | - Yu-Chun Chiu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan
| | - Huey-Ling Chen
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Yen-Hsuan Ni
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Hepatitis Research Center, National Taiwan University Hospital, Taipei, Taiwan
| | - Hong-Yuan Hsu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan; Department of Medical Education and Bioethics, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Jia-Feng Wu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan.
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Nielsen J, Nerup N, Møller S, de Nijs R, Rasmussen A, Bo Svendsen L, Kjaer MS, Brix Christensen V, Borgwardt L. Minimally invasive assessment of hepatic function in children with indocyanine green elimination: a validation study. Scand J Gastroenterol 2019; 54:485-491. [PMID: 30924709 DOI: 10.1080/00365521.2019.1591497] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Objectives: Pediatric liver disease (PLD) covers a variety of etiologies and severities, from mild temporary illness to diseases with fatal outcomes. There is a demand for minimally invasive and reliable measures for assessment of the severity of PLD. Indocyanine green (ICG) elimination kinetics to estimate hepatic function has been used in adults for decades, however, due to invasiveness, the use in PLD is still limited. The aim of the present study was to evaluate minimally invasive estimation of ICG elimination by pulse spectrophotometry (ICGLi), in comparison with traditional spectrophotometry using serial blood samples (ICGbs). Methods: One hundred children aged 0-18 years were included in the study. ICG elimination kinetics was measured with ICGLi and ICGbs, and results compared by failure rates, mean difference, limits of agreement, Bland Altman plots and linear regression analysis. Plasma disappearance rates (PDRLi and PDRbs) were used for comparison. Results: One hundred and twelve simultaneous measurements in 87 patients were performed successfully. Mean difference for PDR (%/min) was 3.58 (95% CI 2.69; 4.47). Limits of agreement were -5.06; 12.22. A linear correlation between the two methods with a regression coefficient of 0.83 (SE 0.02 95% CI 0.80; 0.87) was found. For conversion we computed the following equation; PDRbs = 0.83 × PDRLi. Conclusions: The present study shows that ICG PDR can be obtained by a minimally invasive method and thus replace measures by serial blood samples in children with liver disease of different etiologies and severities. However, a systematic relative difference between the two methods exists. Our proposed correction factor needs to be validated in larger cohorts.
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Affiliation(s)
- Jon Nielsen
- a Department of Paediatrics and Adolescent Medicine , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Nikolaj Nerup
- b Department of Surgical Gastroenterology and Transplantation , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Søren Møller
- c Department of Clinical Physiology, Center of Functional Imaging and Research, Faculty of Health Sciences , Hvidovre Hospital , Hvidovre , Denmark.,d Faculty of Health and Medical Sciences, Department of Clinical Medicine, University of Copenhagen , Copenhagen , Denmark
| | - Robin de Nijs
- e Department of Clinical Physiology, Nuclear Medicine and PET , Copenhagen University Hospital, Rigshospitalet , Copenhagen Ø , Denmark
| | - Allan Rasmussen
- b Department of Surgical Gastroenterology and Transplantation , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Lars Bo Svendsen
- b Department of Surgical Gastroenterology and Transplantation , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Mette Skalshøi Kjaer
- f Department of Medical Gastroenterology and Hepatology , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Vibeke Brix Christensen
- a Department of Paediatrics and Adolescent Medicine , Copenhagen University Hospital Rigshospitalet , Copenhagen Ø , Denmark
| | - Lise Borgwardt
- e Department of Clinical Physiology, Nuclear Medicine and PET , Copenhagen University Hospital, Rigshospitalet , Copenhagen Ø , Denmark
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Squires JE, Rudnick DA, Hardison RM, Horslen S, Ng VL, Alonso EM, Belle SH, Squires RH. Liver Transplant Listing in Pediatric Acute Liver Failure: Practices and Participant Characteristics. Hepatology 2018; 68:2338-2347. [PMID: 30070372 PMCID: PMC6275095 DOI: 10.1002/hep.30116] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Accepted: 05/24/2018] [Indexed: 12/19/2022]
Abstract
Liver transplant (LT) decisions in pediatric acute liver failure (PALF) are complex. Three phases of the PALF registry, containing data on 1,144 participants over 15 years, were interrogated to characterize clinical features associated with listing status. A decrease in the cumulative incidence of listing (P < 0.005) and receiving (P < 0.05) LT occurred without an increase in the cumulative incidence of death (P = 0.67). Time to listing was constant and early (1 day; quartiles 1-3 = 0-2; P = 0.88). The most frequent reasons for not listing were "not sick enough" and "medically unsuitable." Participants listed for LT were more likely male, with coma grade scores >0; had higher international normalized ratio, bilirubin, lactate, and venous ammonia; and had lower peripheral lymphocytes and transaminase levels compared to those deemed "not sick enough." Participants listed versus those deemed "medically unsuitable" were older; had higher serum aminotransferase levels, bilirubin, platelets, and albumin; and had lower lactate, venous ammonia, and lymphocyte count. An indeterminate diagnosis was more prevalent in listed participants. Ventilator (23.8%) and vasopressor (9.2%) support occurred in a significant portion of listed participants but less frequently than in those who were not "medically suitable." Removal from the LT list was a rare event. Conclusion: The cumulative incidence of listing for and receiving LT decreased throughout the PALF study without an increase in the cumulative incidence of death. While all participants fulfilled entry criteria for PALF, significant differences were noted between participants listed for LT and those deemed "not sick enough" as well as those who were "medically unsuitable." Having an indeterminate diagnosis and a requirement for cardiopulmonary support appeared to influence decisions toward listing; optimizing listing decisions in PALF may reduce the frequency of LT without increasing the frequency of death.
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Affiliation(s)
- James E Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - David A Rudnick
- Pediatric Hepatology Departments of Pediatrics and Developmental Biology, Washington University School of Medicine, St. Louis, MO, United States
| | - Regina M Hardison
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Simon Horslen
- Pediatric Hepatology, Seattle Children’s Hospital, Seattle, WA, United States
| | - Vicky L Ng
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, University of Toronto, ON, Canada
| | - Estella M Alonso
- Pediatric Hepatology, Ann and Robert H Lurie Children’s Hospital, Chicago, IL, United States
| | - Steven H Belle
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert H Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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Bryce CL, Chang CCH, Ren Y, Yabes J, Zenarosa G, Iyer A, Tomko H, Squires RH, Roberts MS. Using time-varying models to estimate post-transplant survival in pediatric liver transplant recipients. PLoS One 2018; 13:e0198132. [PMID: 29851966 PMCID: PMC5978879 DOI: 10.1371/journal.pone.0198132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 05/14/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To distinguish clinical factors that have time-varying (as opposed to constant) impact upon patient and graft survival among pediatric liver transplant recipients. METHODS Using national data from 2002 through 2013, we examined potential clinical and demographic covariates using Gray's piecewise constant time-varying coefficients (TVC) models. For both patient and graft survival, we estimated univariable and multivariable Gray's TVC, retaining significant covariates based on backward selection. We then estimated the same specification using traditional Cox proportional hazards (PH) models and compared our findings. RESULTS For patient survival, covariates included recipient diagnosis, age, race/ethnicity, ventilator support, encephalopathy, creatinine levels, use of living donor, and donor age. Only the effects of recipient diagnosis and donor age were constant; effects of other covariates varied over time. We retained identical covariates in the graft survival model but found several differences in their impact. CONCLUSION The flexibility afforded by Gray's TVC estimation methods identify several covariates that do not satisfy constant proportionality assumptions of the Cox PH model. Incorporating better survival estimates is critical for improving risk prediction tools used by the transplant community to inform organ allocation decisions.
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Affiliation(s)
- Cindy L Bryce
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Chung Chou H Chang
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Yi Ren
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Jonathan Yabes
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Gabriel Zenarosa
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Aditya Iyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Heather Tomko
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Robert H Squires
- Department of Pediatrics, School of Medicine; Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Mark S Roberts
- Department of Health Policy and Management, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Clinical and Translational Science, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.,Department of Industrial Engineering, Swanson School of Engineering, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
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Gilbert Pérez JJ, Jordano Moreno B, Rodríguez Salas M. Aetiology, outcomes and prognostic indicators of paediatric acute liver failure. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
Extracorporeal liver support systems (ELSS), encompassing artificial and bioartificial devices, have been used for decades, with the aim of supporting patients with acute liver failure and acute-on chronic liver failure, as a bridge to recovery (acute liver failure only) or liver transplantation, in an era of organ donation shortage. Although biochemical efficacy has been consistently demonstrated by these devices, translation into clinical and survival benefits has been unclear, due to study limitations and lack of reliable prognostic scoring in liver failure. Consequently, extracorporeal devices are not widely accepted as routine therapy in adult liver failure. Recent large multicentre trials using artificial liver systems have not revealed beneficial outcomes associated with albumin dialysis but plasma exchange practices have shown some potential. In paediatric liver failure, data on extracorporeal systems is scarce, comprising few reports on albumin dialysis (namely, Molecular Adsorbent Recirculating System; MARS) and plasma exchange. When extrapolating data from adult studies differences in disease presentation, aetiology, prognosis and the suitability, and safety of such devices in children must be considered. The aim of this review is to critically appraise current practices of extracorporeal liver support systems to help determine efficacy in paediatric liver failure.
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Abstract
OBJECTIVES To describe the epidemiological features, clinical characteristics and outcomes of neonates diagnosed with liver failure, as well as determine prognostic factors. METHODS Cohort study conducted at a single tertiary referral and university-affiliated pediatric center. Hospital records of all neonates diagnosed with liver failure between January 2003 and December 2015 were retrospectively reviewed, and data on clinical and laboratory findings, treatment, and outcomes were collected. Survival analysis (Kaplan-Meier) and Cox regression were performed to identify prognostic factors at diagnosis. Liver failure diagnosis was established using the pediatric acute liver failure study group's diagnostic criteria for every patient with coagulopathy and biochemical pattern of liver disease. RESULTS Forty-five patients were included. In our series, most cases were secondary to ischemia (28.9%). Other causes were neonatal hemochromatosis (17.8%), viral infections (13.3%), and inborn errors of metabolism (13.3%). A total 55.6% (25/45) of the patients died (median age: 16 days; range 1-235 days). Alanine aminotransferase (ALT) at diagnosis was associated with higher mortality or the need for liver transplantation on day 21 after diagnosis (P = .006). For every 500 IU/L increase in ALT serum levels, the mortality/liver transplantation rate increased 1.3 times (hazard ratio 95% confidence interval: 1.1-1.6). Although ischemic neonatal acute liver failure presents with higher ALT levels, these cases appear to have better outcomes. Higher international normalized ratio tended to increase mortality/transplantation (hazard ratio 1.02; 95% confidence interval 0.91-1.2). CONCLUSIONS Neonatal liver failure should perhaps be considered in the differential diagnoses of any coagulopathy. ALT and international normalized ratio levels at diagnosis could predict prognosis in the short term. Ischemic liver failure appears to have a better prognosis.
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Gilbert Pérez JJ, Jordano Moreno B, Rodríguez Salas M. [Aetiology, outcomes and prognostic indicators of paediatric acute liver failure]. An Pediatr (Barc) 2017; 88:63-68. [PMID: 28395968 DOI: 10.1016/j.anpedi.2017.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/23/2017] [Accepted: 02/28/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute liver failure (ALF) is a multisystem disease with severe impairment of liver function of acute onset. The Paediatric End-stage Liver Disease (PELD) score is used as a predictor of mortality in chronic liver disease, however experience is limited in ALF. OBJECTIVES To evaluate the aetiology and outcomes of children with ALF in a Children's Liver Transplant Centre, and to investigate the validity of PELD as a prognostic indicator. PATIENTS AND METHODS A retrospective study was conducted on patients diagnosed with ALF in our hospital from 2000 to 2013 using the criteria of the Paediatric ALF Study Group. RESULTS The study included 49 patients with an age range 0-14years. The most frequent aetiologies were: indeterminate (36.7%) and metabolic (26.5%). Liver transplant (LT) was required by 42.8%, and there were 16.3% deaths. Patients with higher levels of bilirubin, INR, or encephalopathy were more likely to require a liver transplant, yielding an OR for INR 1.93. A cut-off of 27 in the PELD score according to the ROC curve showed a sensitivity of 86% and a specificity of 85%, predicting a worse outcome (AUC: 0.90; P<.001). The survival of patients with ALF without transplantation seems more likely in those who have low values of PELD and absence of encephalopathy, with a RR of 0.326. CONCLUSIONS ALF patients with a high PELD score and the presence of encephalopathy had worse outcomes. The PELD score could be a useful tool to establish the optimum time for inclusion in the transplant list, however further studies are still needed.
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Affiliation(s)
- Juan José Gilbert Pérez
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España
| | - Belén Jordano Moreno
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España.
| | - Mónica Rodríguez Salas
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España
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Jain V, Dhawan A. Prognostic modeling in pediatric acute liver failure. Liver Transpl 2016; 22:1418-30. [PMID: 27343006 DOI: 10.1002/lt.24501] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/12/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is the only proven treatment for pediatric acute liver failure (PALF). However, over a period of time, spontaneous native liver survival is increasingly reported, making us wonder if we are overtransplanting children with acute liver failure (ALF). An effective prognostic model for PALF would help direct appropriate organ allocation. Only patients who would die would undergo LT, and those who would spontaneously recover would avoid unnecessary LT. Deriving and validating such a model for PALF, however, encompasses numerous challenges. In particular, the heterogeneity of age and etiology in PALF, as well as a lack of understanding of the natural history of the disease, contributed by the availability of LT has led to difficulties in prognostic model development. Several prognostic laboratory variables have been identified, and the incorporation of these variables into scoring systems has been attempted. A reliable targeted prognostic model for ALF in Wilson's disease has been established and externally validated. The roles of physiological, immunological, and metabolomic parameters in prognosis are being investigated. This review discusses the challenges with prognostic modeling in PALF and describes predictive methods that are currently available and in development for the future. Liver Transplantation 22 1418-1430 2016 AASLD.
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Affiliation(s)
- Vandana Jain
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK.
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Li R, Belle SH, Horslen S, Chen LW, Zhang S, Squires RH. Clinical Course among Cases of Acute Liver Failure of Indeterminate Diagnosis. J Pediatr 2016; 171:163-70.e1-3. [PMID: 26831743 PMCID: PMC4808594 DOI: 10.1016/j.jpeds.2015.12.065] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Revised: 11/05/2015] [Accepted: 12/23/2015] [Indexed: 01/04/2023]
Abstract
OBJECTIVE To investigate the heterogeneity in clinical course among those with pediatric acute liver failure (PALF) of indeterminate disease etiology. STUDY DESIGN We studied participants enrolled in the PALF registry study with indeterminate final diagnosis. Growth mixture modeling was used to analyze participants' international normalized ratio, total bilirubin, and hepatic encephalopathy trajectories in the first 7 days following enrollment. Participants with at least 3 values for 1 or more of the measurements were included. We examined the association between the resulting latent subgroup classification with participants' characteristics and disease outcomes. Data from participants with PALF of specified etiologies were used to investigate the potential diagnostic value of the latent subgroups. RESULTS In this sample of 380 participants with indeterminate final diagnosis, 115 (30%) experienced mild and quickly improving disease trajectories and another 48 (13%) started with severe disease but improved by day 7. The majority of participants (216, 57%) had disease trajectories that worsened over time. The identified patterns of disease trajectories are predictive of outcome (P < .001). The trajectory patterns are associated with the underlying disease etiology (P < .001) for the 488 participants with PALF of specified etiologies. CONCLUSIONS The clinical courses of participants with PALF of indeterminate disease etiology exhibit distinct trajectory patterns, which have important prognostic and potentially diagnostic value.
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Affiliation(s)
- Ruosha Li
- Department of Biostatistics, University of Texas School of Public Health, Houston, TX
| | - Steven H Belle
- Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA
| | - Simon Horslen
- Division of Gastroenterology, Seattle Children's Hospital, Seattle, WA
| | - Ling-wan Chen
- Department of Statistics, University of Pittsburgh, Pittsburgh, PA
| | - Song Zhang
- Department of Biostatistics, University of Pittsburgh, Pittsburgh, PA
| | - Robert H Squires
- Division of Gastroenterology, Hepatology and Nutrition, Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center, Pittsburgh, PA.
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Abstract
Pediatric acute liver failure (PALF) is a progressive, potentially fatal clinical syndrome occurring in previously healthy children. Our study aimed to determine the current leading causes of PALF in a single center in Germany, identifying possible prognostic markers. Thirty-seven pediatric patients with PALF were included. Medical records were reviewed for demographic, laboratory and clinical data. Laboratory results on admission and at peak value, PELD and MELD score on admission, and intensive care support were assessed. Fifteen patients recovered spontaneously, 14 died without transplantation, and 8 received a liver transplant. Patients who survived were significantly older than patients who died. Specific causes of PALF could be identified as infectious diseases (16%), metabolic diseases (14%), toxic liver injury (11%), immunologic diseases (8%), or vascular diseases (8%). Causes of PALF remained indeterminate in 43%. High ammonia, low albumin, and low ALT levels on admission were associated with worse outcome. Absence of need of ventilation, hemodialysis, and circulatory support predicted spontaneous recovery. In conclusion, infections are the most common known cause of PALF. However, in a large proportion of patients the cause for PALF remains cryptic. Ammonia and albumin levels may be of prognostic value to predict outcomes.
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Lexmond WS, Van Dael CML, Scheenstra R, Goorhuis JF, Sieders E, Verkade HJ, Van Rheenen PF, Kömhoff M. Experience with molecular adsorbent recirculating system treatment in 20 children listed for high-urgency liver transplantation. Liver Transpl 2015; 21:369-80. [PMID: 25366362 DOI: 10.1002/lt.24037] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2014] [Accepted: 10/13/2014] [Indexed: 12/13/2022]
Abstract
For more than 10 years, children at our national center for pediatric liver transplantation (LT) have been treated with Molecular Adsorbent Recirculating System (MARS) liver dialysis as a bridging therapy to high-urgency LT. Treatment was reserved for 20 patients with the highest degrees of hepatic encephalopathy (HE; median grade = 3.5). Death from neurological sequelae was considered imminent for these patients, and this was further reflected in significantly higher international normalized ratios and ammonia levels and worse prognostic liver indices (Model for End-Stage Liver Disease/Pediatric End-Stage Liver Disease scores and liver injury units) in comparison with 32 wait-listed patients who did not receive MARS dialysis. MARS therapy was generally well tolerated, with a reduction in thrombocytes and hemorrhaging as the most common side effects. HE improvement was documented in 30% of the treated patients, but progression to grade IV encephalopathy occurred in 45% of the patients despite the treatment. Serum ammonia, bilirubin, bile acid, and creatinine levels significantly decreased during treatment. Eighty percent of MARS-treated patients survived to undergo LT, and their survival was equivalent to that of non-MARS-treated patients with severe liver failure (69%, P = 0.52). The heterogeneity between MARS-treated patients and non-MARS-treated patients in our cohort precluded a statistical evaluation of a benefit from MARS for patient survival. Our data demonstrate the safety of MARS even in the most severely ill patients awaiting LT, but strategies that promote the more rapid and widespread availability of high-quality donor organs remain of critical importance for improving patient survival in cases of severe acute liver failure.
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Affiliation(s)
- Willem S Lexmond
- Division of Pediatric Nephrology, Beatrix Children's Hospital, University Medical Center Groningen, Groningen, the Netherlands
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Pediatric acute liver failure: variations in referral timing are associated with disease subtypes. Eur J Pediatr 2015; 174:169-75. [PMID: 25005716 DOI: 10.1007/s00431-014-2363-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED In pediatric acute liver failure (PALF), rapid referral to a transplant center (TC) is advocated. Clinical variability of PALF may influence referral timing. We aimed to analyze early or late timing of referral in relation to clinical characteristics and outcome in PALF. We conducted a retrospective, single-center, comparative analysis of clinical and liver function parameters in two PALF cohorts (n = 23 per cohort): cohort 1 (early referral, duration of in-patient care before referral (DCR) <7 days) vs. cohort 2 (late referral, DCR ≥ 7 days). Compared to late referrals, patients referred early were more frequently non-icteric and encephalopathic at initial presentation (n = 14 vs. 5 and n = 13 vs. 4, each p < 0.05). Early referred PALF patients had lower hepatic encephalopathy (HE) grades and bilirubin (grade 1 vs. 2, p < 0.02; 215 vs. 439 μmol/l, p < 0.001, respectively) but higher alanine aminotransferase (ALAT) levels (4,340 vs. 963 U/l, p < 0.001). Cumulative poor prognostic indicators were lower in early referrals (2 vs. 4, p < 0.001). In multivariate analysis, subacute liver failure (SLF >7 days between disease onset and development of encephalopathy) was independently associated with late referral (relative risk 9.48; 95 % CI 1.37-64.85, p < 0.02). Differences in survival to discharge were not significant. CONCLUSION In PALF, referral timing variability is associated with distinct clinical and liver function patterns. Early recognition of prognostic indicators and of SLF may help to improve referral timing and thus PALF management.
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Quintero J, Miserachs M, Ortega J, Bueno J, Dopazo C, Bilbao I, Castells L, Charco R. Indocyanine green plasma disappearance rate: a new tool for the classification of paediatric patients with acute liver failure. Liver Int 2014; 34:689-94. [PMID: 24112412 DOI: 10.1111/liv.12298] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 06/15/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Pediatric acute liver failure is a rare disorder which results in death or the need for liver transplantation in 25-50% of cases. The adults scores are unable to predict survival without liver transplantation of pediatric patients. The present study assessed the use the of indocyanine green plasma disappearance rate as a tool to predict the evolution of pediatric patients with acute liver failure. PATIENTS AND METHODS All patients met the criteria of acute liver failure according to the Pediatric Acute Liver Failure Study Group. King's College, Clichy's criteria and ICG-PDR were obtained on admission or when acute liver failure was diagnosed and repeated every 12-24 hours, respectively. RESULTS Thirteen out of 48 patients suffered an irreversible liver damage. Seven of them underwent a liver transplantation and 6 died on the waiting. A total of 154 ICG-PDR measurements were taken during the study (Median 12.4 %/min, r:6.2 - 26.3). The ICG-PDR was significantly lower in patients who suffered irreversible liver damage compared with those who survived without liver transplantation (median ICG-PDR 4.1 %/min; r:4.0 - 5.7 vs median ICG-PDR 20.3 %/min; r: 9.1 - 30.1; respectively. P < 0.001). Using a ROC curve the cutoff of ICG-PDR for assessing the need for liver transplantation was set at 5.9 %/min (sensitivity 92.3%, specificity 97.1%). Sensitivity, specificity, PPV, NPV and DA for ICG-PDR were higher than the King's College and Clichy's criteria. CONCLUSIONS ICG-PDR is a powerful tool that would improve the categorization of patients with pediatric acute liver failure.
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Affiliation(s)
- Jesús Quintero
- Pediatric Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Catalunya, Spain
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EEG abnormalities are associated with increased risk of transplant or poor outcome in children with acute liver failure. J Pediatr Gastroenterol Nutr 2014; 58:449-56. [PMID: 24345828 DOI: 10.1097/mpg.0000000000000271] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES There are limited data on the incidence of seizures and utility of brain imaging and electroencephalogram (EEG) to predict outcome of children with acute liver failure (ALF). We investigated the association between hepatic encephalopathy (HE) scores, abnormal EEG or neuroimaging, and short-term outcome. METHODS Single-center retrospective observational study of infants and children with ALF who underwent continuous EEG monitoring and brain imaging within 24 hours of admission to the intensive care unit (ICU). RESULTS A total of 19 patients with ALF with a mean age of 6.8 ± 1.5 years were evaluated. The majority of cases (74%) were indeterminate. Of the total, 10 patients (53%) survived to discharge without liver transplant (LT), 5 (26%) received LT, and 4 (21%) died without LT. Seizures occurred in only 2 cases (19%). Patients who had an abnormal EEG on admission (n = 7) were significantly more likely to die or require LT (P < 0.05, Fisher exact test). Patients with either an admission HE score ≤ 2, or liver injury unit score <222, combined with a normal or mildly abnormal EEG were more likely to survive without LT. Neuroimaging was normal in the majority of cases (87%) and was not associated with outcome. CONCLUSIONS Children with a moderate or severe abnormality of EEG background on admission were significantly more likely to require LT or to die. Children with an HE score ≤ 2, and a normal or only mildly abnormal EEG, were significantly more likely to survive without needing LT. These findings are an initial step toward distinguishing patients with ALF who may recover spontaneously from those who will require LT.
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Rajanayagam J, Frank E, Shepherd RW, Lewindon PJ. Artificial neural network is highly predictive of outcome in paediatric acute liver failure. Pediatr Transplant 2013; 17:535-42. [PMID: 23802584 DOI: 10.1111/petr.12100] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/29/2013] [Indexed: 12/28/2022]
Abstract
Current prognostic models in PALF are unreliable, failing to account for complex, non-linear relationships existing between multiple prognostic factors. A computational approach using ANN should provide superior modelling to PELD-MELD scores. We assessed the prognostic accuracy of PELD-MELD scores and ANN in PALF in children presenting to the QLTS, Australia. A comprehensive registry-based data set was evaluated in 54 children (32M, 22F, median age 17 month) with PALF. PELD-MELD scores calculated at (i) meeting PALF criteria and (ii) peak. ANN was evaluated using stratified 10-fold cross-validation. Outcomes were classified as good (transplant-free survival) or poor (death or LT) and predictive accuracy compared using AUROC curves. Mean PELD-MELD scores were significantly higher in non-transplanted non-survivors (i) 37 and (ii) 46 and transplant recipients (i) 32 and (ii) 43 compared to transplant-free survivors (i) 26 and (ii) 30. Threshold PELD-MELD scores ≥27 and ≥42, at meeting PALF criteria and peak, gave AUROC 0.71 and 0.86, respectively, for poor outcome. ANN showed superior prediction for poor outcome with AUROC 0.96, sensitivity 82.6%, specificity 96%, PPV 96.2% and NPV 85.7% (cut-off 0.5). ANN is superior to PELD-MELD for predicting poor outcome in PALF.
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Affiliation(s)
- J Rajanayagam
- Department of Pediatric Gastroenterology Hepatology and Nutrition, Starship Children's Hospital, Auckland, New Zealand
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Lu BR, Zhang S, Narkewicz MR, Belle SH, Squires RH, Sokol RJ. Evaluation of the liver injury unit scoring system to predict survival in a multinational study of pediatric acute liver failure. J Pediatr 2013; 162:1010-6.e1-4. [PMID: 23260095 PMCID: PMC3786160 DOI: 10.1016/j.jpeds.2012.11.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 10/04/2012] [Accepted: 11/02/2012] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the predictive value of the Liver Injury Units (LIU) and admission values (aLIU) of bilirubin and prothrombin time and international normalized ratio scores in a large cohort from the Pediatric Acute Liver Failure (PALF) Study Group, a multinational prospective study. STUDY DESIGN LIU and aLIU scores were calculated for 461 and 579 individuals, respectively, enrolled in the PALF study from 1999 to 2008. Receiver operator characteristic curves were used to evaluate the scores with respect to survival without liver transplantation (LT), death, or LT by 21 days after enrollment. RESULTS At 21 days, 50.3% of participants were alive without LT, 36.2% underwent LT, and 13.4% died. The c-indices for transplant-free survival were 0.81 based on the LIU score with the international normalized ratio (95% CI, 0.78-0.85) and 0.76 based on the aLIU score (95% CI, 0.72-0.79). The LIU score predicted LT better than it predicted death (c-index for LT 0.84, c-index for death 0.76). CONCLUSION Based on data from a large, multicenter cohort of patients with PALF, the LIU score was a better predictor of transplant-free survival than was the aLIU score. The LIU score might be a helpful, dynamic tool to predict clinical outcomes in patients with PALF.
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Affiliation(s)
- Brandy R. Lu
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Song Zhang
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Children's Hospital Colorado, Aurora, CO
| | - Steven H. Belle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Department of Pediatrics, University of Pittsburgh and the Children's Hospital of UPMC, Pittsburgh, PA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Children's Hospital Colorado, Aurora, CO
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Abstract
OBJECTIVES We sought to determine whether markers of T-cell immune activation, including soluble interleukin 2 receptor alpha (sIL2Rα) levels predict outcome in pediatric acute liver failure and may target potential candidates for immunomodulatory therapy. METHODS We analyzed markers of immune activation in 77 patients with pediatric acute liver failure enrolled in a multinational, multicenter study. The outcomes were survival with native liver, liver transplantation (LT), and death without transplantation within 21 days after enrollment. RESULTS Adjusting for multiple comparisons, only normalized serum sIL2Rα level differed significantly among the 3 outcomes, and was significantly higher in patients who died (P=0.02) or underwent LT (P=0.01) compared with those who survived with their native liver. The 37 patients with normal sIL2Rα levels all lived, 30 with their native liver. Of the 15 subjects with markedly high sIL2Rα (≥5000 IU/mL), 5 survived with their native liver, 2 died, and 8 underwent LT. CONCLUSIONS Evidence of immune activation is present in some patients who die or undergo LT. Patients with higher sIL2Rα levels were more likely to die or undergo LT within 21 days than those with lower levels. Identifying a subset of patients at risk for poor outcome may form the foundation for targeted clinical trials with immunomodulatory drugs.
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Sundaram V, Shneider BL, Dhawan A, Ng VL, Im K, Belle S, Squires RH. King's College Hospital Criteria for non-acetaminophen induced acute liver failure in an international cohort of children. J Pediatr 2013; 162:319-23.e1. [PMID: 22906509 PMCID: PMC3504621 DOI: 10.1016/j.jpeds.2012.07.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Revised: 05/09/2012] [Accepted: 07/05/2012] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To validate King's College Hospital criteria (KCHC) in children with non-acetaminophen induced pediatric acute liver failure (PALF) and to determine whether re-optimizing the KCHC would improve predictive accuracy. STUDY DESIGN We used the PALF study group database. Primary outcomes were survival without liver transplantation vs death at 21 days following enrollment. Classification and regression tree analysis was used to determine if modification of KCHC parameters would improve classification of death vs survival. RESULTS Among 163 patients who met KCHC, 54 patients (33.1%) died within 21 days. Sensitivity of KCHC in this cohort was significantly lower than in the original study (61% vs 91%, P = .002), and specificity did not differ significantly. The positive predictive value (PPV) and negative predictive value (NPV) of KCHC for this cohort was 33% and 88% respectively. Classification and regression tree analysis yielded the following optimized parameters to predict death: grade 2-4 encephalopathy, international normalized ratio >4.02, and total bilirubin >2.02 mg/dL. These parameters did not improve PPV, but NPV was significantly better (88% vs 92%, P < .0001). CONCLUSIONS KCHC does not reliably predict death in PALF. With a PPV of 33%, twice as many participants who met KCHC recovered spontaneously than died, indicating that using KCHC may cause over utilization of liver transplantation. Re-optimized cutpoints for KCHC parameters improved NPV, but not PPV. Parameters beyond the KCHC should be evaluated to create a predictive model for PALF.
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Affiliation(s)
- Vinay Sundaram
- Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Benjamin L. Shneider
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
| | - Anil Dhawan
- Paediatric Liver Center, King’s College Hospital, London, United Kingdom
| | - Vicky L. Ng
- Division of Gastroenterology, Hepatology, and Nutrition, Hospital for Sick Children, Toronto, ON, Canada
| | - Kyungah Im
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Steven Belle
- Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Division of Pediatric Gastroenterology, Hepatology, and Nutrition, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA
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Srivastava A, Yachha SK, Poddar U. Predictors of outcome in children with acute viral hepatitis and coagulopathy. J Viral Hepat 2012; 19:e194-201. [PMID: 22239519 DOI: 10.1111/j.1365-2893.2011.01495.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The presence of coagulopathy in acute viral hepatitis (AVH) in children raises issues about prognosis and need for liver transplantation. We evaluated factors predicting outcome in such patients and determined the applicability of the paediatric acute liver failure study group (PALFSG) definition of acute liver failure (ALF) of coagulopathy alone in comparison with coagulopathy and encephalopathy. Children with AVH (clinical features, raised transaminases and positive viral serology) with uncorrectable coagulopathy [prothrombin time (PT) > 15 s] with or without hepatic encephalopathy (HE) were enrolled. Comparative analysis was based on (i) outcome: survivors/nonsurvivors and (ii) ALF criteria: group A coagulopathy (PT > 15 s) and encephalopathy and group B coagulopathy (PT > 20 s). We studied 130 children (86 boys, mean age 7.5 ± 4.5 years): 86 recovered and 44 died. Single virus infection was present in 96 (74%), hepatitis A being the commonest (n-69). On multiple stepwise logistic regression analysis, age <3.5 years, serum bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and clinical signs of cerebral oedema were independent predictors of mortality. Mortality increased from 0% with single to 100% with four risk factors. Ninety-seven cases met the PALFSG criteria: group A-79 and group B-18. Group A subjects had higher mortality (55.6%vs 0%) and poorer liver functions (bilirubin 18.1 ± 8.9 vs 13.8 ± 6.9 mg/dL, PT 63.9 ± 35.1 vs 27.2 ± 5.2 s) than group B. PT deteriorated significantly with the appearance and progression of HE. One-third of children with AVH with coagulopathy die without transplantation. Age <3.5 years, bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and signs of cerebral oedema are predictors of poor outcome. Children with encephalopathy and coagulopathy have a poorer outcome than those with coagulopathy alone.
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Affiliation(s)
- A Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Heffron TG, Pillen T, Smallwood G, Rodriguez J, Sekar S, Henry S, Vos M, Casper K, Gupta NA, Fasola CG, Romero R. Pediatric liver transplantation for acute liver failure at a single center: a 10-yr experience. Pediatr Transplant 2010; 14:228-32. [PMID: 19519799 PMCID: PMC4380080 DOI: 10.1111/j.1399-3046.2009.01202.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Children transplanted for ALF urgently require an optimal graft and have lower post-transplant survival compared with children transplanted for chronic liver disease. Over 10 yr, 33 consecutive children transplanted for ALF were followed. Demographics, encephalopathy, intubation, dialysis, laboratory values, graft type ABOI, XL (GRWR > 5%), DDSLT, LDLT and WLT were evaluated. Complications and survival were determined. ALF accounted for 33/201 (16.4%) of transplants during this period. Twelve of 33 received ABOI, five XL grafts, 18 DDSLT, and three LDLT. Waiting time pretransplant was 2.1 days. One- and three-yr patient survival in the ALF group was 93.4% and 88.9%, and graft survivals were 86.4% and 77.7%. Median follow-up was 1452 days. ABOI one- and three yr patient and graft survival in the ALF was 91.6% and 78.6%. No difference in graft or patient survival was noted in the ALF and chronic liver disease group or the ABOI and the ABO compatible group. A combination of ABO incompatible donor livers, XL grafts, DDSLT, LDLT and WLT led to a short wait time and subsequent graft and patient survival comparable to patients with non-acute disease.
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Pattern of diagnostic evaluation for the causes of pediatric acute liver failure: an opportunity for quality improvement. J Pediatr 2009; 155:801-806.e1. [PMID: 19643443 PMCID: PMC4035352 DOI: 10.1016/j.jpeds.2009.06.005] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2008] [Revised: 04/16/2009] [Accepted: 06/02/2009] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To describe the frequency of diagnostic testing for the 4 most common causes of pediatric acute liver failure (PALF) (drugs, metabolic disease, autoimmune process, and infections) in indeterminate PALF within the PALF Study Group Database. STUDY DESIGN PALF was defined by severe hepatic dysfunction within 8 weeks of onset of illness, with no known underlying chronic liver disease in patients from birth through 17 years of age. RESULTS Of the 703 patients in the database, 329 (47%) had indeterminate PALF. In this group, a drug history was obtained in 325 (99%) urine toxicology screenings performed in 118 (36%) and acetaminophen level measured in 124 (38%) patients. No testing for common metabolic diseases was done in 179 (54%) patients. Anti-nuclear antibody, anti-smooth muscle antibody, and anti-liver kidney microsomal autoantibodies associated with autoimmunity were determined in 239 (73%), 233 (71%), and 208 (63%) patients, and no tests were obtained in 70 (21%). Testing was performed for hepatitis A virus, hepatitis B virus, and Epstein Barr virus in 80%, 86%, and 68%, respectively. CONCLUSIONS Current practice indicates that investigation for metabolic and autoimmune causes of PALF are infrequent in patients ultimately given a diagnosis of indeterminate acute liver failure. This offers an opportunity to improve diagnosis and potential treatment options in children with acute liver failure.
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Fulminant hepatic failure in children: superior and durable outcomes with liver transplantation over 25 years at a single center. Ann Surg 2009; 250:484-93. [PMID: 19730179 DOI: 10.1097/sla.0b013e3181b480ad] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE(S) Death occurs in half of all children with fulminant hepatic failure (FHF). Although liver transplantation (LT) is potentially life-saving, there are only a few published series with limited experience. The aim was to examine predictors of survival after LT for FHF. METHODS Between 1984 and 2008, all LT for FHF performed in recipients less than or equal to 18 years of age were analyzed from a prospectively maintained database using 35 demographic, laboratory, and operative variables. Unique calculated variables included creatinine clearance (cCrCl) and Pediatric End-Stage Liver Disease score (PELD). Study end-points were patient and death censored graft survival. Median follow-up was 98 months. Statistical analysis involved the log-rank test and Cox proportional hazards model. RESULTS A total of 122 children underwent 159 LTx. Cryptogenic was the primary etiology (70%) and the median age was 53 months. The significant (P < 0.05) univariate predictors of worse graft survival were: recipient age <24 months, cCrCl <60 mL/min/1.73m, PELD >25 points, and warm ischemia time >60 minutes. The significant (P < 0.05) univariate predictors of worse patient survival were: recipient African-American and Asian race, recipient age <24 months, cCrCl <60 mL/min/1.73m, and time from onset jaundice to encephalopathy <7 days. On multivariate analysis, survival was significantly impacted by 4 variables: cCrCl <60 mL/min/1.73m (GRAFT and PATIENT), PELD >25 points (GRAFT), recipient age <24 months (GRAFT), and time from onset jaundice to encephalopathy <7 days (PATIENT). While overall 5- and 10-year survival was 73% and 72% (GRAFT) and 77% and 73% (PATIENT), these were significantly worse when a combination of multivariate risk-factors were present. CONCLUSIONS This data from a large, single-center experience demonstrates that LT is the treatment of choice for FHF and results in durable survival. Analysis revealed 4 novel outcome predictors. Young children with rapid onset acute liver failure are a high-risk subpopulation. Unique to this study, cCrCl and PELD accurately predicted the end-points. This analysis identifies patient subpopulations requiring early aggressive intervention with LT.
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Rudnick DA, Dietzen DJ, Turmelle Y, Shepherd R, Zhang S, Belle SH, Squires R. Serum alpha-NH-butyric acid may predict spontaneous survival in pediatric acute liver failure. Pediatr Transplant 2009; 13:223-30. [PMID: 18643912 PMCID: PMC2659723 DOI: 10.1111/j.1399-3046.2008.00998.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
ALF is a serious, often fatal condition. Up to half of PALF patients do not survive without liver transplantation; however, early identification of those least likely to survive spontaneously remains difficult. Clinical experience suggests that recovery from ALF depends on the ability of the liver to regenerate. Based on this, we hypothesized that bio-markers of hepatic regeneration could have utility as predictors of recovery from PALF. In the studies reported here, we used comprehensive amino acid analysis to search for novel metabolomic markers of liver regeneration in mice subjected to partial hepatectomy. This analysis identified alpha-NH(2)-adipic acid and alpha-NH(2)-butyric acid as significantly increased in liver and plasma samples from mice subjected to partial hepatectomy compared to controls. Next, we tested whether serum levels of these markers were associated with clinical outcomes in PALF patients. This examination, performed on the initially collected serum samples from 40 randomly selected patients enrolled in the PALF Study Group, showed increased alpha-NH(2)-butyric-acid (Aab) and Aab:leucine (Aab:Leu) ratio in patients who survived without transplantation compared to those who were transplanted or died. These data indicate that Aab and the Aab:Leu ratio may predict clinical outcomes in PALF.
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Affiliation(s)
- David A. Rudnick
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO,Department of Developmental Biology, Washington University School of Medicine
| | - Dennis J. Dietzen
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Yumirle Turmelle
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ross Shepherd
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Song Zhang
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Steven H. Belle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Rob Squires
- Department of Pediatrics, University of Pittsburgh Medical Center
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Lu BR, Gralla J, Liu E, Dobyns EL, Narkewicz MR, Sokol RJ. Evaluation of a scoring system for assessing prognosis in pediatric acute liver failure. Clin Gastroenterol Hepatol 2008; 6:1140-5. [PMID: 18928939 PMCID: PMC2581795 DOI: 10.1016/j.cgh.2008.05.013] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2008] [Accepted: 05/24/2008] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pediatric acute liver failure (PALF) results in death or need for liver transplantation (LT) in up to 50% of patients. A scoring system for predicting death or LT (Liver Injury Units [LIU] score) in PALF was previously derived by our group, and used peak values during hospital admission of total bilirubin, prothrombin time/international normalized ratio, and ammonia as significant predictors of outcome. The aims of this study were to test the predictive value of the LIU score in a subsequent validation set of patients and to derive a hospital admission LIU (aLIU) score predictive of outcome. METHODS Data were obtained from 53 children admitted with PALF from 2002 to 2006. Outcome was defined at 16 weeks as alive without LT, death, or LT. RESULTS Survival without LT at 16 weeks for each LIU score quartile was 92%, 44%, 60%, and 12%, respectively (P < .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 86.3. An admission LIU score was derived using admission total bilirubin and prothrombin time/international normalized ratio. Survival without LT at 16 weeks for each quartile using the aLIU score was 85%, 77%, 69%, and 31% (P = .001). The receiver operating characteristic C index for predicting death or LT by 4 weeks was 83.7. CONCLUSIONS The original LIU score is a valid predictor of outcome in PALF. The aLIU score is promising and needs to be validated in subsequent patients.
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Affiliation(s)
- Brandy R Lu
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Pediatric Liver Center and Liver Transplantation Program, Department of Pediatrics, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
| | - Jane Gralla
- Pediatric Clinical Translational Research Center, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
| | - Edwin Liu
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Pediatric Liver Center and Liver Transplantation Program, Department of Pediatrics, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
| | - Emily L. Dobyns
- Section of Critical Care Medicine, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Pediatric Liver Center and Liver Transplantation Program, Department of Pediatrics, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Pediatric Liver Center and Liver Transplantation Program, Department of Pediatrics, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA,Pediatric Clinical Translational Research Center, The Children’s Hospital and University of Colorado Denver School of Medicine, Aurora, CO, 80045, USA
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Abstract
Acute liver failure (ALF) is a rare but challenging clinical syndrome with multiple causes; a specific etiology cannot be identified in 15% of adult and 50% of pediatric cases. The course of ALF is variable and the mortality rate is high. Liver transplantation is the only therapy of proven benefit, but the rapidity of progression and the variable course of ALF limit its use. Currently in the United States, spontaneous survival occurs in approximately 45%, liver transplantation in 25%, and death without transplantation in 30% of adults with ALF. Higher rates of spontaneous recovery (56%) and transplantation (31%) with lower rates of death (13%) occur in children. The outcome of ALF varies by etiology, favorable prognoses being found with acetaminophen overdose, hepatitis A, and ischemia (approximately 60% spontaneous survival), and poor prognoses with drug-induced ALF, hepatitis B, and indeterminate cases (approximately 25% spontaneous survival). Excellent intensive care is critical in management of patients with ALF. Nonspecific therapies are of unproven benefit. Future possible therapeutic approaches include N-acetylcysteine, hypothermia, liver assist devices, and hepatocyte transplantation. Advances in stem cell research may allow provision of cells for bioartificial liver support. ALF presents many challenging opportunities in both clinical and basic research.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School, Dallas, TX 75390-8887, USA.
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