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Biswas S, Anand A, Vaishnav M, Mehta S, Swaroop S, Aggarwal A, Arora U, Agarwal A, Elhence A, Mahapatra SJ, Agarwal S, Gunjan D, Sehgal T, Aggarwal M, Dhawan R, Gamanagatti S, Shalimar. Thromboelastography-Guided versus Standard-of-Care or On-Demand Platelet Transfusion in Patients with Cirrhosis and Thrombocytopenia Undergoing Procedures: A Randomized Controlled Trial. J Vasc Interv Radiol 2024; 35:1508-1518.e2. [PMID: 38925267 DOI: 10.1016/j.jvir.2024.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 06/11/2024] [Accepted: 06/14/2024] [Indexed: 06/28/2024] Open
Abstract
PURPOSE To determine the rate of platelet transfusion in patients with cirrhosis and severe thrombocytopenia (platelet counts <50 × 109/L) undergoing high-risk invasive procedures when prescribed by thromboelastography (TEG) compared with empirical and on-demand transfusion strategies. MATERIALS AND METHODS This was a single-center, single-blinded, randomized controlled trial. Patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures were randomized into 3 groups: TEG group, transfusions based on TEG parameters; standard of care (SOC) group, 3 units of random donor platelets before procedure; and on-demand group, transfusions based on procedural adverse events/clinician's discretion. The primary outcome was periprocedural platelet transfusion in each arm. RESULTS Eighty-seven patients were randomized (29 in each group) with no significant differences in demographics/coagulation profile/procedures. The median platelet count was 33 × 109/L (interquartile range, 26-43 × 109/L). Percutaneous liver biopsy was the most common procedure (46, 52.9%). Significantly lower number of patients in the TEG group received platelets (4 cases, 13.8%; 95% CI, 3.9-31.7) compared with SOC group (100%; 95% CI, 88.1-100; P < .001). Four patients in the on-demand group received platelets (13.8%; 95% CI, 3.9-31.7). Minor (World Health Organization [WHO] Grade 2) procedure-related bleeding occurred in 3 (10%; 95% CI, 2.2-27.4) patients in the TEG-guided transfusion group compared with 1 (3.4%; 95% CI, 0.1-17.8) patient each in the SOC and on-demand groups (P = .43), although the study was not powered for comparison of bleeding rates. No bleeding-related mortality was observed in any of the 3 groups. CONCLUSIONS TEG-prescribed transfusion reduced prophylactic transfusions in patients with cirrhosis and severe thrombocytopenia undergoing high-risk invasive procedures. The study was not powered for comparison of bleeding rates.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India. https://twitter.com/JustSagnik
| | - Abhinav Anand
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shubham Mehta
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya Jagannath Mahapatra
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Samagra Agarwal
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India
| | - Tushar Sehgal
- Department of Laboratory Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Mukul Aggarwal
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Rishi Dhawan
- Department of Hematology, All India Institute of Medical Sciences, New Delhi, India
| | - Shivanand Gamanagatti
- Department of Radiodiagnosis and Interventional Radiology, All India Institute of Medical Sciences, New Delhi, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, India.
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Rodríguez-Negrete EV, Gálvez-Martínez M, Sánchez-Reyes K, Fajardo-Felix CF, Pérez-Reséndiz KE, Madrigal-Santillán EO, Morales-González Á, Morales-González JA. Liver Cirrhosis: The Immunocompromised State. J Clin Med 2024; 13:5582. [PMID: 39337069 PMCID: PMC11432654 DOI: 10.3390/jcm13185582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Revised: 09/11/2024] [Accepted: 09/17/2024] [Indexed: 09/30/2024] Open
Abstract
Systemic inflammation and immunodeficiency are important components of cirrhosis-associated immune dysfunction (CAID), the severity of which is dynamic, progressive, and associated with the greater deterioration of liver function. Two inflammation phenotypes have been described: low-grade and high-grade systemic inflammation. Both of these phenotypes are related to liver cirrhosis function; thus, high-grade inflammation is correlated with the severity of hepatic insufficiency, bacterial translocation, and organic insufficiency, with which the risk of infections increases and the prognosis worsens. Bacterial translocation (BT) plays a relevant role in persistent systemic inflammation in patients with cirrhosis, and the prophylactic employment of antibiotics is useful for reducing events of infection and mortality.
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Affiliation(s)
- Elda Victoria Rodríguez-Negrete
- Servicio de Gastroenterología, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Ciudad de México 06720, Mexico
- Laboratorio de Medicina de Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico
| | - Marisol Gálvez-Martínez
- Servicio de Gastroenterología, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Ciudad de México 06720, Mexico
| | - Karina Sánchez-Reyes
- Servicio de Cirugía General, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Ciudad de México 06720, Mexico
| | - Carlos Fernando Fajardo-Felix
- Servicio de Gastroenterología, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Ciudad de México 06720, Mexico
| | - Karla Erika Pérez-Reséndiz
- Servicio de Gastroenterología, Hospital de Especialidades, Centro Médico Nacional Siglo XXI, Ciudad de México 06720, Mexico
| | | | - Ángel Morales-González
- Escuela Superior de Cómputo, Instituto Politécnico Nacional, Unidad Profesional "A. López Mateos", Ciudad de México 07738, Mexico
| | - José Antonio Morales-González
- Laboratorio de Medicina de Conservación, Escuela Superior de Medicina, Instituto Politécnico Nacional, Mexico City 11340, Mexico
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Jothimani D, Rela M, Kamath PS. Management of Portal Hypertension in the Older Patient. Curr Gastroenterol Rep 2024; 26:231-240. [PMID: 38780678 DOI: 10.1007/s11894-024-00930-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2024] [Indexed: 05/25/2024]
Abstract
PURPOSE OF THIS REVIEW Aging is a process of physiological slowing, reduced regenerative capacity and inability to maintain cellular homeostasis. World Health Organisation declared the commencement of population aging globally, largely attributed to improvement in the healthcare system with early diagnosis and effective clinical management. Liver ages similar to other organs, with reduction in size and blood flow. In this review we aim to evaluate the effect of aging in liver disease. RECENT FINDINGS Aging causes dysregulation of major carbohydrate, fat and protein metabolism in the liver. Age is a major risk factor for liver fibrosis accelerated by sinusoidal endothelial dysfunction and immunological disharmony. Age plays a major role in patients with liver cirrhosis and influence outcomes in patients with portal hypertension. Transient elastography may be an useful tool in the assessment of portal hypertension. Hepatic structural distortion, increased vascular resistance, state of chronic inflammation, associated comorbidities, lack of physiological reserve in the older population may aggravate portal hypertension in patients with liver cirrhosis and may result in pronounced variceal bleed. Cut-offs for other non-invasive markers of fibrosis may differ in the elderly population. Non-selective beta blockers initiated at lower dose followed by escalation are the first line of therapy in elderly patients with cirrhosis and portal hypertension, unless contraindicated. Acute variceal bleed in the elderly cirrhotic patients can be life threatening and may cause rapid exsanguination due to poor reserve and associated comorbidities. Vasoactive drugs may be associated with more adverse reactions. Early endoscopy may be warranted in the elderly patients with acute variceal bleed. Role of TIPS in the elderly cirrhotics discussed. Management of portal hypertension in the older population may pose significant challenges to the treating clinician.
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Affiliation(s)
- Dinesh Jothimani
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India.
| | - Mohamed Rela
- Institute of Liver disease and Transplantation, Dr Rela Institute and Medical Centre, Chennai, India
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine and Science, Rochester, MN, 55906, USA
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Drolz A. [Bleeding in liver diseases]. Med Klin Intensivmed Notfmed 2024; 119:458-464. [PMID: 39138654 DOI: 10.1007/s00063-024-01167-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Accepted: 07/08/2024] [Indexed: 08/15/2024]
Abstract
Bleeding events are feared complications in patients with advanced liver diseases and are associated with morbidity and mortality. In this context, gastrointestinal bleeding, particularly upper gastrointestinal bleeding, has a special clinical importance. In addition to endoscopic measures for hemostasis, reducing portal pressure in particular is a key component of treatment. Although the standard coagulation parameters are often altered in patients with liver diseases, optimizing coagulation plays a secondary role. Typically, a bundle of measures are employed in patients with portal hypertensive bleeding, which nowadays in most cases can halt the bleeding and stabilize the situation. The measures include endoscopy, antibiotic treatment, vasopressor treatment and, if necessary, shunt placement (transjugular intrahepatic portosystemic shunt).
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Affiliation(s)
- Andreas Drolz
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
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Artzner T, Goldberg DS, Sundaram V, Faitot F, Karvellas CJ, Asrani SK. Improvement in Survival After Transplantation for Critically Ill Patients With Cirrhosis in the United States. Am J Gastroenterol 2024:00000434-990000000-01227. [PMID: 38976367 DOI: 10.14309/ajg.0000000000002944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2023] [Accepted: 06/06/2024] [Indexed: 07/10/2024]
Abstract
INTRODUCTION There is considerable debate over the indication of liver transplantation (LT) for critically ill patients with cirrhosis, in part due to their potentially poor post-LT prognosis. We analyzed the epidemiology and outcome of LT for critically ill patients with cirrhosis over 4 time periods of 4 years. METHODS We included adult patients who underwent liver transplant alone between 2005 and 2020 using the United Network for Organ Sharing registry database. We defined critically ill patients with cirrhosis as being in the intensive care unit with 1 or more of the following characteristics at the time of LT: (i) grade III/IV hepatic encephalopathy, (ii) mechanical ventilation, (iii) dialysis, and (iv) vasopressors. RESULTS A total of 85,594 LT recipients were included, 5,827 (6.8%) of whom were classified as being critically ill with cirrhosis at the time of LT. The number and percentage of critically ill LT recipients with cirrhosis increased over the study period: 819 (4.3%) in 2005-2008 vs 2,067 (7.9%) in 2017-2020, P < 0.001. There was a 17% absolute increase in 1-year survival after LT: 72.5% in 2005-2008 vs 89.5% in 2017-2020, P < 0.001. The 1-year post-LT survival gap between critically ill and noncritically ill patients with cirrhosis narrowed over the study period: 16.7 percentage points in 2005-2008 vs 4.6 percentage points in 2017-2020. The year of LT was independently associated with lower 1-year post-LT mortality (hazard ratio 0.92, 95% confidence interval 0.91-0.93, P < 0.001). DISCUSSION The absolute number and relative percentage of LT recipients who were critically ill increased over time, as did 1-year post-LT survival. Meanwhile, the gap in survival between this group of patients and noncritically ill patients with cirrhosis decreased but persisted. Cautious access to selected LT candidates who are critically ill may be warranted, provided the gap in survival with noncritically ill patients remains as small as possible.
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Affiliation(s)
- Thierry Artzner
- Liver Transplant Unit, Strasbourg University Hospital, Strasbourg, France
| | - David S Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vinay Sundaram
- Karsh Division of Gastroenterology and Hepatology, Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - François Faitot
- Liver Transplant Unit, Strasbourg University Hospital, Strasbourg, France
| | - Constantine J Karvellas
- Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Sumeet K Asrani
- Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA
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Hohlstein P, Salvarcioglu C, Pollmanns MR, Adams JK, Abu Jhaisha S, Kabak E, Eisert A, Hamesch K, Weiskirchen R, Koch A, Wirtz TH. Diagnostic and Prognostic Value of Serum Leptin in Critically Ill Patients with Acute versus Acute-on-Chronic Liver Failure. Biomedicines 2024; 12:1170. [PMID: 38927377 PMCID: PMC11200812 DOI: 10.3390/biomedicines12061170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
Differentiation between acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) can be challenging in patients with de novo liver disease but is important to indicate the referral to a transplant center and urgency of organ allocation. Leptin, an adipocyte-derived cytokine that regulates energy storage and satiety, has multiple regulatory functions in the liver. We enrolled 160 critically ill patients with liver disease and 20 healthy individuals to measure serum leptin concentrations as a potential biomarker for diagnostic and prognostic purposes. Notably, patients with ALF had higher concentrations of serum leptin compared to patients with decompensated advanced chronic liver disease (dACLD) or ACLF (110 vs. 50 vs. 29 pg/mL, p < 0.001). Levels of serum leptin below 56 pg/mL excluded ALF in patients with acute hepatic disease, with a negative predictive value (NPV) of 98.8% in our cohort. Lastly, serum leptin did not show any dynamic changes within the first 48 h of ICU treatment, especially not in comparison with patients with ALF vs. ACLF or survivors vs. non-survivors. In conclusion, serum leptin may represent a helpful biomarker to exclude ALF in critically ill patients who present with acute liver dysfunction.
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Affiliation(s)
- Philipp Hohlstein
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Can Salvarcioglu
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Maike R. Pollmanns
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Jule K. Adams
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Samira Abu Jhaisha
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Elena Kabak
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Albrecht Eisert
- Hospital Pharmacy, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
- Institute of Clinical Pharmacology, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Karim Hamesch
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Alexander Koch
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Theresa H. Wirtz
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
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Haselwanter P, Scheiner B, Balcar L, Semmler G, Riedl-Wewalka M, Schmid M, Reiberger T, Zauner C, Schneeweiss-Gleixner M. Use of the CytoSorb adsorber in patients with acute-on-chronic liver failure. Sci Rep 2024; 14:11309. [PMID: 38760460 PMCID: PMC11101465 DOI: 10.1038/s41598-024-61658-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 05/08/2024] [Indexed: 05/19/2024] Open
Abstract
CytoSorb is a hemoadsorptive column used to remove high concentrations of proinflammatory cytokines in septic shock. Data on CytoSorb application in acute-on-chronic liver failure (ACLF) is lacking. This retrospective observational study analyzed 21 ACLF patients admitted to ICUs at the Vienna General Hospital who received CytoSorb adsorber therapy between 2017 and 2023. Median ICU length of stay was 8 days (IQR: 3-13), the ICU survival rate was 23.8% (n = 5). Significant decreases in bilirubin (median peak: 20.7 mg/dL to median post-treatment: 10.8 mg/dL; - 47.8%; p < 0.001), procalcitonin (1.34 to 0.74 pg/mL; - 44.6%; p < 0.001), interleukin-6 (385 to 131 ng/mL; - 66.0%; p = 0.0182)-but also of platelets (72 to 31 G/L; - 56.9%; p = 0.0014) and fibrinogen (230 to 154 mg/dL; - 33.0%; p = 0.0297) were detected. ICU survivors had a trend towards a stronger relative decrease in bilirubin (- 76.1% vs. - 48.2%), procalcitonin (- 90.6% vs. - 23.5%), and IL-6 (- 54.6% vs. - 17.8%) upon CytoSorb treatment. Moreover, no serious CytoSorb-attributed complications were detected. In conclusion, use of CytoSorb adsorber in ACLF patients results in a significant decrease in bilirubin and proinflammatory cytokines, while platelets and fibrinogen were also lowered. Prospective trials are warranted to investigate the impact of CytoSorb on clinical outcomes of ACLF patients with high proinflammatory cytokine levels.
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Affiliation(s)
- Patrick Haselwanter
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bernhard Scheiner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Lorenz Balcar
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Georg Semmler
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Marlene Riedl-Wewalka
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Monika Schmid
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Thomas Reiberger
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Christian Zauner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Mathias Schneeweiss-Gleixner
- Intensive Care Unit 13H1, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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Alukal JJ, Li F, Thuluvath PJ. Older Patients With Acute on Chronic Liver Failure Have a Higher Waitlist Mortality, but Acceptable Post Liver Transplantation Survival When Compared to Younger Patients. Clin Gastroenterol Hepatol 2024; 22:1014-1023.e6. [PMID: 38072285 DOI: 10.1016/j.cgh.2023.11.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 11/19/2023] [Accepted: 11/27/2023] [Indexed: 01/17/2024]
Abstract
BACKGROUND & AIMS There is a paucity of studies on older patients (≥65 years) who develop acute on chronic liver failure (ACLF). The objectives of our study were to determine clinical characteristics and outcomes of older patients listed for liver transplantation (LT). METHODS Adults listed for LT with estimated ACLF (Est-ACLF) between 2005 and 2021 were identified using the United Network for Organ Sharing database and subdivided into older and younger age (18-64 years) groups. Kaplan-Meier survival analyses were used to evaluate survival, and a competing-risk model (Fine-Gray) was used to evaluate risk factors for survival on the waitlist. Logistic regression was done to evaluate risk factors. RESULTS A total of 4313 older (14%) and 26,628 younger (86%) patients were listed for LT, and 2142 (49.6%) and 16,931 (63.5%) were transplanted, respectively. Older patients had a higher 30-day waitlist mortality than younger patients (20.4% vs 16.7%; P < .0001); this was more pronounced in Est-ACLF-2 (23.7% vs 14.8%; P < .0001) and Est-ACLF-3 (43.3% vs 29.9%; P < .0001). One-year post-LT, patient survival in older patients with Est-ACLF grades 1, 2, and 3 were 86.4%, 85.5%, and 77% respectively; younger patients had better survival across all Est-ACLF grades. When adjusted for transplant eras, respiratory failure was the only independent risk factor for increased 1-year post-LT mortality in older patients. CONCLUSION Older patients with Est-CLF had significantly higher waitlist mortality than younger patients, but had acceptable 1-year post-LT survival including those with Est-ACLF-3; therefore, age alone should not be considered as a contraindication for LT. Older patients with respiratory failure should be carefully selected for LT.
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Affiliation(s)
- Joseph J Alukal
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland; Department of Medicine, University of California Riverside School of Medicine, Riverside, California
| | - Feng Li
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland
| | - Paul J Thuluvath
- Institute of Digestive Health & Liver Diseases, Mercy Medical Center, Baltimore, Maryland; Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland.
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Yadav M, Maiwal R, Kumar Br V, Tripathi G, Sharma N, Sharma N, Bindal V, Mathew B, Pandey S, Singh SP, Tevathia HV, Maras JS, Sarin SK. Comparative metabolome analysis reveals higher potential of haemoperfusion adsorption in providing favourable outcome in ACLF patients. Liver Int 2024; 44:1189-1201. [PMID: 38358068 DOI: 10.1111/liv.15858] [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: 03/30/2023] [Revised: 01/02/2024] [Accepted: 01/21/2024] [Indexed: 02/16/2024]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a serious illness associated with altered metabolome, organ failure and high mortality. Need for therapies to improve the metabolic milieu and support liver regeneration are urgently needed. METHODS We investigated the ability of haemoperfusion adsorption (HA) and therapeutic plasma exchange (TPE) in improving the metabolic profile and survival in ACLF patients. Altogether, 45 ACLF patients were randomized into three groups: standard medical therapy (SMT), HA and TPE groups. Plasma metabolomics was performed at baseline, post-HA and TPE sessions on days 7 and 14 using high-resolution mass spectrometry. RESULTS The baseline clinical/metabolic profiles of study groups were comparable. We identified 477 metabolites. Of these, 256 metabolites were significantly altered post 7 days of HA therapy (p < .05, FC > 1.5) and significantly reduced metabolites linked to purine (12 metabolites), tryptophan (7 metabolites), primary bile acid (6 metabolites) and arginine-proline metabolism (6 metabolites) and microbial metabolism respectively (p < .05). Metabolites linked to taurine-hypotaurine and histidine metabolism were reduced and temporal increase in metabolites linked to phenylalanine and tryptophan metabolism was observed post-TPE therapy (p < .05). Finally, weighted metabolite correlation network analysis (WMCNA) along with inter/intragroup analysis confirmed significant reduction in inflammatory (tryptophan, arachidonic acid and bile acid metabolism) and secondary energy metabolic pathways post-HA therapy compared to TPE and SMT (p < .05). Higher baseline plasma level of 11-deoxycorticosterone (C03205; AUROC > 0.90, HR > 3.2) correlated with severity (r2 > 0.5, p < .05) and mortality (log-rank-p < .05). Notably, 51 of the 64 metabolite signatures (ACLF non-survivor) were reversed post-HA treatment compared to TPE and SMT(p < .05). CONCLUSION HA more potentially (~80%) improves plasma milieu compared to TPE and SMT. High baseline plasma 11-deoxycorticosterone level correlates with early mortality in ACLF patients.
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Affiliation(s)
- Manisha Yadav
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinay Kumar Br
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Gaurav Tripathi
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Neha Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Nupur Sharma
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vasundhra Bindal
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Babu Mathew
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sushmita Pandey
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Satender Pal Singh
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Jaswinder Singh Maras
- Department of Molecular and Cellular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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10
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Biswas S, Kumar R, Shalimar, Acharya SK. Viral hepatitis-induced acute liver failure. Indian J Gastroenterol 2024; 43:312-324. [PMID: 38451383 DOI: 10.1007/s12664-024-01538-w] [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: 01/04/2024] [Accepted: 01/18/2024] [Indexed: 03/08/2024]
Abstract
Viral hepatitis-induced acute liver failure (ALF) is a preventable cause for liver-related mortality worldwide. Viruses are the most common cause for ALF in developing nations in contrast to the west, where acetaminophen is largely responsible. Viruses may be hepatotropic or affect the liver secondary to a systemic infection. In tropical countries, infections such as leptospirosis, scrub typhus and malaria can mimic the symptoms of ALF. Differentiating these ALF mimics is crucial because they require etiology-specific therapy. Treatment of viral hepatitis-induced ALF is two-pronged and directed towards providing supportive care to prevent organ failures and antiviral drugs for some viruses. Liver transplantation (LT) is an effective modality for patients deteriorating despite adequate supportive care. Early referral and correct identification of patients who require a transplant are important. Liver support devices and plasma exchange have evolved into "bridging modalities" for LT. Preventive strategies such as hand hygiene, use of clean and potable water and inclusion of vaccines against viral hepatitis in the national program are simple yet very effective methods focusing on the preventive aspect of this disease.
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Affiliation(s)
- Sagnik Biswas
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, 801 507, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India.
| | - Subrat Kumar Acharya
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 110 029, India
- KIIT University, Bhubaneswar, 751 024, India
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India
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11
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Yu X, Yang F, Shen Z, Zhang Y, Sun J, Qiu C, Zheng Y, Zhao W, Yuan S, Zeng D, Zhang S, Long J, Zhu M, Zhang X, Wu J, Ma Z, Zhu H, Su M, Xu J, Li B, Mao R, Su Z, Zhang J. BTLA contributes to acute-on-chronic liver failure infection and mortality through CD4 + T-cell exhaustion. Nat Commun 2024; 15:1835. [PMID: 38418488 PMCID: PMC10901893 DOI: 10.1038/s41467-024-46047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/08/2024] [Indexed: 03/01/2024] Open
Abstract
B- and T-lymphocyte attenuator (BTLA) levels are increased in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). This condition is characterized by susceptibility to infection and T-cell immune exhaustion. However, whether BTLA can induce T-cell immune exhaustion and increase the risk of infection remains unclear. Here, we report that BTLA levels are significantly increased in the circulating and intrahepatic CD4+ T cells from patients with HBV-ACLF, and are positively correlated with disease severity, prognosis, and infection complications. BTLA levels were upregulated by the IL-6 and TNF signaling pathways. Antibody crosslinking of BTLA activated the PI3K-Akt pathway to inhibit the activation, proliferation, and cytokine production of CD4+ T cells while promoting their apoptosis. In contrast, BTLA knockdown promoted their activation and proliferation. BTLA-/- ACLF mice exhibited increased cytokine secretion, and reduced mortality and bacterial burden. The administration of a neutralizing anti-BTLA antibody reduced Klebsiella pneumoniae load and mortality in mice with ACLF. These data may help elucidate HBV-ACLF pathogenesis and aid in identifying novel drug targets.
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Affiliation(s)
- Xueping Yu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China.
- Department of Infectious Diseases, First Hospital of Quanzhou Affiliated to Fujian Medical University, 362000, Quanzhou, China.
| | - Feifei Yang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Zhongliang Shen
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Yao Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Jian Sun
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Chao Qiu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Yijuan Zheng
- Department of Infectious Diseases, First Hospital of Quanzhou Affiliated to Fujian Medical University, 362000, Quanzhou, China
| | - Weidong Zhao
- Department of Laboratory Medicine, Clinical Medicine College, Dali University, 671000, Dali, China
| | - Songhua Yuan
- Shanghai Public Health Clinical Center and Institutes of Biomedical Science, Shanghai Medical College, Fudan University, 200040, Shanghai, China
| | - Dawu Zeng
- Department of Hepatology, the First Affiliated Hospital, Fujian Medical University, 350000, Fuzhou, China
| | - Shenyan Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Jianfei Long
- Department of Pharmacy, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Mengqi Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Xueyun Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Jingwen Wu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Zhenxuan Ma
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Haoxiang Zhu
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China
| | - Milong Su
- Department of Infectious Diseases, First Hospital of Quanzhou Affiliated to Fujian Medical University, 362000, Quanzhou, China
| | - Jianqing Xu
- Shanghai Public Health Clinical Center and Institutes of Biomedical Science, Shanghai Medical College, Fudan University, 200040, Shanghai, China
| | - Bin Li
- Shanghai Institute of Immunology, Shanghai JiaoTong University School of Medicine, 200040, Shanghai, China
| | - Richeng Mao
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China.
| | - Zhijun Su
- Department of Infectious Diseases, First Hospital of Quanzhou Affiliated to Fujian Medical University, 362000, Quanzhou, China.
| | - Jiming Zhang
- Department of Infectious Diseases, Shanghai Key Laboratory of Infectious Diseases and Biosafety Emergency Response, Shanghai Institute of Infectious Diseases and Biosecurity, National Medical Center for Infectious Diseases, Huashan Hospital, Fudan University, 200040, Shanghai, China.
- Key Laboratory of Medical Molecular Virology (MOE/MOH), Shanghai Medical College, Fudan University, 200040, Shanghai, China.
- Department of Infectious Diseases, Jing'An Branch of Huashan Hospital, Fudan University, 200040, Shanghai, China.
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12
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Ghallab A, González D, Strängberg E, Hofmann U, Myllys M, Hassan R, Hobloss Z, Brackhagen L, Begher-Tibbe B, Duda JC, Drenda C, Kappenberg F, Reinders J, Friebel A, Vucur M, Turajski M, Seddek AL, Abbas T, Abdelmageed N, Morad SAF, Morad W, Hamdy A, Albrecht W, Kittana N, Assali M, Vartak N, van Thriel C, Sous A, Nell P, Villar-Fernandez M, Cadenas C, Genc E, Marchan R, Luedde T, Åkerblad P, Mattsson J, Marschall HU, Hoehme S, Stirnimann G, Schwab M, Boor P, Amann K, Schmitz J, Bräsen JH, Rahnenführer J, Edlund K, Karpen SJ, Simbrunner B, Reiberger T, Mandorfer M, Trauner M, Dawson PA, Lindström E, Hengstler JG. Inhibition of the renal apical sodium dependent bile acid transporter prevents cholemic nephropathy in mice with obstructive cholestasis. J Hepatol 2024; 80:268-281. [PMID: 37939855 PMCID: PMC10849134 DOI: 10.1016/j.jhep.2023.10.035] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 10/06/2023] [Accepted: 10/23/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND & AIMS Cholemic nephropathy (CN) is a severe complication of cholestatic liver diseases for which there is no specific treatment. We revisited its pathophysiology with the aim of identifying novel therapeutic strategies. METHODS Cholestasis was induced by bile duct ligation (BDL) in mice. Bile flux in kidneys and livers was visualized by intravital imaging, supported by MALDI mass spectrometry imaging and liquid chromatography-tandem mass spectrometry. The effect of AS0369, a systemically bioavailable apical sodium-dependent bile acid transporter (ASBT) inhibitor, was evaluated by intravital imaging, RNA-sequencing, histological, blood, and urine analyses. Translational relevance was assessed in kidney biopsies from patients with CN, mice with a humanized bile acid (BA) spectrum, and via analysis of serum BAs and KIM-1 (kidney injury molecule 1) in patients with liver disease and hyperbilirubinemia. RESULTS Proximal tubular epithelial cells (TECs) reabsorbed and enriched BAs, leading to oxidative stress and death of proximal TECs, casts in distal tubules and collecting ducts, peritubular capillary leakiness, and glomerular cysts. Renal ASBT inhibition by AS0369 blocked BA uptake into TECs and prevented kidney injury up to 6 weeks after BDL. Similar results were obtained in mice with humanized BA composition. In patients with advanced liver disease, serum BAs were the main determinant of KIM-1 levels. ASBT expression in TECs was preserved in biopsies from patients with CN, further highlighting the translational potential of targeting ASBT to treat CN. CONCLUSIONS BA enrichment in proximal TECs followed by oxidative stress and cell death is a key early event in CN. Inhibiting renal ASBT and consequently BA enrichment in TECs prevents CN and systemically decreases BA concentrations. IMPACT AND IMPLICATIONS Cholemic nephropathy (CN) is a severe complication of cholestasis and an unmet clinical need. We demonstrate that CN is triggered by the renal accumulation of bile acids (BAs) that are considerably increased in the systemic blood. Specifically, the proximal tubular epithelial cells of the kidney take up BAs via the apical sodium-dependent bile acid transporter (ASBT). We developed a therapeutic compound that blocks ASBT in the kidneys, prevents BA overload in tubular epithelial cells, and almost completely abolished all disease hallmarks in a CN mouse model. Renal ASBT inhibition represents a potential therapeutic strategy for patients with CN.
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Affiliation(s)
- Ahmed Ghallab
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany; Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, South Valley University, 83523 Qena, Egypt.
| | - Daniela González
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | | | - Ute Hofmann
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tübingen, Auerbachstr. 112, 70376 Stuttgart, Germany
| | - Maiju Myllys
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Reham Hassan
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany; Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, South Valley University, 83523 Qena, Egypt
| | - Zaynab Hobloss
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Lisa Brackhagen
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Brigitte Begher-Tibbe
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Julia C Duda
- Department of Statistics, TU Dortmund University, 44227 Dortmund, Germany
| | - Carolin Drenda
- Department of Statistics, TU Dortmund University, 44227 Dortmund, Germany
| | | | - Joerg Reinders
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Adrian Friebel
- Institute of Computer Science & Saxonian Incubator for Clinical Research (SIKT), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Mihael Vucur
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty at Heinrich-Heine-University, 40225 Dusseldorf, Germany
| | - Monika Turajski
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Abdel-Latief Seddek
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, South Valley University, 83523 Qena, Egypt
| | - Tahany Abbas
- Histology Department, Faculty of Medicine, South Valley University, 83523 Qena, Egypt
| | - Noha Abdelmageed
- Department of Pharmacology, Faculty of Veterinary Medicine, Sohag University, 82524 Sohag, Egypt
| | - Samy A F Morad
- Department of Pharmacology, Faculty of Veterinary Medicine, South Valley University, 83523 Qena, Egypt
| | - Walaa Morad
- Histology Department, Faculty of Medicine, South Valley University, 83523 Qena, Egypt
| | - Amira Hamdy
- Department of Forensic Medicine and Toxicology, Faculty of Veterinary Medicine, South Valley University, 83523 Qena, Egypt
| | - Wiebke Albrecht
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Naim Kittana
- Department of Biomedical Sciences, An-Najah National University, P.O. Box 7 Nablus, Palestine, Israel
| | - Mohyeddin Assali
- Department of Pharmacy, An-Najah National University, P.O. Box 7 Nablus, Palestine, Israel
| | - Nachiket Vartak
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Christoph van Thriel
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Ansam Sous
- Department of Pharmacy, An-Najah National University, P.O. Box 7 Nablus, Palestine, Israel
| | - Patrick Nell
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Maria Villar-Fernandez
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Cristina Cadenas
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Erhan Genc
- MRI Unit, Leibniz Research Centre for Working Environment and Human Factors, Department of Psychology and Neurosciences, Technical University Dortmund, 44139 Dortmund, Germany
| | - Rosemarie Marchan
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Duesseldorf, Medical Faculty at Heinrich-Heine-University, 40225 Dusseldorf, Germany
| | | | | | - Hanns-Ulrich Marschall
- Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Sahlgrenska Academy, University of Gothenburg, 41345 Gothenburg, Sweden
| | - Stefan Hoehme
- Institute of Computer Science & Saxonian Incubator for Clinical Research (SIKT), University of Leipzig, Haertelstraße 16-18, 04107 Leipzig, Germany
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, Inselspital University Hospital, University of Bern, 3010 Bern, Switzerland
| | - Matthias Schwab
- Dr. Margarete Fischer-Bosch Institute of Clinical Pharmacology and University of Tübingen, Auerbachstr. 112, 70376 Stuttgart, Germany; Departments of Clinical Pharmacology, and of Biochemistry and Pharmacy, University Tuebingen, 72076 Tuebingen, Germany; Cluster of Excellence iFIT (EXC2180), Image-Guided and Functionally Instructed Tumor Therapies, University of Tuebingen, 69120 Tuebingen, Germany
| | - Peter Boor
- Institute of Pathology and Department of Nephrology, University Hospital RWTH Aachen, Pauwelsstr. 30, 52074 Aachen, Germany
| | - Kerstin Amann
- Department of Nephropathology, Friedrich-Alexander-University Erlangen-Nuremberg, 91054 Erlangen, Germany
| | - Jessica Schmitz
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, 30625 Hannover, Germany
| | - Jan H Bräsen
- Institute of Pathology, Nephropathology Unit, Hannover Medical School, 30625 Hannover, Germany
| | - Jörg Rahnenführer
- Department of Statistics, TU Dortmund University, 44227 Dortmund, Germany
| | - Karolina Edlund
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany
| | - Saul J Karpen
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Emory University, Atlanta, GA 30322, United States
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria; Hans Popper Laboratory of Molecular Hepatology, Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Paul A Dawson
- Department of Pediatrics, Division of Gastroenterology, Hepatology, and Nutrition, Emory University, Atlanta, GA 30322, United States
| | | | - Jan G Hengstler
- Department of Toxicology, Leibniz Research Centre for Working Environment and Human Factors, Technical University Dortmund, Ardeystr. 67, 44139 Dortmund, Germany.
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13
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Kim JH, Kim SE, Song DS, Kim HY, Yoon EL, Kang SH, Jung YK, Kwon JH, Lee SW, Han SK, Chang Y, Jeong SW, Yoo JJ, Jin YJ, Cheon GJ, Kim BS, Seo YS, Kim H, Park JW, Kim TH, Sinn DH, Chung WJ, Kim HY, Lee HA, Nam SW, Kim IH, Kim JH, Chae HB, Sohn JH, Cho JY, Park JG, Cho HC, Kim YJ, Yang JM, Suk KT, Kim MY, Kim SG, Yim HJ, Kim W, Jang JY, Kim DJ. The Clinical Courses and Prognosis of Cirrhotic Patients after First Acute Decompensation: Prospective Cohort Study. Diagnostics (Basel) 2023; 14:14. [PMID: 38201324 PMCID: PMC10795755 DOI: 10.3390/diagnostics14010014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Revised: 12/15/2023] [Accepted: 12/15/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium suggested that the clinical courses after acute decompensation (AD) stratify the long-term prognosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre acute-on-chronic liver failure (pre ACLF), and ACLF. However, previous studies included patients with a history of previous AD and had limitations associated with identifying the clinical factors related to prognosis after the first AD. METHOD The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort included cirrhotic patients who were hospitalised with first AD between July 2015 and August 2018. We analysed the factors associated with readmission after the first AD and compared the characteristics and prognosis among each subgroup to evaluate the risk factors for the occurrence of pre ACLF after AD. RESULT A total of 746 cirrhotic patients who were hospitalised with first AD were enrolled. The subgroups consisted of SDC (n = 565), UDC (n = 29), pre ACLF (n = 28), and ACLF (n = 124). Of note, pre ACLF showed a poorer prognosis than ACLF. The risk factors associated with readmission within 3 months of first AD were non-variceal gastrointestinal (GI) bleeding, hepatic encephalopathy (HE), and high MELD score. Viral aetiology was associated with the occurrence of pre ACLF compared with alcohol aetiology regardless of baseline liver function status. CONCLUSION Cirrhotic patients with first AD who present as non-variceal GI bleeding and HE can easily relapse. Interestingly, the occurrence of AD with organ failure within 3 months of first AD (pre ACLF) has worse prognosis compared with the occurrence of organ failure at first AD (ACLF). In particular, cirrhotic patients with viral hepatitis with/without alcohol consumption showed poor prognosis compared to other aetiologies. Therefore, patients with ACLF after AD within 3 months should be treated more carefully and definitive treatment through LT should be considered.
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Affiliation(s)
- Jung Hee Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Sung-Eun Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Eileen L. Yoon
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea; (E.L.Y.); (J.H.S.)
| | - Seong Hee Kang
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Young-Kul Jung
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Jung Hyun Kwon
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Sung Won Lee
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Seul Ki Han
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.K.H.); (M.Y.K.)
| | - Young Chang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Jeong Ju Yoo
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Republic of Korea; (J.J.Y.); (S.G.K.)
| | - Young-Joo Jin
- Department of Internal Medicine, Inha University Hospital, Inha University School of Medicine, Incheon 22212, Republic of Korea;
| | - Gab Jin Cheon
- Department of Internal Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung 25440, Republic of Korea;
| | - Byung Seok Kim
- Department of Internal Medicine, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea;
| | - Yeon Seok Seo
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Hyoungsu Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Ji Won Park
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Tae Hyung Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Dong Hyun Sinn
- Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul 06531, Republic of Korea;
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu 42601, Republic of Korea;
| | - Hwi Young Kim
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea (H.A.L.)
| | - Han Ah Lee
- Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul 07804, Republic of Korea (H.A.L.)
| | - Seung Woo Nam
- Department of Internal Medicine, National Medical Center, Seoul 04564, Republic of Korea;
| | - In Hee Kim
- Department of Internal Medicine, Chonbuk National University Hospital, Chonbuk National University Medical School, Jeonju 54896, Republic of Korea;
| | - Ji Hoon Kim
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Hee Bok Chae
- Department of Internal Medicine, Medical Research Institute, Chungbuk National University College of Medicine, Cheongju 28644, Republic of Korea;
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul 04763, Republic of Korea; (E.L.Y.); (J.H.S.)
| | - Ju Yeon Cho
- Department of Internal Medicine, College of Medicine, Chosun University, Gwangju 61452, Republic of Korea;
| | - Jung Gil Park
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu 42415, Republic of Korea;
| | - Hyun Chin Cho
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju 52727, Republic of Korea;
| | - Yoon Jun Kim
- Department of Internal Medicine, Liver Research Institute, Seoul National University College of Medicine, Seoul 03080, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (D.S.S.); (H.Y.K.); (J.H.K.); (S.W.L.); (J.M.Y.)
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju 26426, Republic of Korea; (S.K.H.); (M.Y.K.)
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon 14584, Republic of Korea; (J.J.Y.); (S.G.K.)
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Medical Center, Seoul 02841, Republic of Korea; (S.H.K.); (Y.S.S.); (J.H.K.); (H.J.Y.)
| | - Won Kim
- Department of Internal Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul 07061, Republic of Korea;
| | - Jae-Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul 04401, Republic of Korea; (Y.C.); (S.W.J.); (J.-Y.J.)
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym Medical Center, Hallym University College of Medicine, Chuncheon 24252, Republic of Korea; (J.H.K.); (H.K.); (K.T.S.); (D.J.K.)
- Institute for Liver and Digestive Diseases, Hallym University, Chuncheon 24252, Republic of Korea
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Cronst J, Prediger L, Pinto MA, Ferraz J, Mattos AZD, Alvares-DA-Silva MR, Kruel CRP, Chedid MF. PROGNOSTIC FACTORS OF LIVER TRANSPLANTATION FOR ACUTE-ON-CHRONIC LIVER FAILURE. ARQUIVOS BRASILEIROS DE CIRURGIA DIGESTIVA : ABCD = BRAZILIAN ARCHIVES OF DIGESTIVE SURGERY 2023; 36:e1779. [PMID: 38088725 PMCID: PMC10712924 DOI: 10.1590/0102-672020230061e1779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/30/2023] [Indexed: 12/17/2023]
Abstract
BACKGROUND Liver transplantation (LT) is the only treatment that can provide long-term survival for patients with acute-on-chronic liver failure (ACLF). Although several studies identify prognostic factors for patients in ACLF who do not undergo LT, there is scarce literature about prognostic factors after LT in this population. AIM Evaluate outcomes of ACLF patients undergoing LT, studying prognostic factors related to 1-year and 90 days post-LT. METHODS Patients with ACLF undergoing LT between January 2005 and April 2021 were included. Variables such as chronic liver failure consortium (CLIF-C) ACLF values and ACLF grades were compared with the outcomes. RESULTS The ACLF survival of patients (n=25) post-LT at 90 days, 1, 3, 5 and 7 years, was 80, 76, 59.5, 54.1 and 54.1% versus 86.3, 79.4, 72.6, 66.5 and 61.2% for patients undergoing LT for other indications (n=344), (p=0.525). There was no statistical difference for mortality at 01 year and 90 days among patients with the three ACLF grades (ACLF-1 vs. ACLF-2 vs. ACLF-3) undergoing LT, as well as when compared to non-ACLF patients. CLIF-C ACLF score was not related to death outcomes. None of the other studied variables proved to be independent predictors of mortality at 90 days, 1 year, or overall. CONCLUSIONS LT conferred long-term survival to most transplant patients. None of the studied variables proved to be a prognostic factor associated with post-LT survival outcomes for patients with ACLF. Additional studies are recommended to clarify the prognostic factors of post-LT survival in patients with ACLF.
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Affiliation(s)
- Jane Cronst
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, Graduate Program in Surgical Sciences - Porto Alegre (RS), Brazil
| | - Lucas Prediger
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit - Porto Alegre (RS), Brazil
| | | | - Julia Ferraz
- Feevale School of Medicine, Medical Sciences - Novo Hamburgo (RS), Brazil
| | | | - Mario Reis Alvares-DA-Silva
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit - Porto Alegre (RS), Brazil
| | - Cleber Rosito Pinto Kruel
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit - Porto Alegre (RS), Brazil
| | - Marcio Fernandes Chedid
- Universidade Federal do Rio Grande do Sul, Porto Alegre University Hospital, Hepatobiliary Surgery and Liver Transplantation Unit - Porto Alegre (RS), Brazil
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15
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Liu L, Chen P, Xiao N, Liu Q, Zhu X. Interleukin-8 predicts short-term mortality in acute-on-chronic liver failure patients with hepatitis B-related-related cirrhosis background. Ann Med 2023; 55:2287708. [PMID: 38052052 PMCID: PMC10836280 DOI: 10.1080/07853890.2023.2287708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a distinctive and severe syndrome, marked by an excessive systemic inflammatory response. In vivo, interleukin 8 (IL-8) is an essential pro-inflammatory cytokine. We aimed to investigate the value of serum IL-8 levels in predicting mortality in ACLF patients in the background of hepatitis B virus-related cirrhosis. METHODS In this study, we conducted a retrospective analysis of the clinical baseline characteristics of 276 patients with ACLF in the context of HBV-related cirrhosis. Logistic regression analysis was employed to identify independent risk factors for short-, intermediate-, and long-term mortality. Using these independent risk factors, we developed a nomogram model, which was subsequently validated. To assess the clinical usefulness of the nomogram model, we performed decision curve analysis (DCA). RESULTS Out of the 276 patients with ACLF, 98 (35.5%), 113 (40.9%), and 128 (46.4%) died within 28, 90, and 180 days, respectively. Serum IL-8 levels were only an independent predictor of 28-day mortality and could simply classify ACLF patients. Conversely, mean arterial pressure (MAP), HBV-DNA, and COSHACLF IIs were independent predictors of mortality across all three observation periods. We constructed a nomogram based on IL-8 that was able to visualise and predict 28-day mortality with a C-index of 0.901 (95% CI: 0.862-0.940). Our calibration curves, Predicted Probability of Death & Actual Survival Status plot, and Confusion Matrix demonstrated the nomogram model's strong predictive power. DCA indicated the nomogram's promising clinical utility in predicting 28-day mortality in ACLF patients. CONCLUSION Serum IL-8 levels predict short-term mortality in ACLF patients in the background of HBV-associated cirrhosis, and the developed Nomogram model has strong predictive power and good clinical utility.
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Affiliation(s)
- Linxiang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Peng Chen
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Nanxi Xiao
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Qi Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
| | - Xuan Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang, China
- Jiangxi Clinical Research Center for Gastroenterology, Nanchang, Jiangxi, China
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16
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Jin D, Kang K, Yan BZ, Zhang JN, Zheng JB, Wang ZH, Wu D, Tang YJ, Wang XT, Lai QQ, Cao Y, Wang HL, Gao Y. Combined Age with Mean Decrease Rates of Total Bilirubin and MELD Score as a Novel and Simple Clinical Predictor on 90-Day Transplant-Free Mortality in Adult Patients with Acute Liver Failure Undergoing Plasma Exchange: A Single-Center Retrospective Study. Can J Gastroenterol Hepatol 2023; 2023:6115499. [PMID: 38021269 PMCID: PMC10645502 DOI: 10.1155/2023/6115499] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 10/13/2023] [Accepted: 10/27/2023] [Indexed: 12/01/2023] Open
Abstract
Background Acute liver failure (ALF), previously known as fulminant hepatic failure, has become a common, rapidly progressive, and life-threatening catastrophic hepatic disease in intensive care unit (ICU) due to the continuous increase in drug abuse, viral infection, metabolic insult, and auto-immune cause. At present, plasma exchange (PE) is the main effective alternative treatment for ALF in ICU clinical practice, and high-volume plasma exchange (HVP) has been listed as a grade I recommendation for ALF management in the American Society for Apheresis (ASFA) guidelines. However, no existing models can provide a satisfactory performance for clinical prediction on 90-day transplant-free mortality in adult patients with ALF undergoing PE. Our study aims to identify a novel and simple clinical predictor of 90-day transplant-free mortality in adult patients with ALF undergoing PE. Methods This retrospective study contained adult patients with ALF undergoing PE from the Medical ICU (MICU) in the Second Affiliated Hospital of Harbin Medical University between January 2017 and December 2020. Baseline and clinical data were collected and calculated on admission to ICU before PE, including gender, age, height, weight, body mass index (BMI), etiology, total bilirubin, direct bilirubin, indirect bilirubin, prothrombin activity, model for end-stage liver disease (MELD) score, and sequential organ failure assessment (SOFA) score. Enrolled adult patients with ALF undergoing PE were divided into a survival group and a death group at discharge and 90 days on account of medical records and telephone follow-up. After each PE, decreased rates of total bilirubin and MELD score and increased rates of prothrombin activity were calculated according to the clinical parameters. In clinical practice, different patients underwent different times of PE, and thus, mean decrease rates of total bilirubin and MELD score and mean increase rate of prothrombin activity were obtained for further statistical analysis. Results A total of 73 adult patients with ALF undergoing 204 PE were included in our retrospective study, and their transplant-free mortality at discharge and 90 days was 6.85% (5/73) and 31.51% (23/73), respectively. All deaths could be attributed to ALF-induced severe and life-threatening complications or even multiple organ dysfunction syndrome (MODS). Most of the enrolled adult patients with ALF were men (76.71%, 56/73), with a median age of 48.77 years. Various hepatitis virus infections, unknown etiology, auto-immune liver disease, drug-induced liver injury, and acute pancreatitis (AP) accounted for 75.34%, 12.33%, 6.85%, 4.11%, and 1.37% of the etiologies in adult patients with ALF, respectively. Univariate analysis showed a significant difference in age, mean decrease rates of total bilirubin and MELD score mean increase rate of prothrombin activity, decrease rates of total bilirubin and MELD score, and increase rate of prothrombin activity after the first PE between the death group and survival group. Multivariate analysis showed that age and mean decrease rates of total bilirubin and MELD score were closely associated with 90-day transplant-free mortality in adult patients with ALF undergoing PE. The 90-day transplant-free mortality was 1.081, 0.908, and 0.893 times of the original value with each one-unit increase in age and mean decrease rates of total bilirubin and MELD score, respectively. The areas under the receiver operatingcharacteristic (ROC) curve of age, mean decrease rates of total bilirubin and MELD score, and the three combined were 0.689, 0.225, 0.123, and 0.912, respectively. The cut-off values of age, mean decrease rates of total bilirubin and MELD score, and the three combined were 61.50, 3.12, 1.21, and 0.33, respectively. The specificity and sensitivity of combined age with mean decrease rates of total bilirubin and MELD score for predicting 90-day transplant-free mortality in adult patients with ALF undergoing PE were 87% and 14%. Conclusion Combined age with mean decrease rates of total bilirubin and MELD score as a novel and simple clinical predictor can accurately predict 90-day transplant-free mortality in adult patients with ALF undergoing PE, which is worthy of application and promotion in clinical practice, especially in the identification of potential transplant candidates.
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Affiliation(s)
- Di Jin
- Department of Anesthesiology, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Kai Kang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Bing-zhu Yan
- Department of Infectious Diseases, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Jian-nan Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Jun-bo Zheng
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Zhi-hui Wang
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin 150027, Heilongjiang Province, China
| | - Di Wu
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin 150027, Heilongjiang Province, China
| | - Yu-jia Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Xin-tong Wang
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Qi-qi Lai
- Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin 150001, Heilongjiang Province, China
| | - Yang Cao
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Hong-liang Wang
- Department of Critical Care Medicine, The Second Affiliated Hospital of Harbin Medical University, Harbin 150086, Heilongjiang Province, China
| | - Yang Gao
- Department of Critical Care Medicine, The Sixth Affiliated Hospital of Harbin Medical University, Harbin 150027, Heilongjiang Province, China
- Institute of Critical Care Medicine, The Sino Russian Medical Research Center of Harbin Medical University, Harbin 150081, Heilongjiang Province, China
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Saeidinejad M, Elshabrawi A, Sriphoosanaphan S, Andreola F, Mehta G, Agarwal B, Jalan R. Novel Therapeutic Approaches in Treatment of Acute-on-Chronic Liver Failure. Semin Liver Dis 2023; 43:429-445. [PMID: 38101419 PMCID: PMC10723941 DOI: 10.1055/s-0043-1776773] [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] [Indexed: 12/17/2023]
Abstract
Acute-on-chronic liver failure (ACLF), a clinical syndrome that can develop at any stage in the progression of cirrhotic liver disease, is characterized by an acute decompensation in liver function with associated multiorgan failure and high short-term mortality. Current evidence points to ACLF being reversible, particularly in those at the lower end of the severity spectrum. However, there are no specific treatments for ACLF, and overall outcomes remain poor. Expedited liver transplantation as a treatment option is limited by organ shortage and a lack of priority allocation for this indication. Other options are therefore urgently needed, and our improved understanding of the condition has led to significant efforts to develop novel therapies. In conclusion, this review aims to summarize the current understanding of the pathophysiological processes involved in the onset, progression, and recovery of ACLF and discuss novel therapies under development.
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Affiliation(s)
- MohammadMahdi Saeidinejad
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Ahmed Elshabrawi
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
- Intensive Care Unit, Endemic Hepatology and Gastroenterology Department, Mansoura University, Mansoura, Egypt
| | - Supachaya Sriphoosanaphan
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok
| | - Fausto Andreola
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Gautam Mehta
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
| | - Banwari Agarwal
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
- Intensive Care Unit, Royal Free Hospital, London, United Kingdom
| | - Rajiv Jalan
- Liver Failure Group, Department of Medicine, Institute for Liver and Digestive Health, University College London, London, United Kingdom
- Hepatology Department, Royal Free Hospital, London, United Kingdom
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
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18
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Zhang W, Jin P, Liu J, Wu Y, Wang R, Zhang Y, Shen Y, Zhang M, Bai X, Fung J, Liang T. Dynamic evaluation based on acute-on-chronic liver failure predicts survival of patients after liver transplantation: a cohort study. Int J Surg 2023; 109:3117-3125. [PMID: 37498133 PMCID: PMC10583902 DOI: 10.1097/js9.0000000000000596] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 06/26/2023] [Indexed: 07/28/2023]
Abstract
BACKGROUND AND AIMS Dynamic evaluation of critically ill patients is the key to predicting their outcomes. Most scores based on the Model for End-stage Liver Disease (MELD) and acute-on-chronic liver failure (ACLF) utilize point-in-time assessment. This study mainly aimed to investigate the impact of dynamic clinical course change on post-liver transplantation (LT) survival. METHODS This study included 637 adults (overall cohort) with benign end-stage liver diseases. The authors compared the MELD scores and our ACLF-based dynamic evaluation scores. Patients enrolled or transplanted with ACLF-3 were defined as the ACLF-3 cohort ( n =158). The primary outcome was 1-year mortality. ΔMELD and ΔCLIF-OF (Chronic Liver Failure-Organ Failure) represented the respective dynamic changes in liver transplant function. Discrimination was assessed using the area under the curve. A Cox regression analysis identified independent risk factors for specific organ failure and 1-year mortality. RESULTS Patients were grouped into three groups: the deterioration group (D), the stable group (S), and the improvement group (I). The deterioration group (ΔCLIF-OF ≥2) was more likely to receive national liver allocation ( P =0.012) but experienced longer cold ischemia time ( P =0.006) than other groups. The area under the curves for ΔCLIF-OF were 0.752 for the entire cohort and 0.767 for ACLF-3 cohorts, both superior to ΔMELD ( P <0.001 for both). Compared to the improvement group, the 1-year mortality hazard ratios (HR) of the deterioration group were 12.57 (6.72-23.48) for the overall cohort and 7.00 (3.73-13.09) for the ACLF-3 cohort. Extrahepatic organs subscore change (HR=1.783 (1.266-2.512) for neurologic; 1.653 (1.205-2.269) for circulation; 1.906 (1.324-2.743) for respiration; 1.473 (1.097-1.976) for renal) were key to transplantation outcomes in the ACLF-3 cohort. CLIF-OF at LT (HR=1.193), ΔCLIF-OF (HR=1.354), and cold ischemia time (HR=1.077) were independent risk factors of mortality for the overall cohort, while ΔCLIF-OF (HR=1.384) was the only independent risk factor for the ACLF-3 cohort. Non-ACLF-3 patients showed a higher survival rate than patients with ACLF-3 in all groups ( P =0.002 for I, P =0.005 for S, and P =0.001 for D). CONCLUSION This was the first ACLF-based dynamic evaluation study. ΔCLIF-OF was a more powerful predictor of post-LT mortality than ΔMELD. Extrahepatic organ failures were core risk factors for ACLF-3 patients. CLIF-OF at LT, ΔCLIF-OF, and cold ischemia time were independent risk factors for post-LT mortality. Patients with a worse baseline condition and a deteriorating clinical course had the worst prognosis. Dynamic evaluation was important in risk stratification and recipient selection.
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Affiliation(s)
- Wei Zhang
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Pingbo Jin
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Junfang Liu
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Yue Wu
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | | | - Yuntao Zhang
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Yan Shen
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Min Zhang
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - Xueli Bai
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
| | - John Fung
- Transplantation Institute, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Tingbo Liang
- Department of Hepatobiliary and Pancreatic Surgery
- Liver Transplant Center
- Key Lab of Combined Multi-organ Transplantation of the Ministry of Health
- Zhejiang Provincial Key Laboratory of Pancreatic Disease, the First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People’s Republic of China
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19
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Kounis I, Sacleux SC, Ordan MA, André S, Boudon M, Coilly A, Sobesky R, De Martin E, Samuel D, Ichaï P, Saliba F. Efficiency and safety of total plasma exchange in critically ill cirrhotic patients with acute on chronic liver failure: A pilot study. Clin Res Hepatol Gastroenterol 2023; 47:102206. [PMID: 37714512 DOI: 10.1016/j.clinre.2023.102206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 08/26/2023] [Accepted: 09/08/2023] [Indexed: 09/17/2023]
Abstract
BACKGROUND AND AIMS Treatment of patients with acute on chronic liver failure (ACLF) admitted to the ICU is very limited. The aim of this pilot study was to evaluate the efficiency on liver function and safety of therapeutic plasma exchange (TPE) in critically ill cirrhotic patients admitted with ACLF in a liver ICU. METHODS This is a prospective cohort of patients with ACLF grade > 2 treated by TPE admitted to the ICU that was matched to a control group. TPE was performed using a plasma filter (TPE2000, BAXTER®) on a CRRT machine (Prismaflex®, Baxter®). Ratio and type of fluid replacement were 50 % with 5 % albumin solution followed by 50 % with fresh frozen plasma. RESULTS Seven patients with a mean age of 50.6 ± 7.8 years (all males) and 14 controls matched to age, sex, etiology and cause of decompensation were recruited. At ICU admission, mean MELD score was 39.1 ± 2.7, mean SOFA score was 11.6 ± 5.2 and mean CLIF SOFA score was 12.9 ± 2.6. The grade of ACLF was 3 for 3 patients (42.9 %) and 2 for 4 patients (57.1 %). The TPE group had significantly higher levels of bilirubin (392.3 ± 117.1μmol/l vs. 219 ± 185μmol/l , p = 0.04), and INR values (5.7 ± 3.4 vs. 3.5 ± 0.9, p < 0.005) compared to the control group. Patient survival was respectively 28.6 % and 14.3 % at 30 and 90 days in the TPE group and 35.7 % and 7.14 % in the control group respectively (HR: 1 (95 % CI 0.19- 5.2; p = 1). One patient in the TPE group had a liver transplantation 13 days after admission to ICU and is still alive and none in the control group. Two (28.6 %) patients died from complications related to the double lumen catheter used for TPE. CONCLUSION This pilot study of TPE in patients with ACLF grade 2 and 3 showed a marked but transient improvement in liver function tests. TPE worth to be evaluated in large trials in ACLF patients, with a liver transplant project, and less organ failure.
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Affiliation(s)
- Ilias Kounis
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Sophie Caroline Sacleux
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Marie Amelie Ordan
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France
| | - Stéphane André
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France
| | - Marc Boudon
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Rodolphe Sobesky
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Philippe Ichaï
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France
| | - Faouzi Saliba
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, France; Inserm, Université Paris-Saclay, UMR-S 1193, France; Inserm, Physiopathogénèse et Traitement des Maladies du Foie, Université Paris-Saclay, France; FHU Hepatinov, Villejuif 94805, France.
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20
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Han F, Zhang Y, Song N, Gao T. TLR pathway signaling molecules in burbot (Lota lota): molecular characterization, basal expression, and their response to Poly(I:C). FISH & SHELLFISH IMMUNOLOGY 2023; 140:108939. [PMID: 37451526 DOI: 10.1016/j.fsi.2023.108939] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 06/19/2023] [Accepted: 07/11/2023] [Indexed: 07/18/2023]
Abstract
Burbot (Lota lota), a fish species of economic and ecological significance found across northern hemisphere freshwater ecosystems, was the focus of this study. We characterized 19 Toll-like receptor (TLR) genes in burbot, tracing their expression patterns following pathogen exposure. TLR genes, crucial to the innate immune system, including TLR13-1/2/3, TLR2/2-2/2-3/2-4/2-5, and TLR22a/22b/22c/22d, were discovered to be tandemly repeated, signifying an evolution in the fish's immune system. Notably, different TLR subfamilies displayed tissue-specific expressions, with TLR1 primarily in spleen and head kidney, TLR13 in head kidney, trunk kidney, and heart, TLR22 in trunk kidney and liver, and TLR3 and TLR9 predominantly in spleen and head kidney, but also in trunk kidney. Further, we investigated the response of TLR genes in burbot to pathogen exposure using qRT-PCR. This involved measuring mRNA expressions of identified TLR genes in spleen and liver tissues after injecting Poly(I:C) to simulate a double-stranded RNA viral infection. The results revealed a time and tissue-specific expression pattern. Specifically, LoTLR3 reached peak expression in the spleen 12 h post-injection, declining thereafter, while TLR2 subfamily members only began expressing after 24 h. In the liver, activation of the TLR3-IRF7 and TLR3-IRF3 signaling pathways was noted. Integrating these results with transcriptomic data illuminated the pivotal role of TLR genes in the burbot's immune response. Such findings are vital in shaping future disease prevention and treatment strategies.
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Affiliation(s)
- Fei Han
- Fishery College, Ocean University of China, Qingdao, Shandong, 266003, China
| | - Yuan Zhang
- CAS Key Laboratory of Tropical Marine Bio-Resources and Ecology, South China Sea Institute of Oceanology, Chinese Academy of Sciences, Guangzhou, Guangdong, 510301, China
| | - Na Song
- Fishery College, Ocean University of China, Qingdao, Shandong, 266003, China
| | - Tianxiang Gao
- Fisheries College, Zhejiang Ocean University, Zhoushan, Zhejiang, 316022, China.
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21
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Chang J, Hoffstall S, Gödiker J, Lehmann J, Schwind L, Lingohr P, Manekeller S, Wehner S, Strassburg CP, Chang P, Praktiknjo M. Surgical site infections are independently associated with the development of postoperative acute-on-chronic liver failure in liver cirrhosis. Liver Transpl 2023; 29:928-939. [PMID: 36950832 DOI: 10.1097/lvt.0000000000000135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 03/03/2023] [Indexed: 03/24/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality ( p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59-3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26-4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.
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Affiliation(s)
- Johannes Chang
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Schwiedhard Hoffstall
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Juliana Gödiker
- Department of Internal Medicine B, Münster University Hospital, Münster, Germany
| | - Jennifer Lehmann
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Lea Schwind
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Philipp Lingohr
- Department of Visceral Surgery, University Hospital Bonn, Bonn, Germany
| | | | - Sven Wehner
- Department of Visceral Surgery, University Hospital Bonn, Bonn, Germany
| | - Christian P Strassburg
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
| | - Petrus Chang
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
- Department of Ophthalmology, University Hospital Bonn, Bonn, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
- Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany
- Department of Internal Medicine B, Münster University Hospital, Münster, Germany
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22
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Goyes D, Trivedi HD, Curry MP. Prognostic Models in Acute-on-Chronic Liver Failure. Clin Liver Dis 2023; 27:681-690. [PMID: 37380291 DOI: 10.1016/j.cld.2023.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by severe hepatic dysfunction leading to multiorgan failure in patients with end-stage liver disease. ACLF is a challenging clinical syndrome with a rapid clinical course and high short-term mortality. There is no single uniform definition of ACLF or consensus in predicting ACLF-related outcomes, which makes comparing studies difficult and standardizing management protocols challenging. This review aims to provide insights into the common prognostic models that define and grade ACLF.
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Affiliation(s)
- Daniela Goyes
- Department of Medicine, Loyola Medicine - MacNeal Hospital, Berwyn, IL, USA
| | - Hirsh D Trivedi
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Michael P Curry
- Department of Medicine and Division of Gastroenterology, Beth Israel Deaconess Medical Center, Boston, MA, USA.
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23
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Estrada-Arce EV, Aguila-Cano R, Lona-Reyes JC, Flores-Fong LE, Rivera-Chávez E. Poor Access to Liver Transplantation and Survival of Children With Acute Liver Failure, Acute-on-chronic Liver Failure or Chronic Liver Disease. JPGN REPORTS 2023; 4:e318. [PMID: 37600617 PMCID: PMC10435031 DOI: 10.1097/pg9.0000000000000318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Accepted: 03/02/2023] [Indexed: 08/22/2023]
Abstract
We describe the survival of children with acute liver failure (ALF), chronic liver disease (CLD), or acute-on-chronic liver failure (ACLF) with poor access to liver transplantation (LT). A retrospective cohort study of 42 patients <18 years of age was conducted in the Hospital Civil de Guadalajara "Dr. Juan I. Menchaca". The median age was 76 months; 57.1% were female, 40.5% presented with ALF, 35.7% with CLD, and 23.8% with ACLF. Also, 38.1% (16/42) presented liver disease of unknown etiology. Death occurred in 45.2%; 14.3% were transferred to another hospital, and none received LT. Mortality in ALF, CLD, and ACLF was 76%, 0%, and 60%, respectively. In the survival analysis, within the first 20 months after diagnosis, the mortality rate was greater than 50% with ALF. The importance of having referral programs that perform liver transplantation is highlighted by the poor prognosis of the patients, despite conservative treatment.
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Affiliation(s)
- Emma Valeria Estrada-Arce
- From the Pediatric Gastroenterology Service, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Salvador Quevedo y Zubieta, Guadalajara, Jalisco, México
- Universidad de Guadalajara, University Center for Health Sciences
| | - Renata Aguila-Cano
- From the Pediatric Gastroenterology Service, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Salvador Quevedo y Zubieta, Guadalajara, Jalisco, México
- Universidad de Guadalajara, University Center for Health Sciences
| | - Juan Carlos Lona-Reyes
- Pediatric Infectology Service, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca"
- Universidad de Guadalajara, Tonalá University Center
| | - Laura Esther Flores-Fong
- From the Pediatric Gastroenterology Service, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Salvador Quevedo y Zubieta, Guadalajara, Jalisco, México
- Universidad de Guadalajara, University Center for Health Sciences
| | - Elva Rivera-Chávez
- From the Pediatric Gastroenterology Service, Hospital Civil de Guadalajara "Dr. Juan I. Menchaca" Salvador Quevedo y Zubieta, Guadalajara, Jalisco, México
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24
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Moreau R, Tonon M, Krag A, Angeli P, Berenguer M, Berzigotti A, Fernandez J, Francoz C, Gustot T, Jalan R, Papp M, Trebicka J. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023; 79:461-491. [PMID: 37364789 DOI: 10.1016/j.jhep.2023.04.021] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/19/2023] [Indexed: 06/28/2023]
Abstract
Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF.
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25
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Marginean CM, Pirscoveanu D, Popescu M, Vasile CM, Docea AO, Mitruț R, Mărginean IC, Iacob GA, Firu DM, Mitruț P. Challenges in Diagnosis and Therapeutic Approach of Acute on Chronic Liver Failure-A Review of Current Evidence. Biomedicines 2023; 11:1840. [PMID: 37509478 PMCID: PMC10376368 DOI: 10.3390/biomedicines11071840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute and severe decompensation of chronic liver disease (CLD) correlated with multiple organ failure, poor prognosis, and increased mortality. In 40-50% of ACLF cases, the trigger is not recognized; for many of these patients, bacterial translocation associated with systemic inflammation is thought to be the determining factor; in the other 50% of patients, sepsis, alcohol consumption, and reactivation of chronic viral hepatitis are the most frequently described trigger factors. Other conditions considered precipitating factors are less common, including acute alcoholic hepatitis, major surgery, TIPS insertion, or inadequate paracentesis without albumin substitution. Host response is likely the primary factor predicting ACLF severity and prognosis, the host immune response having a particular significance in this syndrome, together with the inflammatory cascade. The management of ACLF includes both the prevention of the precipitating factors that lead to acute liver decompensation and the support of vital functions, the prevention and management of complications, the estimation of prognosis, and the opportunity for liver transplantation.
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Affiliation(s)
- Cristina Maria Marginean
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Denisa Pirscoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Corina Maria Vasile
- Department of Pediatric Cardiology, "Marie Curie" Emergency Children's Hospital, 041451 Bucharest, Romania
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Radu Mitruț
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania
| | | | - George Alexandru Iacob
- Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Mihai Firu
- Ph.D. School Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Paul Mitruț
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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26
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Silberhumer GR, Györi G, Brugger J, Baumann L, Zehetmayer S, Soliman T, Berlakovich G. MELD-Na Alterations on the Liver Transplant Waiting List and Their Impact on Listing Outcome. J Clin Med 2023; 12:jcm12113763. [PMID: 37297957 DOI: 10.3390/jcm12113763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/19/2023] [Accepted: 05/09/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Dynamic MELD deterioration (Delta MELD) during waiting time was shown to have significant impact on post-transplant survival. The aim of this study was to analyze the impact of MELD-Na score alterations on waiting list outcomes in liver transplant candidates. METHOD 36,806 patients listed at UNOS for liver transplantation in 2011-2015 were analyzed according to their delisting reasons. Several different MELD-Na alterations during waiting time were analyzed (e.g., maximal change, last change before delisting/transplantation). Outcome estimates were calculated according to MELD-Na scores at listing and Delta MELD. RESULTS Patients who died while on the waiting list showed a significantly higher deterioration in MELD-Na during the waiting time (6.8 ± 8.4 points) than stable patients who remained actively listed (-0.1 ± 5.2 points; p < 0.01). Patients who were considered too healthy for transplantation improved by more than 3 points on average during the waiting time. The mean peak MELD-Na alteration during the waiting time was 10.0 ± 7.6 for patients who died on the waiting list, compared to 6.6 ± 6.1 in the group of patients who finally underwent transplantation. CONCLUSIONS Deterioration of MELD-Na during waiting time and maximal MELD-Na deterioration have a significant negative impact on the liver transplant waiting list outcome.
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Affiliation(s)
- Gerd R Silberhumer
- Department of Transplant Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Georg Györi
- Department of Transplant Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Jonas Brugger
- Department of CeMSIIS, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Lukas Baumann
- Department of CeMSIIS, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Sonja Zehetmayer
- Department of CeMSIIS, Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, 1090 Vienna, Austria
| | - Thomas Soliman
- Department of Transplant Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Gabriela Berlakovich
- Department of Transplant Surgery, Medical University of Vienna, 1090 Vienna, Austria
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27
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Yu Y, Mao X, Wang J, Chen M, Wang F, Kong X, Hang H. SPP1 as a risk factor for patients with acute on chronic liver failure undergoing liver transplantation. Int Immunopharmacol 2023; 120:110355. [PMID: 37257271 DOI: 10.1016/j.intimp.2023.110355] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2023] [Revised: 04/19/2023] [Accepted: 05/15/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Acute on chronic liver failure (ACLF) is characterized by systemic inflammation and significant mortality, calling for accurate assessment due to the diverse prognosis of liver transplantation (LT). METHODS 8 patients with ACLF and 4 normal controls (NC) underwent peripheral blood mononuclear cells (PBMCs) transcriptomics, whereas 9 patients with ACLF and 3 NC had hepatic CD45+ T cells transcriptomics. Thecandidateindicatorfoundinthetranscriptomicswas confirmedbya retrospective cohort (n = 137) and one prospective cohort (n = 68). RESULTS Transcriptomics revealed significant differentially expression genes (DEGs) and bioprocesses related to the PBMCs and hepatic CD45+ T cells. Secreted phosphoprotein 1 (SPP1) was identified as a potential indicator for ACLF patients receiving LT, which was supported by evidence from the cross-sectional cohorts. As the condition of ACLF got worse, so did SPP1 levels, which were associated with liver failure and coagulation failure. SPP1 levels prior to LT were considerably greater in non-survivors of ACLF within 90 days than that in survivors. In the derivation cohort and validation cohort, ACLF patients with elevated SPP1 levels had significantly shorter cumulative survival durations than those with low SPP1 levels, P = 0.02 and P < 0.001, respectively. The SPP1-MELD and SPP1-chronic liver failure consortium (CLIF-C) ACLF scores had comparatively larger areas under the receiver operating characteristic curves (AUCs) than MELD (P = 0.0388) and CLIF-C ACLF (P = 0.045). CONCLUSIONS The circulating SPP1 showed promise as a predictor for ACLF patients receiving LT, which demonstrated the need for tracking the clinical outcome of LT.
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Affiliation(s)
- Yeping Yu
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, China
| | - Xinyi Mao
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jieying Wang
- Clinical Research Center, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Mo Chen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Wang
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, China
| | - Xiaoni Kong
- Central Laboratory, Department of Liver Diseases, ShuGuang Hospital Affiliated to Shanghai University of Chinese Traditional Medicine, Shanghai, China
| | - Hualian Hang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
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28
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Nagel M, Westphal R, Hilscher M, Galle PR, Schattenberg JM, Schreiner O, Labenz C, Wörns MA. Validation of the CLIF-C OF Score and CLIF-C ACLF Score to Predict Transplant-Free Survival in Patients with Liver Cirrhosis and Concomitant Need for Intensive Care Unit Treatment. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050866. [PMID: 37241098 DOI: 10.3390/medicina59050866] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/07/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023]
Abstract
Both the Chronic Liver Failure Consortium (CLIF-C) organ failure score (OFs) and the CLIF-C acute-on-chronic-liver failure (ACLF) score (ACLFs) were developed for risk stratification and to predict mortality in patients with liver cirrhosis and ACLF. However, studies validating the predictive ability of both scores in patients with liver cirrhosis and concomitant need for intensive care unit (ICU) treatment are scarce. The aim of the present study is to validate the predictive ability of the CLIF-C OFs and CLIF-C ACLFs regarding the rationale of ongoing ICU treatment and to investigate their predictive ability regarding 28-days (short-), 90-days (medium-), and 365-days (long-term) mortality in patients with liver cirrhosis treated in an ICU. Patients with liver cirrhosis and acute decompensation (AD) or ACLF and concomitant need for ICU treatment were retrospectively analyzed. Predictive factors for mortality, defined as transplant-free survival, were identified using multivariable regression analyses and the predictive ability of CLIF-C OFs, CLIF-C ACLFs, MELD score, and AD score (ADs) was assessed by determining the AUROC. Of 136 included patients, 19 patients presented with AD and 117 patients with ACLF at ICU admission. In multivariable regression analyses, CLIF-C OFs as well as CLIF-C ACLFs were independently associated with higher short-, medium-, and long-term mortality after adjusting for confounding variables. The predictive ability of the CLIF-C OFs in the total cohort in short-term was 0.687 (95% CI 0.599-0.774). In the subgroup of patients with ACLF, the respective AUROCs were 0.652 (95% CI 0.554-0.750) and 0.717 (95% CI 0.626-0.809) for the CLIF-C OFs and for the CLIF-C ACLFs, respectively. ADs performed well in the subgroup of patients without ACLF at ICU admission with an AUROC of 0.792 (95% CI 0.560-1.000). In the long-term, the AUROCs were 0.689 (95% Cl 0.581-0.796) and 0.675 (95% Cl 0.550-0.800) for CLIF-C OFs and CLIF-C ACLFs, respectively. The predictive ability of CLIF-C OFs and CLIF-C ACLFs was relatively low to predict short- and long-term mortality in patients with ACLF with concomitant need for ICU treatment. However, the CLIF-C ACLFs may have special merit in judging futility of further ICU treatment.
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Affiliation(s)
- Michael Nagel
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, 44137 Dortmund, Germany
| | - Ruben Westphal
- Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Max Hilscher
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, 44137 Dortmund, Germany
| | - Peter R Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Jörn M Schattenberg
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Oliver Schreiner
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Christian Labenz
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
| | - Marcus Alexander Wörns
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Cirrhosis Center Mainz (CCM), University Medical Center of the Johannes Gutenberg-University, 55131 Mainz, Germany
- Department of Gastroenterology, Hematology, Oncology and Endocrinology, Klinikum Dortmund, 44137 Dortmund, Germany
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Popescu M, David C, Marcu A, Olita MR, Mihaila M, Tomescu D. Artificial Liver Support with CytoSorb and MARS in Liver Failure: A Retrospective Propensity Matched Analysis. J Clin Med 2023; 12:jcm12062258. [PMID: 36983259 PMCID: PMC10058971 DOI: 10.3390/jcm12062258] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 03/06/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
Background: Liver failure represents a life-threatening organ dysfunction with liver transplantation as the only proven curable therapy to date. Liver assist devices have been extensively researched to either bridge such patients to transplantation or promote spontaneous recovery. The aim of our study was to compare two such devices, the Molecular Adsorbent Recirculating System (MARS) and CytoSorb, in patients with liver failure. Methods: We retrospectively included 15 patients who underwent MARS during their intensive care unit stay and matched them to 15 patients who underwent hemoadsorption using CytoSorb. Clinical and paraclinical data obtained after each individual session, after the course of treatment, as well as at the end of the intensive care unit stay were compared between the two groups. Results: Single sessions of CytoSorb and MARS were both associated with a significant decrease in bilirubin (p = 0.04 and p = 0.04, respectively) and ammonia levels (p = 0.04 and p = 0.04, respectively), but only CytoSorb therapy was associated with a decrease in lactate dehydrogenase levels (p = 0.04) and in platelet count (p = 0.04). After the course of treatment, only CytoSorb was associated with a significant decrease in lactate (p = 0.01), bilirubin (p = 0.01), ammonia (p = 0.02), and lactate dehydrogenase levels (p = 0.01), while patients treated with MARS did not show any improvement in paraclinical liver tests. In addition, only CytoSorb treatment was associated with a significant improvement in the Model for End-Stage Liver Disease Score (p = 0.04). Conclusion: In conclusion, our results show a potential benefit of CytoSorb in rebalancing liver functional tests in patients with liver failure compared to MARS but the exact effects on patient outcome, including hospital length of stay and survival, should be further investigated in randomized control trials.
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Affiliation(s)
- Mihai Popescu
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 022328 Bucharest, Romania
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania
- Correspondence: ; Tel.: +40-75-107-5995
| | - Corina David
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Alexandra Marcu
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mihaela Roxana Olita
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 022328 Bucharest, Romania
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Mariana Mihaila
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania
| | - Dana Tomescu
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 022328 Bucharest, Romania
- Department of Anaesthesia and Intensive Care, Fundeni Clinical Institute, 022328 Bucharest, Romania
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30
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Wang S, Zhu H, Pan L, Zhang M, Wan X, Xu H, Hua R, Zhu M, Gao P. Systemic inflammatory regulators and risk of acute-on-chronic liver failure: A bidirectional mendelian-randomization study. Front Cell Dev Biol 2023; 11:1125233. [PMID: 36743413 PMCID: PMC9892464 DOI: 10.3389/fcell.2023.1125233] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 01/06/2023] [Indexed: 01/20/2023] Open
Abstract
Inflammation plays a role in the pathogenesis of acute-on-chronic liver failure (ACLF), however, whether there is a causal relationship between inflammation and ACLF remains unclear. A two-sample Mendelian randomization (MR) approach was used to investigate the causal relationship between systemic inflammatory regulators and ACLF. The study analyzed 41 cytokines and growth factors from 8,293 individuals extracted from a genome-wide association study (GWAS) meta-analysis database involving 253 ACLF cases and 456,095 controls. Our results showed that lower stem cell factor (SCF) levels, lower basic fibroblast growth factor (bFGF) levels and higher Interleukin-13 (IL-13) levels were associated with an increased risk of ACLF (OR = 0.486, 95% CI = 0.264-0.892, p = 0.020; OR = 0.323, 95% CI = 0.107-0.972, p = 0.044; OR = 1.492, 95% CI = 1.111-2.004, p = 0.008, respectively). In addition, genetically predicted ACLF did not affect the expression of systemic inflammatory regulators. Our results indicate that cytokines play a crucial role in the pathogenesis of ACLF. Further studies are needed to determine whether these biomarkers can be used to prevent and treat ACLF.
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Affiliation(s)
- Shengnan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hao Zhu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Lin Pan
- Clinical College, Jilin University, Changchun, China
| | - Mengyuan Zhang
- Department of Respiratory, The First Hospital of Jilin University, Changchun, China
| | - Xiaoqiang Wan
- Department of Interventional Radiology, The First Hospital of Jilin University, Changchun, China
| | - Hongqin Xu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Rui Hua
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China
| | - Mingqin Zhu
- Department of Neurology, The First Hospital of Jilin University, Changchun, China,*Correspondence: Mingqin Zhu, ; Pujun Gao,
| | - Pujun Gao
- Department of Hepatology, The First Hospital of Jilin University, Changchun, China,*Correspondence: Mingqin Zhu, ; Pujun Gao,
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31
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Ngu NLY, Flanagan E, Bell S, Le ST. Acute-on-chronic liver failure: Controversies and consensus. World J Gastroenterol 2023; 29:232-240. [PMID: 36687118 PMCID: PMC9846945 DOI: 10.3748/wjg.v29.i2.232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/01/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a poorly defined syndrome characterised by rapid clinical deterioration in patients with chronic liver disease. Consequences include high short-term morbidity, mortality, and healthcare resource utilisation. ACLF encompasses a dysregulated, systemic inflammatory response, which can precipitate extra hepatic organ failures. Common precipitants include infection, alcoholic hepatitis, and reactivation of viral hepatitis although frequently no cause is identified. Heterogenous definitions, diagnostic criteria, and treatment guidelines, have been proposed by international hepatology societies. This can result in delayed or missed diagnoses of ACLF, significant variability in clinical management, and under-estimation of disease burden. Liver transplantation may be considered but the mainstay of treatment is organ support, often in the intensive care unit. This review will provide clarity around where are the controversies and consensus in ACLF including: Epidemiology and resource utilisation, key clinical and diagnostic features, strategies for management, and research gaps.
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Affiliation(s)
- Natalie L Y Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Department of Gastroenterology and Hepatology, Alfred Health, Melbourne 3004, Victoria, Australia
| | - Eliza Flanagan
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
| | - Suong T Le
- Department of Gastroenterology and Hepatology, Monash Health, Clayton 3168, Victoria, Australia
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton 3800, Victoria, Australia
- Monash digital Therapeutics and Innovation Laboratory (MoTILa), Monash University, Clayton 3168, Victoria, Australia
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Canillas L, Pelegrina A, Álvarez J, Colominas-González E, Salar A, Aguilera L, Burdio F, Montes A, Grau S, Grande L, Carrión JA. Clinical Guideline on Perioperative Management of Patients with Advanced Chronic Liver Disease. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010132. [PMID: 36676081 PMCID: PMC9860873 DOI: 10.3390/life13010132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/06/2023]
Abstract
(1) Background: Patients with advanced chronic liver disease (ACLD) are living longer with more comorbidities because of improved medical and surgical management. However, patients with ACLD are at increased risk of perioperative morbidity and mortality; (2) Methods: We conducted a comprehensive review of the literature to support a narrative clinical guideline about the assessment of mortality risk and management of perioperative morbidity in patients with ACLD undergoing surgical procedures; (3) Results: Slight data exist to guide the perioperative management of patients with ACLD, and most recommendations are based on case series and expert opinion. The severity of liver dysfunction, portal hypertension, cardiopulmonary and renal comorbidities, and complexity of surgery and type (elective versus emergent) are predictors of perioperative morbidity and mortality. Expert multidisciplinary teams are necessary to evaluate and manage ACLD before, during, and after surgical procedures; (4) Conclusions: This clinical practice document updates the available data and recommendations to optimize the management of patients with advanced chronic liver disease who undergo surgical procedures.
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Affiliation(s)
- Lidia Canillas
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
| | - Amalia Pelegrina
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Juan Álvarez
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Elena Colominas-González
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Pharmacy Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Antonio Salar
- Haematology Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Lluís Aguilera
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Fernando Burdio
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
| | - Antonio Montes
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Anesthesia Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Santiago Grau
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Pharmacy Department, Hospital del Mar, 08003 Barcelona, Spain
| | - Luis Grande
- Department of Surgery, Hospital del Mar, 08003 Barcelona, Spain
- Department de Medicina, Universitat Autònoma de Barcelona, 08003 Barcelona, Spain
| | - José A. Carrión
- Department of Medicine and Life Sciences, Universitat Pompeu Fabra, 08003 Barcelona, Spain
- Liver Section, Gastroenterology Department, Hospital del Mar, 08003 Barcelona, Spain
- IMIM (Hospital del Mar Medical Research Institute), 08003 Barcelona, Spain
- Correspondence: ; Tel.: +93-248-3220; Fax: +93-221-8644
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Majeed A, Bailey M, Kemp W, Majumdar A, Bellomo R, Pilcher D, Roberts SK. Improved survival of cirrhotic patients with infections in Australian and New Zealand ICUs between 2005 and 2017. Liver Int 2023; 43:49-59. [PMID: 35532544 DOI: 10.1111/liv.15285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 03/22/2022] [Accepted: 04/23/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS Changes in outcomes of cirrhotic patients admitted to intensive care units (ICUs) with infections are poorly understood. We aimed to describe changes over time in outcomes for such patients and to compare them to other ICU admissions. METHODS Analysis of consecutive admissions to 188 ICUs between 2005 and 2017 as recorded in the Australian and New Zealand Intensive Care Society Centre for Outcome and Research Evaluation Adult Patient Database. RESULTS Admissions for cirrhotic patients with infections accounted for 4645 (0.6%) of 813 189 non-elective ICU admissions. Hospital mortality rate (35.5%) was significantly higher compared with other cirrhotic patients' admissions (28.5%), and other ICU admissions for infection (17.1%, p < .0001), and increased to 52.2% in the presence of acute-on-chronic liver failure (ACLF). Hospital mortality in cirrhotic patients' ICU admissions for infection decreased significantly over time (annual decline odds ratio, 0.97; 95% CI, 0.95-0.99, p = .002). There was a comparable reduction in-hospital mortality rates over time in other ICU admissions for infections and other cirrhotic patients' ICU admissions. However, mortality rates did not change over time in the ACLF subgroup. Median hospital and ICU length of stays for cirrhotic patients' ICU admissions for infections were 12.1 and 3.5 days, respectively, and decreased significantly by 1 day every 4 years in-hospital survivors(p < .0001). CONCLUSION Hospital mortality in ICU admissions for cirrhotic patients with infection is double that of non-cirrhotic patients with infection but has declined significantly over time. Outcomes in the subgroup with ACLF remained poor without significant improvement over the study period.
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Affiliation(s)
- Ammar Majeed
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia.,ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
| | - William Kemp
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
| | - Avik Majumdar
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, Australia.,Central Clinical School, The University of Sydney, Sydney, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive Medicine, Monash University, Australia.,ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Stuart K Roberts
- Department of Gastroenterology, The Alfred Hospital, Melbourne, Australia.,Central Clinical School, Monash University, Melbourne, Australia
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Schulz MS, Mengers J, Gu W, Drolz A, Ferstl PG, Amoros A, Uschner FE, Ackermann N, Guttenberg G, Queck A, Brol MJ, Graf C, Stoffers P, de la Vera ALL, Cremonese C, Erasmus HP, Welker MW, Grünewaldt A, Arroyo V, Bojunga J, Fernandez J, Zeuzem S, Kluwe J, Peiffer KH, Welsch C, Fuhrmann V, Rohde G, Trebicka J. Pulmonary impairment independently determines mortality in critically ill patients with acute-on-chronic liver failure. Liver Int 2023; 43:180-193. [PMID: 35727853 DOI: 10.1111/liv.15343] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/26/2022] [Accepted: 06/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS In ACLF patients, an adequate risk stratification is essential, especially for liver transplant allocation, since ACLF is associated with high short-term mortality. The CLIF-C ACLF score is the best prognostic model to predict outcome in ACLF patients. While lung failure is generally regarded as signum malum in ICU care, this study aims to evaluate and quantify the role of pulmonary impairment on outcome in ACLF patients. METHODS In this retrospective study, 498 patients with liver cirrhosis and admission to IMC/ICU were included. ACLF was defined according to EASL-CLIF criteria. Pulmonary impairment was classified into three groups: unimpaired ventilation, need for mechanical ventilation and defined pulmonary failure. These factors were analysed in different cohorts, including a propensity score-matched ACLF cohort. RESULTS Mechanical ventilation and pulmonary failure were identified as independent risk factors for increased short-term mortality. In matched ACLF patients, the presence of pulmonary failure showed the highest 28-day mortality (83.7%), whereas mortality rates in ACLF with mechanical ventilation (67.3%) and ACLF without pulmonary impairment (38.8%) were considerably lower (p < .001). Especially in patients with pulmonary impairment, the CLIF-C ACLF score showed poor predictive accuracy. Adjusting the CLIF-C ACLF score for the grade of pulmonary impairment improved the prediction significantly. CONCLUSIONS This study highlights that not only pulmonary failure but also mechanical ventilation is associated with worse prognosis in ACLF patients. The grade of pulmonary impairment should be considered in the risk assessment in ACLF patients. The new score may be useful in the selection of patients for liver transplantation.
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Affiliation(s)
- Martin S Schulz
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Jan Mengers
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Wenyi Gu
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Andreas Drolz
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip G Ferstl
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Alex Amoros
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Frank E Uschner
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Nora Ackermann
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Georg Guttenberg
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Alexander Queck
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Maximilian J Brol
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Christiana Graf
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Philipp Stoffers
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | | | - Carla Cremonese
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Hans-Peter Erasmus
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Martin W Welker
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Achim Grünewaldt
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Vincente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Jörg Bojunga
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Javier Fernandez
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain.,Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Stefan Zeuzem
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Johannes Kluwe
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Christoph Welsch
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gernot Rohde
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany.,European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
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Luxenburger H, Schmidt K, Biever P, Supady A, Sekandarzad A, Roehlen N, Reincke M, Neumann-Haefelin C, Schultheiss M, Wengenmayer T, Thimme R, Bettinger D. Survival prediction using the Freiburg index of post-TIPS survival (FIPS) in critically ill patients with acute- on chronic liver failure: A retrospective observational study. Front Med (Lausanne) 2022; 9:1042674. [PMID: 36619640 PMCID: PMC9812953 DOI: 10.3389/fmed.2022.1042674] [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: 09/12/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background and aim Liver cirrhosis in patients treated in the intensive care unit (ICU) is associated with high mortality. Well established scores are useful to allow for assessment of prognosis and support ICU treatment guidance. However, currently used scoring systems often do not reflect the complexity of critically ill patients. Therefore, we tested the newly developed Freiburg index-of post-TIPS survival (FIPS) score in order to assess its potential role for prognostication of cirrhotic patients in the ICU. Methods A total of 310 patients with liver cirrhosis treated in the ICU between 2010 and 2021 were enrolled in this retrospective observational study. Prognostic factors for mortality and 28-day mortality were assessed. Moreover, using c indices the prognostic discrimination of different prognostic scores was analyzed. Results The FIPS score allowed to discriminate patients with high ICU mortality and within 28-days after ICU treatment (ICU mortality: 42.2 vs. 59.9%, p = 0.008 and 28-day mortality: 43.3 vs. 74.1%, p < 0.001). However, the FIPS score in its current composition showed no superior prognostic discrimination compared to other established scores. Multivariable analyses identified the FIPS score (HR 1.25 [1.04-1.49], p = 0.015) and lactate at admission (HR 1.07 [1.04-1.09], p < 0.001) as significant predictors of ICU mortality. Lactate at admission substantially improved patient risk stratification within each FIPS risk groups. Conclusion Similar to other commonly used scores, the FIPS score in its current composition does not allow a sufficiently reliable prognostication of critically ill patients treated in the ICU. However, adding lactate as additional factor to the FIPS score may improve its prognostic ability.
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Affiliation(s)
- Hendrik Luxenburger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,IMM-PACT, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Paul Biever
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Asieb Sekandarzad
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Natascha Roehlen
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,*Correspondence: Dominik Bettinger,
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Engelmann C, Habtesion A, Hassan M, Kerbert AJ, Hammerich L, Novelli S, Fidaleo M, Philips A, Davies N, Ferreira-Gonzalez S, Forbes SJ, Berg T, Andreola F, Jalan R. Combination of G-CSF and a TLR4 inhibitor reduce inflammation and promote regeneration in a mouse model of ACLF. J Hepatol 2022; 77:1325-1338. [PMID: 35843375 DOI: 10.1016/j.jhep.2022.07.006] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 05/22/2022] [Accepted: 07/04/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterised by high short-term mortality, systemic inflammation, and failure of hepatic regeneration. Its treatment is a major unmet medical need. This study was conducted to explore whether combining TAK-242, a Toll-like receptor-4 (TLR4) antagonist, with granulocyte-colony stimulating factor (G-CSF), could reduce inflammation whilst enhancing liver regeneration. METHODS Two mouse models of ACLF were investigated. Chronic liver injury was induced by carbon tetrachloride; lipopolysaccharide (LPS) or galactosamine (GalN) were then administered as extrahepatic or hepatic insults, respectively. G-CSF and/or TAK-242 were administered daily. Treatment durations were 24 hours and 5 days in the LPS model and 48 hours in the GalN model. RESULTS In a mouse model of LPS-induced ACLF, treatment with G-CSF was associated with significant mortality (66% after 48 hours vs. 0% without G-CSF). Addition of TAK-242 to G-CSF abrogated mortality (0%) and significantly reduced liver cell death, macrophage infiltration and inflammation. In the GalN model, both G-CSF and TAK-242, when used individually, reduced liver injury but their combination was significantly more effective. G-CSF treatment, with or without TAK-242, was associated with activation of the pro-regenerative and anti-apoptotic STAT3 pathway. LPS-driven ACLF was characterised by p21 overexpression, which is indicative of hepatic senescence and inhibition of hepatocyte regeneration. While TAK-242 treatment mitigated the effect on senescence, G-CSF, when co-administered with TAK-242, resulted in a significant increase in markers of hepatocyte regeneration. CONCLUSION The combination of TAK-242 and G-CSF inhibits inflammation, promotes hepatic regeneration and prevents mortality in models of ACLF; thus, this combination could be a potential treatment option for ACLF. LAY SUMMARY Acute-on-chronic liver failure is associated with severe liver inflammation and poor short-term survival. Therefore, effective treatments are urgently needed. Herein, we have shown, using mouse models, that the combination of granulocyte-colony stimulating factor (which can promote liver regeneration) and TAK-242 (which inhibits a receptor that plays a key role in inflammation) could be effective for the treatment of acute-on-chronic liver failure.
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Affiliation(s)
- Cornelius Engelmann
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany; Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Germany; Berlin Institute of Health - Charité - Universitätsmedizin Berlin, Germany
| | - Abeba Habtesion
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Mohsin Hassan
- Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Germany
| | - Annarein Jc Kerbert
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Linda Hammerich
- Medical Department, Division of Hepatology and Gastroenterology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Germany
| | - Simone Novelli
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Department of Mechanical and Aerospace Engineering, Sapienza University of Rome, Rome, Italy
| | - Marco Fidaleo
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; Department of Biology and Biotechnology "C. Darwin", University of Rome Sapienza, 00185 Rome, Italy
| | - Alexandra Philips
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Nathan Davies
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Sofia Ferreira-Gonzalez
- MRC Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh BioQuarter, 5 Little France Drive, Edinburgh, United Kingdom
| | - Stuart J Forbes
- MRC Centre for Regenerative Medicine, The University of Edinburgh, Edinburgh BioQuarter, 5 Little France Drive, Edinburgh, United Kingdom
| | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University Medical Center, Leipzig, Germany
| | - Fausto Andreola
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, United Kingdom; European Foundation of the Study of Chronic Liver Failure, Barcelona, Spain.
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Qian YB, Chen F, Hang HL, Shen C, Han LZ, Deng YX, Xia L, Zhang JJ, Xia Q. Risk factors and outcomes of early infection in liver transplant recipients with acute-on-chronic liver failure. J Dig Dis 2022; 23:642-650. [PMID: 36617995 DOI: 10.1111/1751-2980.13151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 12/29/2022] [Accepted: 01/05/2023] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Patients with acute-on-chronic liver failure (ACLF) have a high risk of infection after liver transplantation (LT). In this study, we aimed to evaluate the prevalence of early post-LT infection (within one month after LT) in recipients with ACLF, and to compare the survival rate between patients with or without post-LT infection. METHODS Patients with ACLF who underwent LT between January 2015 and December 2017 were retrospectively included. Characteristics of the patients, prevalence, site and pathogen of post-LT infection, and its risk factors were evaluated. RESULTS A total of 62 patients with ACLF developed bacterial or fungal infection after LT. The 30-day, 90-day, and 1-year survival rates in the infected group were found to be significantly lower than those in the non-infected group (67.7% vs 98.5%, 64.5% vs 97.7%, and 48.4% vs 95.4%; all P < 0.001). The most common pathogens involved were carbapenem-resistant gram-negative organisms, including Acinetobacter baumannii, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Acinetobacter lwoffi. Multivariate analysis demonstrated that reoperation and length of intensive care unit stay were independently associated with post-LT infection. In addition, living donor LT and early allograft dysfunction were independently associated with 30-day all-cause mortality, whereas red blood cell transfusion and post-LT infection were independently associated with all-cause 30-day and 90-day mortality after LT. CONCLUSIONS Early infection after LT is a major prognostic factor in patients with ACLF. Constant vigilance for the risk factors of early infection after LT is needed for timely diagnosis and prompt intervention.
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Affiliation(s)
- Yong Bing Qian
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fang Chen
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Lian Hang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chuan Shen
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Long Zhi Han
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yu Xiao Deng
- Department of Critical Care Medicine, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Jun Zhang
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Qiang Xia
- Department of Liver Surgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Kwon HM, Kim JH, Kim JY, Hwang GS. Five-year all-cause mortality in critically ill liver transplant patients with coronary artery disease: analysis of acute-on chronic liver failure. Anesth Pain Med (Seoul) 2022; 17:412-419. [DOI: 10.17085/apm.22168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with acute-on-chronic liver failure (ACLF) are critically ill and have high waiting-list mortality. Although studies demonstrated that appropriately treated coronary artery disease (CAD) should not be regarded as a contraindication to liver transplant (LT), data regarding long-term outcomes in critically ill liver LT recipients are lacking. The aim of this study was to compare the rates of all-cause death at 5 years following LT in patients with ACLF with or without CAD.Methods: Between 2010 and 2020, we evaluated 921 consecutive LT patients (MELD score, 32 ± 9) and ACLF classified by CLIF-C ACLF score. Up to 5-year all-cause death according to the CAD status was examined. CAD was defined as a preoperative history of coronary artery bypass graft or a percutaneous intervention and old myocardial infarction. Kaplan-Meier survival analysis was used.Results: Up to 5 years, 212 (23.0%) of all ACLF patients (n = 921) in whom 17 (29.3%) of 58 CAD patients died. In patients with CAD (6.3%, 58/921), the Kaplan-Meier cumulative mortality rate at 5 years was numerically higher but was not statistically significant when compared with those without CAD (32.9% vs. 23.5%, log-rank, P = 0.25). In subgr oup analysis, there were comparable risks of cumulative mortalities at 5 years across the stratification of ACLF grade 1, 2, and 3 (log-rank P = 0.062, P = 0.72, and P = 0.999, respectively).Conclusions: All-cause mortality is high in patients with ACLF after LT but is not related to the presence of revascularized or treated CAD, across the stratification of ACLF grades.
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39
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Tang D, Wang RY, Sun KW, Wu Y, Ding L, Mo Y. Network pharmacology-based prediction of active compounds in the Wenyang Jiedu Huayu formula acting on acute-on-chronic liver failure with experimental support in vitro and in vivo. Front Pharmacol 2022; 13:1003479. [PMID: 36339606 PMCID: PMC9631206 DOI: 10.3389/fphar.2022.1003479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 09/28/2022] [Indexed: 11/25/2022] Open
Abstract
Acute-on-chronic liver failure (ACLF) is characterized by undermined liver function, massive necrosis/apoptosis of hepatocytes, and hepatic inflammatory cell recruitment, leading to multiorgan failure. Traditional Chinese medicine (TCM) has been widely applied in clinical and experimental studies of ACLF. In this study, 23 compounds with 6,386 drug targets were obtained from Wenyang Jiedu Huayu (WYJDHY), and 8,096 genes were identified as ACLF disease targets, among which 3,132 were overlapping co-targets. Expression profile analysis identified 105 DEGs among the co-targets, which were associated with biological activities such as lymphocyte activation, immune response regulation, and pathways such as Th17 cell differentiation and NF-κB signaling. After PPI analysis and network construction, atractylenolide I (AT-1) has been identified as the hub active ingredient of the WYJDHY formula. LPS stimulation inhibited rat hepatocytes’ BRL 3A cell viability, promoted cell apoptosis, increased the levels of ALT, AST, IL-6, and VCAM-1 within the culture medium, and activated NF-κB signaling, whereas AT-1 treatment significantly attenuated LPS-induced toxicity on BRL 3A cells. Furthermore, the NF-κB signaling inhibitor PDTC exerted effects on LPS-stimulated BRL 3A cells similar to those of AT-1, and the combination of PDTC and AT-1 further attenuated LPS-induced toxicity on BRL 3A cells. In vivo, AT-1 alone or with PDTC improved the symptoms and local inflammation in ACLF model rats. In conclusion, 23 active ingredients of six herbs in the WYJDHY formula were retrieved, and 105 co-targets were differentially expressed in ACLF. AT-1 exerts protective effects on LPS-stimulated hepatocytes and ACLF rats, possibly by inhibiting the NF-κB pathway.
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Affiliation(s)
- Dan Tang
- Department of Hepatology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, China
| | - Ruo-Yu Wang
- Department of Hepatology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, China
| | - Ke-Wei Sun
- Department of Hepatology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, China
- *Correspondence: Ke-Wei Sun,
| | - Yunan Wu
- Department of Hepatology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, China
| | - Lin Ding
- Department of Hepatology, The First Hospital of Hunan University of Traditional Chinese Medicine, Changsha, China
| | - Yang Mo
- Academic Affairs Office, Hunan University of Traditional Chinese Medicine, Changsha, China
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40
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Dong FC, Tan WT, Wang XB, Zheng X, Huang Y, Li BL, Meng ZJ, Gao YH, Qian ZP, Liu F, Lu XB, Shang J, Shi Y, Zheng YB, Yan HD, Zhang Y, Xu BY, Hou YX, Zhang Q, Xiong Y, Zou CC, Chen J, Huang ZB, Jiang XH, Luo S, Chen YY, Gao N, Liu CY, Yuan W, Mei X, Li J, Li T, Zheng RJ, Zhou XY, Chen JJ, Deng GH, Mei XX, Zhang WT, Li H. The neutrophil-to-lymphocyte ratio represents a systemic inflammation marker and reflects the relationship with 90-day mortality in non-cirrhotic chronic severe hepatitis. J Dig Dis 2022; 23:587-596. [PMID: 36326787 DOI: 10.1111/1751-2980.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/16/2022] [Accepted: 11/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVES To investigate the relationship between systemic inflammatory response and short-term mortality in patients with non-cirrhotic chronic severe hepatitis (CSH) by using several indicators of inflammation including neutrophil-to-lymphocyte ratio (NLR), neutrophil (NEU), white blood cell (WBC), platelet-to lymphocyte ratio (PLR), and monocyte-to-lymphocyte ratio (MLR). METHODS Data were collected from two prospectively enrolled CATCH-LIFE noncirrhotic cohorts. Cox regression analysis was used to investigate the association between systemic inflammatory biomarkers and 90-day liver transplant (LT)-free mortality. A generalized additive model (GAM) was used to illustrate the quantitative curve relationship between NLR and 90-day LT-free mortality. Kaplan-Meier method was used to estimate the 90-year LT-free survival. RESULTS The prevalence of CSH was 20.5% (226/1103). The 28-day and 90-day LT-free mortality rates were 17.7% and 26.1%, respectively, for patients with non-cirrhotic CSH. Patients with no infection accounted for 75.0% of all CSH patients, and NLR was independently associated with 90-day LT-free mortality. NLR of 2.9 might be related to disease deterioration in CSH patients without infection. CONCLUSIONS NLR may be an independent risk factor for 90-day LT-free mortality in patients with non-cirrhotic chronic liver disease. A NLR of 2.9 as the cut-off value can be used to predict disease aggravation in CSH patients without infection.
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Affiliation(s)
- Fu Chen Dong
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Chinese Ministry of Health (Shanghai Jiao Tong University), Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wen Ting Tan
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xian Bo Wang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Xin Zheng
- Department of Infectious Diseases, Institute of Infection and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yan Huang
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Bei Ling Li
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Zhong Ji Meng
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Yan Hang Gao
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Zhi Ping Qian
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Feng Liu
- Tianjin Institute of Hepatology, Nankai University Second People's Hospital, Tianjin, China.,Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Xiao Bo Lu
- Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Jia Shang
- Department of Infectious Diseases, Henan Provincial People's Hospital, Zhengzhou, Henan Province, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Yu Bao Zheng
- Department of Infectious Diseases, The Third Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, China
| | - Hua Dong Yan
- Department of Infectious Diseases, Hwamei Hospital, Ningbo No. 2 Hospital, University of Chinese Academy of Sciences, Ningbo, Zhejiang Province, China
| | - Yan Zhang
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Chinese Ministry of Health (Shanghai Jiao Tong University), Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Bao Yan Xu
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Yi Xin Hou
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Qun Zhang
- Center of Integrative Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yan Xiong
- Department of Infectious Diseases, Institute of Infection and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Cong Cong Zou
- Department of Infectious Diseases, Institute of Infection and Immunology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Jun Chen
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Ze Bing Huang
- Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, Hunan Province, China
| | - Xiu Hua Jiang
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Sen Luo
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Yuan Yuan Chen
- Department of Infectious Diseases, Taihe Hospital, Hubei University of Medicine, Shiyan, Hubei Province, China
| | - Na Gao
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Chun Yan Liu
- Department of Hepatology, The First Hospital of Jilin University, Changchun, Jilin Province, China
| | - Wei Yuan
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Xue Mei
- Department of Liver Intensive Care Unit, Shanghai Public Health Clinical Centre, Fudan University, Shanghai, China
| | - Jing Li
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Tao Li
- Department of Infectious Diseases and Hepatology, The Second Hospital of Shandong University, Jinan, Shandong Province, China
| | - Rong Jiong Zheng
- Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Xin Yi Zhou
- Infectious Disease Center, The First Affiliated Hospital of Xinjiang Medical University, Urumqi, Xinjiang Uygur Autonomous Region, China
| | - Jin Jun Chen
- Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
| | - Guo Hong Deng
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xiang Xiao Mei
- Department of Infectious Diseases, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wei Tuo Zhang
- Clinical Research Center, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hai Li
- Division of Gastroenterology and Hepatology, Shanghai Institute of Digestive Disease, Key Laboratory of Gastroenterology and Hepatology, Chinese Ministry of Health (Shanghai Jiao Tong University), Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Ngu NL, Saxby E, Worland T, Anderson P, Stothers L, Figredo A, Hunter J, Elford A, Ha P, Hartley I, Roberts A, Seah D, Tambakis G, Liew D, Rogers B, Sievert W, Bell S, Le S. A home-based, multidisciplinary liver optimisation programme for the first 28 days after an admission for acute-on-chronic liver failure (LivR well): a study protocol for a randomised controlled trial. Trials 2022; 23:744. [PMID: 36064596 PMCID: PMC9444080 DOI: 10.1186/s13063-022-06679-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 08/20/2022] [Indexed: 11/22/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) represents a rising global healthcare burden, characterised by increasing prevalence among patients with decompensated cirrhosis who have a 28-day transplantation-free mortality of 33.9%. Due to disease complexity and a high prevalence of socio-economic disadvantage, there are deficits in quality of care and adherence to guideline-based treatment in this cohort. Compared to other chronic conditions such as heart failure, those with liver disease have reduced access to integrated ambulatory care services. The LivR Well programme is a multidisciplinary intervention aimed at improving 28-day mortality and reducing 30-day readmission through a home-based, liver optimisation programme implemented in the first 28 days after an admission with either ACLF or hepatic decompensation. Outcomes from our feasibility study suggest that the intervention is safe and acceptable to patients and carers. Methods We will recruit adult patients with chronic liver disease from the emergency departments, in-patient admissions, and an ambulatory liver clinic of a multi-site quaternary health service in Melbourne, Australia. A total of 120 patients meeting EF-Clif criteria will be recruited to the ACLF arm, and 320 patients to the hepatic decompensation arm. Participants in each cohort will be randomised to the intervention arm, a 28-day multidisciplinary programme or to standard ambulatory care in a 1:1 ratio. The intervention arm includes access to nursing, pharmacy, physiotherapy, dietetics, social work, and neuropsychiatry clinicians. For the ACLF cohort, the primary outcome is 28-day mortality. For the hepatic decompensation cohort, the primary outcome is 30-day re-admission. Secondary outcomes assess changes in liver disease severity and quality of life. An interim analysis will be performed at 50% recruitment to consider early cessation of the trial if the intervention is superior to the control, as suggested in our feasibility study. A cost-effectiveness analysis will be performed. Patients will be followed up for 12 weeks from randomisation. Three exploratory subgroup analyses will be conducted by (a) source of referral, (b) unplanned hospitalisation, and (c) concurrent COVID-19. The trial has been registered with the Australian New Zealand Clinical Trials Registry. Discussion This study implements a multidisciplinary intervention for ACLF patients with proven benefits in other chronic diseases with the addition of novel digital health tools to enable remote patient monitoring during the COVID-19 pandemic. Our feasibility study demonstrates safety and acceptability and suggests clinical improvement in a small sample size. An RCT is required to generate robust outcomes in this frail, high healthcare resource utilisation cohort with high readmission and mortality risk. Interventions such as LivR Well are urgently required but also need to be evaluated to ensure feasibility, replicability, and scalability across different healthcare systems. The implications of this trial include the generalisability of the programme for implementation across regional and urban centres. Trial registration Australian New Zealand Clinical Trials Registry (ANZCTR) ACTRN12621001703897. Registered on 13 December 2021. WHO Trial Registration Data Set. See Appendix 1 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06679-x.
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Affiliation(s)
- Natalie Ly Ngu
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia. .,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.
| | - Edward Saxby
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Thomas Worland
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Patricia Anderson
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Lisa Stothers
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Anita Figredo
- Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Jo Hunter
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Alexander Elford
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Phil Ha
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Imogen Hartley
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Andrew Roberts
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Dean Seah
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - George Tambakis
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - Danny Liew
- Adelaide Medical School, The University of Adelaide, Corner of North Terrace & George St, Adelaide, South Australia, 5000, Australia
| | - Benjamin Rogers
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia.,Hospital in the Home, Level 4, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - William Sievert
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Sally Bell
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
| | - Suong Le
- Department of Gastroenterology and Hepatology, Monash Health, Level 3, 246 Clayton Rd, Clayton, Victoria, 3168, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Wellington Rd, Clayton, Victoria, 3800, Australia
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Cardiovascular Mapping in Cirrhosis From the Compensated Stage to Hepatorenal Syndrome: A Magnetic Resonance Study. Am J Gastroenterol 2022; 117:1269-1278. [PMID: 35916685 DOI: 10.14309/ajg.0000000000001847] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/02/2022] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Arterial vasodilation and hyperdynamic circulation are considered hallmarks of the pathophysiological mechanisms of decompensation in cirrhosis. However, detailed characterization of peripheral, splanchnic, renal, and cardiac hemodynamic have not previously been published in a spectrum from healthy stage to advanced decompensated liver disease with hepatorenal syndrome-acute kidney injury (HRS-AKI). METHODS We included 87 patients with cirrhosis and 27 healthy controls in this prospective cohort study. The population comprised patients with compensated cirrhosis (n = 27) and decompensated cirrhosis (n = 60); patients with decompensated cirrhosis were further separated into subsets of responsive ascites (33), refractory ascites (n = 16), and HRS-AKI (n = 11). We measured portal pressure and assessed regional blood flow by magnetic resonance imaging. RESULTS Patients with compensated cirrhosis experienced higher azygos venous flow and higher hepatic artery flow fraction of cardiac index than controls ( P < 0.01), but other flow parameters were not significantly different. Patients with decompensated cirrhosis experienced significantly higher cardiac index ( P < 0.01), higher superior mesenteric artery flow ( P = 0.01), and lower systemic vascular resistance ( P < 0.001) compared with patients with compensated cirrhosis. Patients with HRS-AKI had the highest cardiac output and lowest renal flow of all groups ( P < 0.01 and P = 0.02, respectively). Associations of single hemodynamic parameters were stronger with model for end-stage liver disease than with portal pressure. DISCUSSION The regional cardiocirculatory changes seem closely linked to clinical symptoms with 3 distinguished hemodynamic stages from compensated to decompensated cirrhosis and, finally, to HRS-AKI. The attenuated renal perfusion despite high cardiac output in patients with HRS-AKI challenges the prevailing pathophysiological hypothesis of cardiac dysfunction as a causal factor in HRS-AKI. Finally, magnetic resonance imaging seems an accurate and reliable noninvasive method to assess hemodynamics and has potential as a diagnostic tool in patients with cirrhosis.
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Singh H, Kelgeri C, Passingham C, Johansen L, van Mourik I, Ong E, Perera MP, Mirza D, Sharif K, Hartley J, Gupte GL. Acute-on-chronic liver failure: A 20-year retrospective review of a tertiary paediatric liver centre. Acta Paediatr 2022; 111:1435-1440. [PMID: 35390187 DOI: 10.1111/apa.16352] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2021] [Revised: 01/10/2022] [Accepted: 04/05/2022] [Indexed: 12/30/2022]
Abstract
AIM Acute-on-chronic liver failure (ACLF) is an acute deterioration of pre-existing chronic liver disease related to a precipitating event. We characterised paediatric ACLF at Birmingham Children's Hospital (BCH) utilising European Association of Liver Disease CLIF criteria, including prevalence, triggers and outcomes. METHODS All BCH patients from 2000 to 2020 with CLD who underwent initial liver transplant or died on the transplant waiting list or whilst too unwell to be listed were reviewed. RESULTS From 2000 to 2020, 24 (4%) children with ACLF were identified. Death occurred in 18 (75%). Transplant occurred in 9 (36%), 3 of which died. ACLF triggers were sepsis organism negative 11 (46%), sepsis organism positive 8 (33%) and GI bleed 5 (17%). Bilirubin at the time of transplant/death in those with ACLF who lived compared with those who died was 529 umol/L (381) versus 665 (210) (p=0.38), creatinine 138 umol/L (147) versus 67 (46) (p=0.41), PT 33 sec (14) versus (32 (15) (p = 0.72), Grade 3, 4 hepatic encephalopathy 1 (17%) versus 10 (56%) (p = 0.17), vasopressor use 1 (17%) versus 17 (94%) (p = 0.001) and ventilation 3 (50%) versus 17 (94%) (p = 0.035). CONCLUSION Acute-on-chronic liver failure whilst infrequent has high rates of mortality. The use of vasopressors and ventilation is more frequent in those who die from ACLF.
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Affiliation(s)
- Harveen Singh
- Liver Unit Birmingham Children’s Hospital Birmingham UK
| | | | | | | | | | - Evelyn Ong
- Liver Unit Birmingham Children’s Hospital Birmingham UK
| | - M.Thamara P.R. Perera
- Liver Unit Birmingham Children’s Hospital Birmingham UK
- Women's Children's Hospital NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust; Liver Unit Birmingham UK
| | - Darius Mirza
- Liver Unit Birmingham Children’s Hospital Birmingham UK
- Women's Children's Hospital NHS Foundation Trust University Hospitals Birmingham NHS Foundation Trust; Liver Unit Birmingham UK
| | - Khalid Sharif
- Liver Unit Birmingham Children’s Hospital Birmingham UK
| | - Jane Hartley
- Liver Unit Birmingham Children’s Hospital Birmingham UK
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Sun J, Yu X, Weng Z, Jin L, Yang J, Zhang H, Gu J, Wang N, Yang J. The impact of hepatotoxic drugs on the outcome of patients with acute deterioration of hepatitis B virus-related chronic disease. Eur J Gastroenterol Hepatol 2022; 34:782-790. [PMID: 35506899 PMCID: PMC9148674 DOI: 10.1097/meg.0000000000002365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Accepted: 02/18/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND AND AIMS Hepatotoxic drugs can worsen outcomes in patients with chronic liver disease (CLD), whereas this negative effect in acute deterioration of hepatitis B virus (HBV)-related CLD (HBV-CLD) is rarely reported. We aimed to assess the impact of hepatotoxic drugs on the outcome of patients with acute deterioration of HBV-CLD. METHODS This retrospective study included consecutive patients admitted to three medical centers in eastern China from 2015 to 2020 for HBV-related severe liver injury (HBV-SLI) or acute decompensation of cirrhosis (HBV-AD). The prevalence of hepatotoxic drugs and their impact on organ failure, the development of acute-on-chronic liver failure (ACLF), and 90-day survival were evaluated. RESULTS A total of 335 patients with HBV flare (median age, 44 years; 85.7% male; 38.2% HBV-SLI and 61.8% HBV-AD) were included. Of them, 72 (21.5%) received hepatotoxic drugs, with herbs (44.4%) being the most common form. Patients in the drugs group had a significantly higher prevalence of all types of organ failure except respiratory failure. The multivariate logistic model showed that hepatotoxic drugs raised the risk of developing ACLF by 7.66-fold. ACLF occurrence was the strongest risk factor for 90-day mortality with a hazard ratio of 5.54 in the Cox regression analysis. In contrast, the hepatitis B envelope antigen status and HBV DNA levels had weak associations with the development of organ failure and ACLF. CONCLUSIONS Hepatotoxic drugs are closely associated with the development of organ failure and ACLF, and contribute to reduced 90-day survival rates among patients with acute deterioration of HBV-CLD.
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Affiliation(s)
- Jian Sun
- Department of Infectious Diseases, the First Affiliated Hospital of Wannan Medical College, Wuhu
| | - Xueping Yu
- Department of Infectious Diseases, the First Hospital of Quanzhou, Fujian Medical University, Quanzhou
| | - Zhangyan Weng
- Department of Infectious Diseases, the First Hospital of Quanzhou, Fujian Medical University, Quanzhou
| | - Lei Jin
- Department of Gastroenterology, the Second Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Jian Yang
- Department of Infectious Diseases, the First Affiliated Hospital of Wannan Medical College, Wuhu
| | - Huatang Zhang
- Department of Infectious Diseases, the First Hospital of Quanzhou, Fujian Medical University, Quanzhou
| | - Jun Gu
- Department of Gastroenterology, the Second Affiliated Hospital of Wannan Medical College, Wuhu, China
| | - Ni Wang
- Department of Infectious Diseases, the First Affiliated Hospital of Wannan Medical College, Wuhu
| | - Jianghua Yang
- Department of Infectious Diseases, the First Affiliated Hospital of Wannan Medical College, Wuhu
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Peng H, Zhang Q, Luo L, Lei S, Xiong T, Long L, Xiong Y, Zhang L, Zheng J, Luo X. A prognostic model of acute-on-chronic liver failure based on sarcopenia. Hepatol Int 2022; 16:964-972. [PMID: 35771410 PMCID: PMC9349113 DOI: 10.1007/s12072-022-10363-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/07/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is characterized by the development of a syndrome associated with a high risk of short-term death in patients with acute decompensated cirrhosis, and better indicators are needed to predict such outcomes. Sarcopenia, a common complication of cirrhosis, is closely associated with poor prognosis and increased mortality. In this study, the skeletal muscle index of ACLF patients was measured to determine whether sarcopenia combined with clinical parameters can aid in identifying those at high risk of progression. METHODS A total of 433 hospitalized patients with ACLF according to the APASL criteria were included and allocated into two groups: transplantation-free survival (n = 293) or progression (n = 140, 107 died; 33 underwent liver transplantation) within 90 days. Muscle mass was assessed based on the skeletal muscle index. The optimal cut-off value of the AMPAS1 model (age, MELD score, platelet count, alpha-fetoprotein level, sarcopenia, and more than one complication combination) for progression prediction was identified using receiver-operating characteristic (ROC) analysis. RESULTS Sarcopenia was an independent risk factor for progression in the ACLF population (HR 3.771 95% CI 2.114-6.727, p < 0.001). AMPAS1 was a good predictor, with an area under the ROC curve of 0.865, and the cut-off value for poor outcome prediction was 0.31 (sensitivity 79.4%, specificity 76.4%). CONCLUSION We demonstrate that sarcopenia is a simple and objective indicator for predicting short-term prognosis in patients with ACLF. Moreover, compared to conventional prognostic scores, AMPAS1 is a better model for predicting 90 day adverse outcomes in ACLF patients.
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Affiliation(s)
- Hong Peng
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Qian Zhang
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Lei Luo
- Good Clinical Practice Center, Guizhou Provincial People's Hospital, Guiyang, Guizhou, China
| | - Siyi Lei
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Tingting Xiong
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Li Long
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Yan Xiong
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Liulu Zhang
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Jinding Zheng
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China
| | - Xinhua Luo
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, 83 Zhongshan Road, Nanming District, Guiyang, 550002, Guizhou, China.
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Singh SA, Pampaniya H, Kumar V, Kumar M, Jadaun SS, Yadav V, Saigal S, Gupta S. Living donor liver transplant outcomes during the COVID-19 pandemic: does a decrease in case volume impact the overall outcomes? KOREAN JOURNAL OF TRANSPLANTATION 2022; 36:127-135. [PMID: 35919202 PMCID: PMC9296980 DOI: 10.4285/kjt.22.0017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/07/2022] [Accepted: 05/14/2022] [Indexed: 11/25/2022] Open
Abstract
Background High-volume centers (HVCs) are classically associated with better outcomes. During the coronavirus disease 2019 (COVID-19) pandemic, there has been a decrease in the regular liver transplantation (LT) activity at our center. This study analyzed the effect of the decline in LT on posttransplant patient outcomes at our HVC. Methods We compared the surgical outcomes of patients who underwent LT during the COVID-19 pandemic lockdown (April 1, 2020 to September 30, 2020) with outcomes in the pre-pandemic calendar year (April 1, 2019 to March 31, 2020). Results During the 6 months of pandemic lockdown, 60 patients underwent LT (43 adults and 17 children) while 228 patients underwent LT (178 adults and 50 children) during the pre-pandemic calendar year. Patients in the pandemic group had significantly higher model for end-stage liver disease (MELD) scores (24.39±9.55 vs. 21.14±9.17, P=0.034), Child-Turcotte-Pugh scores (11.46±2.32 vs. 10.25±2.24, P=0.03), and incidence of acute-on-chronic liver failure (30.2% vs. 10.2%, P=0.002). Despite performing LT in sicker patients with COVID-19-related challenges, the 30-day (14% vs. 18.5%, P=0.479), 3-month (16.3% vs. 20.2%, P=0.557), and 6-month mortality rates (23.3% vs. 28.7%, P=0.477) were lower, but not statistically significant when compared to the pre-pandemic cohort. Conclusions During the COVID-19 pandemic lockdown the number of LT procedures performed at our HVC declined by half because prevailing conditions allowed LT in very sick patients only. Despite these changes, outcomes were not inferior during the pandemic period compared to the pre-pandemic calendar year. Greater individualization of patient care contributed to non-inferior outcomes in these sick recipients.
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Affiliation(s)
- Shweta A. Singh
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Hetal Pampaniya
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vikram Kumar
- Department of Paediatric Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Mukesh Kumar
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplant, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Shekhar Singh Jadaun
- Department of Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Vivek Yadav
- Department of Anaesthesiology and Critical Care, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Sanjiv Saigal
- Department of Paediatric Gastroenterology and Hepatology, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
| | - Subhash Gupta
- Department of Hepatobiliary, Pancreatic Surgery and Liver Transplant, Center for Liver and Biliary Sciences, Max Super Speciality Hospital, Saket, New Delhi, India
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Correlation between the Lymphocyte-To-Monocyte Ratio (LMR) and Child–Pugh and MELD/MELDNa Scores in Vietnamese Patients with Liver Cirrhosis. GASTROENTEROLOGY INSIGHTS 2022. [DOI: 10.3390/gastroent13020019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022] Open
Abstract
Objectives: This study aims to determine cirrhotic patients’ clinical and laboratory characteristics, thereby examining the correlation between lymphocyte-to-monocyte ratio and Child–Pugh and MELD/MELDNa scores. Methods: A cross-sectional study with an analysis of 153 patients admitted to the Department of Gastroenterology–Clinical Hematology at Can Tho Central General Hospital. Data were collected via patient interviews and medical records. Results: The included patients were more likely to be male (66.7%) and were ≥60 years old (51.6%). Excessive alcohol consumption and hepatitis B were the dominant causes of cirrhosis (35.3% and 34.0%). The clinical and laboratory characteristics were similar to previous studies in cirrhotic patients. The mean Child score was 9.3 ± 2.1, including 9.8% of patients with Child A, 44.4% for Child B, and 45.8% for Child C. The mean MELD and MELDNa scores were 16.9 ± 7.1 and 19.4 ± 8.1, respectively. The mean lymphocyte-to-monocyte ratio (LMR) is 2.0 ± 2.2 (from 0.09 to 25.3), being negatively correlated with the other scores (Pearson correlation coefficients were −0.238; −0.211 and −0.245, respectively, all p-values < 0.01). Patients with LMR below 3.31 were more likely to be classified as Child–Pugh B and C. Conclusion: The correlation between LMR with Child–Pugh, MELD, and MELDNa scores was weak and negative.
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Are MELD and MELDNa Still Reliable Tools to Predict Mortality on the Liver Transplant Waiting List? Transplantation 2022; 106:2122-2136. [PMID: 35594480 DOI: 10.1097/tp.0000000000004163] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Liver transplantation is the only curative treatment for end-stage liver disease. Unfortunately, the scarcity of donor organs and the increasing pool of potential recipients limit access to this life-saving procedure. Allocation should account for medical and ethical factors, ensuring equal access to transplantation regardless of recipient's gender, race, religion, or income. Based on their short-term prognosis prediction, model for end-stage liver disease (MELD) and MELD sodium (MELDNa) have been widely used to prioritize patients on the waiting list for liver transplantation resulting in a significant decrease in waiting list mortality/removal. Recent concern has been raised regarding the prognostic accuracy of MELD and MELDNa due, in part, to changes in recipients' profile such as body mass index, comorbidities, and general condition, including nutritional status and cause of liver disease, among others. This review aims to provide a comprehensive view of the current state of MELD and MELDNa advantages and limitations and promising alternatives. Finally, it will explore future options to increase the donor pool and improve donor-recipient matching.
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Influence of Advanced Organ Support (ADVOS) on Cytokine Levels in Patients with Acute-on-Chronic Liver Failure (ACLF). J Clin Med 2022; 11:jcm11102782. [PMID: 35628913 PMCID: PMC9144177 DOI: 10.3390/jcm11102782] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Revised: 05/07/2022] [Accepted: 05/10/2022] [Indexed: 02/04/2023] Open
Abstract
Background: ADVanced Organ Support (ADVOS) is a novel type of extracorporeal albumin dialysis that supports multiorgan function in patients with acute-on-chronic liver failure (ACLF). No data exist on whether ADVOS affects inflammatory cytokine levels, which play a relevant role in ACLF. Aim: Our aim was to quantify cytokine levels both before and after a single ADVOS treatment in patients with ACLF at a regular dialysis ward. Methods and results: In this prospective study, 15 patients (60% men) with ACLF and an indication for renal replacement therapy were included. Patient liver function was severely compromised, reflected by a median CLIF-consortium ACLF score of 38 (IQR 35; 40). Blood samples were directly taken before and after ADVOS dialysis. The concentration of cytokines for IL-1β, IFN-α2, IFN-γ, TNF-α, MCP-1, IL-6, IL-8, IL-10, IL-12p70, IL-17A, IL-18, IL-23, IL-33 were quantified via a cytometric bead array. We found no significant (p > 0.05) change in cytokine levels, even when patients were stratified for dialysis time (<480 min versus ≥480 min). The relevance of the assessed cytokines in contributing to systemic inflammation in ACLF was demonstrated by Ingenuity pathway analysis®. Conclusion: Concentrations of pathomechanistically relevant cytokines remained unchanged both before and after ADVOS treatment in patients with ACLF.
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Téllez L, Guerrero A. Management of Liver Decompensation in Advanced Liver Disease (Renal Impairment, Liver Failure, Adrenal Insufficiency, Cardiopulmonary Complications). Clin Drug Investig 2022; 42:15-23. [PMID: 35522396 PMCID: PMC9205830 DOI: 10.1007/s40261-022-01149-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2022] [Indexed: 12/17/2022]
Abstract
Systemic complications often occur in patients with advanced liver disease. In particular, the development of renal complications (acute kidney injury, hepatorenal syndrome), acute-on-chronic liver failure, cardiopulmonary diseases, or relative adrenal insufficiency can be serious in patients with advanced liver disease and may determine the patient’s quality of life and prognosis. Therefore, the early diagnosis of possible complications is the key to the prompt initiation of specific treatments that can improve quality of life and survival. For this purpose, networking with reference centers where multidisciplinary units are available is essential so that every patient is evaluated in clinical discussions involving specialists from different fields.
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Affiliation(s)
- Luis Téllez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain.
| | - Antonio Guerrero
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Insituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Centro de Investigación Biomédica en Red (CIBERehd), Universidad de Alcalá, Ctra. Colmenar Viejo, km 9,100, 28034, Madrid, Spain
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