1
|
Kim K, Yim SH, Lee JG, Joo DJ, Kim MS, Park JY, Ahn SH, Kim DG, Lee HW. Robust Predictive Performance of the SALT-M Score for Clinical Outcomes in Asian Patients With Acute-on-Chronic Liver Failure. Aliment Pharmacol Ther 2024. [PMID: 39392334 DOI: 10.1111/apt.18335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2024] [Revised: 07/07/2024] [Accepted: 09/28/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a syndrome of patients with chronic liver disease presenting with multiple organ failures. Recently, Sundaram-ACLF-LT Mortality (SALT-M) score has been developed to predict 1-year post-liver transplantation mortality. We validated the SALT-M score in a large-volume, Asian single-centre cohort. AIMS We validated the SALT-M score in a large-volume, Asian single-centre cohort. METHODS We analysed 224 patients of ACLF grade 2-3. Area under the receiver operating characteristic curve (AUROC) and concordance index (c-index) were used to assess and compare the predictability of posttransplant mortality of SALT-M and other scores. Moreover, we compared the survivals of patients with high and low SALT-M, in conjunction with MELD score and ACLF grade. RESULTS The AUROC for prediction of 1-year post-LT survival was higher in SALT-M (0.691) than in MELD, MELD-Na, MELD 3.0 and delta-MELD. Similarly, the c-index of the SALT-M (0.650) was higher than aforementioned MELD systems. When categorised by the cut-off of SALT-M ≥ 20 and MELD ≥ 30, patients with high SALT-M exhibited lower post-LT survival than those with low SALT-M scores regardless of high or low MELD (40.0% for high SALT-M/high MELD vs. 42.9% for high SALT-M/low MELD vs. 73.8% for low SALT-M/high MELD vs. 63.7% for low SALT-M/low MELD, p < 0.001). In patients with ACLF grade 3, SALT-M effectively stratified the posttransplant mortality (39.4% for high SALT-M vs. 63.1% for low SALT-M, p = 0.018). CONCLUSIONS SALT-M outperformed previous MELD systems for predicting posttransplant mortality in Asian LT cohort with severe ACLF. Transplantability for patients with severe ACLF could be determined based on SALT-M.
Collapse
Affiliation(s)
- Kunhee Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
| | - Seung Hyuk Yim
- Department of Surgery, Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jae Geun Lee
- Department of Surgery, Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Jin Joo
- Department of Surgery, Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Myoung Soo Kim
- Department of Surgery, Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yong Park
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| | - Deok-Gie Kim
- Department of Surgery, Institute for Transplantation, Yonsei University College of Medicine, Seoul, South Korea
| | - Hye Won Lee
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, South Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul, South Korea
- Yonsei Liver Center, Severance Hospital, Seoul, South Korea
| |
Collapse
|
2
|
Ge J, Kim WR, Kwong AJ. Common definitions and variables are needed for the United States to join the conversation on acute-on-chronic liver failure. Am J Transplant 2024; 24:1755-1760. [PMID: 38977243 PMCID: PMC11439574 DOI: 10.1016/j.ajt.2024.06.021] [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: 02/10/2024] [Revised: 06/19/2024] [Accepted: 06/28/2024] [Indexed: 07/10/2024]
Abstract
Acute-on-chronic liver failure (ACLF) is a variably defined syndrome characterized by acute decompensation of cirrhosis with organ failures. At least 13 different definitions and diagnostic criteria for ACLF have been proposed, and there is increasing recognition that patients with ACLF may face disadvantages in the current United States liver allocation system. There is a need, therefore, for more standardized data collection and consensus to improve study design and outcome assessment in ACLF. In this article, we discuss the current landscape of transplantation for patients with ACLF, strategies to optimize organ utility, and data opportunities based on emerging technologies to facilitate improved data collection.
Collapse
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California - San Francisco, San Francisco, California, USA
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Allison J Kwong
- Division of Gastroenterology and Hepatology, Department of Medicine, Stanford University School of Medicine, Stanford, California, USA.
| |
Collapse
|
3
|
Campos-Varela I, Castells L, Quiroga S, Vargas V, Simon-Talero M. Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting. Ann Hepatol 2024; 29:101515. [PMID: 38851394 DOI: 10.1016/j.aohep.2024.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/17/2023] [Accepted: 05/31/2024] [Indexed: 06/10/2024]
Abstract
Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.
Collapse
Affiliation(s)
- Isabel Campos-Varela
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain.
| | - Lluis Castells
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Sergi Quiroga
- Radiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Victor Vargas
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| | - Macarena Simon-Talero
- Liver Unit, Vall d'Hebron Hospital Universitari, Vall d'Hebron Institut of Research (VHIR), Vall d'Hebron Barcelona Hospital Campus, Universitat Autònoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
| |
Collapse
|
4
|
Brozat JF, Pohl J, Engelmann C, Tacke F. [Liver transplantation in acute and acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2024; 119:484-492. [PMID: 39043956 DOI: 10.1007/s00063-024-01158-4] [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: 05/08/2024] [Accepted: 06/04/2024] [Indexed: 07/25/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are diseases with a rapidly progressive course and high mortality. Apart from treating the underlying triggers and intensive care measures, there are very limited therapeutic options for either condition. Liver transplantation is often the only life-saving treatment, but it cannot always be employed due to contraindications and severe disease progression. ACLF is characterized by underlying liver cirrhosis and typical triggers such as bacterial infections, bleeding, or alcohol binges. ALF occurs in previously healthy livers, usually as a result of purely hepatotoxic events. Disease differences are also reflected in the course and regulations of liver transplantation. Newer prognostic parameters and prioritization programs for ACLF can help improve both waiting list mortality and outcomes after transplantation.
Collapse
Affiliation(s)
- Jonathan F Brozat
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Julian Pohl
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Cornelius Engelmann
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland.
| |
Collapse
|
5
|
Kwon HM, Kim JH, Kim SH, Jun IG, Song JG, Moon DB, Hwang GS. Benefits of liver transplant in critically ill patients with acute-on-chronic liver failure: Implementation of an urgent living-donor program. Am J Transplant 2024:S1600-6135(24)00494-5. [PMID: 39155023 DOI: 10.1016/j.ajt.2024.08.008] [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: 08/17/2023] [Revised: 08/08/2024] [Accepted: 08/09/2024] [Indexed: 08/20/2024]
Abstract
We evaluated the liver transplantation (LT) criteria in acute-on-chronic liver failure (ACLF), incorporating an urgent living-donor LT (LDLT) program. Critically ill patients with a Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C_ACLF_score) ≥65, previously considered unsuitable for LT, were included to explore the excess mortality threshold of the CLIF-C_ACLF_score (CLIF-C_ACLF_score_threshold). We followed 854 consecutive patients with ACLF (276 ACLF grade 2 and 215 ACLF grade 3) over 10 years among 4432 LT recipients between 2008 and 2019. For advanced ACLF patients without immediate deceased-donor (DD) allocation, an urgent LDLT program was expedited. The CLIF-C_ACLF_score_threshold was determined by the metrics of transplant survival benefit: >60% 1-year and >50% 5-year survival rate. In predicting post-LT mortality, the CLIF-C_ACLF_score outperformed the (model for end-stage liver disease-sodium) MELD-Na and (model for end-stage liver disease) MELD-3.0 scores but was comparable to the Sundaram ACLF-LT-mortality score. A CLIF-C_ACLF_score ≥65 (n = 54) demonstrated posttransplant survival benefits, with 1-year and 5-year survival rates of 66.7% and 50.4% (P < .001), respectively. Novel CLIF-C_ACLF_score_threshold for 1-year and 5-year mortalities was 70 and 69, respectively. A CLIF-C_ACLF_score-based nomogram for predicting survival probabilities, integrating cardiovascular disease, diabetes, and donor type (LDLT vs DDLT), was generated. This study suggests reconsidering the criteria for unsuitable LT with a CLIF-C_ACLF_score ≥65. Implementing a timely salvage LT strategy, and incorporating urgent LDLT, can enhance survival rates.
Collapse
Affiliation(s)
- Hye-Mee Kwon
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jae Hwan Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Sung-Hoon Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Gu Jun
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jun-Gol Song
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Deok-Bog Moon
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
| |
Collapse
|
6
|
Cerutti E, D'Arcangelo F, Becchetti C, Cilla M, Cossiga V, Guarino M, Invernizzi F, Lapenna L, Lavezzo B, Marra F, Merli M, Morelli MC, Toniutto P, Burra P, Zanetto A. Sex disparities in acute-on-chronic liver failure: From admission to the intensive care unit to liver transplantation. Dig Liver Dis 2024:S1590-8658(24)00921-6. [PMID: 39164168 DOI: 10.1016/j.dld.2024.08.002] [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: 06/14/2024] [Revised: 07/01/2024] [Accepted: 08/04/2024] [Indexed: 08/22/2024]
Abstract
Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome characterized by acute liver decompensation in patients with chronic liver disease, marked by systemic inflammation and systemic organ failure. In this review, we discussed sex-related disparities in the incidence, prognosis, and access to liver transplantation (LT) for patients with ACLF, particularly during Intensive Care Unit (ICU) management. Some studies have suggested that ACLF is more prevalent among male patients admitted to the ICU, and they have higher mortality rates than females. Available prognostic scores, such as CLIF-C or TAM-score, lack sex-specific adjustments. Sarcopenia seems to enhance the accuracy of these scores though this is observed only in male individuals. LT is the only effective treatment for patients with ACLF grade 2-3 who do not respond to medical therapies. Sex-related disparities occur in both access to LT and post-transplant outcomes, although the influence of sex on the prevalence, clinical course, and listing for LT in ACLF remains largely undetermined. A sex-orientated analysis of ICU outcomes in ACLF would facilitate the development of sex-orientated management strategies, thereby improving patients' outcomes.
Collapse
Affiliation(s)
- Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Francesca D'Arcangelo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marta Cilla
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Valentina Cossiga
- Diseases of the Liver and Biliary System Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Maria Guarino
- Diseases of the Liver and Biliary System Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Bruna Lavezzo
- Emergency Department, Anesthesia and Intensive Care Unit, SS Annunziata Hospital, Savigliano ASL Cuneo, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Maria Cristina Morelli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy.
| | - Alberto Zanetto
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy
| |
Collapse
|
7
|
Li S, Zhang Y, Lin Y, Zheng L, Fang K, Wu J. Development and validation of prediction models for nosocomial infection and prognosis in hospitalized patients with cirrhosis. Antimicrob Resist Infect Control 2024; 13:85. [PMID: 39113159 PMCID: PMC11304655 DOI: 10.1186/s13756-024-01444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/27/2024] [Indexed: 08/10/2024] Open
Abstract
BACKGROUND Nosocomial infections (NIs) frequently occur and adversely impact prognosis for hospitalized patients with cirrhosis. This study aims to develop and validate two machine learning models for NIs and in-hospital mortality risk prediction. METHODS The Prediction of Nosocomial Infection and Prognosis in Cirrhotic patients (PIPC) study included hospitalized patients with cirrhosis at the Qingchun Campus of the First Affiliated Hospital of Zhejiang University. We then assessed several machine learning algorithms to construct predictive models for NIs and prognosis. We validated the best-performing models with bootstrapping techniques and an external validation dataset. The accuracy of the predictions was evaluated through sensitivity, specificity, predictive values, and likelihood ratios, while predictive robustness was examined through subgroup analyses and comparisons between models. RESULTS We enrolled 1,297 patients into derivation cohort and 496 patients into external validation cohort. Among the six algorithms assessed, the Random Forest algorithm performed best. For NIs, the PIPC-NI model achieved an area under the curve (AUC) of 0.784 (95% confidence interval [CI] 0.741-0.826), a sensitivity of 0.712, and a specificity of 0.702. For in-hospital mortality, the PIPC- mortality model achieved an AUC of 0.793 (95% CI 0.749-0.836), a sensitivity of 0.769, and a specificity of 0.701. Moreover, our PIPC models demonstrated superior predictive performance compared to the existing MELD, MELD-Na, and Child-Pugh scores. CONCLUSIONS The PIPC models showed good predictive power and may facilitate healthcare providers in easily assessing the risk of NIs and prognosis among hospitalized patients with cirrhosis.
Collapse
Affiliation(s)
- Shuwen Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yu Zhang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Yushi Lin
- Department of Infectious Diseases, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Luyan Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Kailu Fang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China
| | - Jie Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, 310003, China.
| |
Collapse
|
8
|
Fernández J, Blasi A, Hidalgo E, Karvellas CJ. Bridging the critically ill patient with acute to chronic liver failure to liver transplantation. Am J Transplant 2024; 24:1348-1361. [PMID: 38548058 DOI: 10.1016/j.ajt.2024.03.026] [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: 12/21/2023] [Revised: 03/16/2024] [Accepted: 03/18/2024] [Indexed: 04/14/2024]
Abstract
Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.
Collapse
Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain; EF Clif, EASL-CLIF Consortium, Barcelona, Spain.
| | - Annabel Blasi
- Anesthesiology Department, Hospital Clínic, and University of Barcelona, Spain
| | - Ernest Hidalgo
- Hepatolobiliary Surgery Department, Hospital Vall d'Hebron, Barcelona, Spain
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, Edmonton, Canada; Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
| |
Collapse
|
9
|
Kulkarni AV, Gustot T, Reddy KR. Liver transplantation for acute liver failure and acute-on-chronic liver failure. Am J Transplant 2024:S1600-6135(24)00435-0. [PMID: 39094950 DOI: 10.1016/j.ajt.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver (ACLF) are distinct phenotypes of liver failure and, thus, need to be compared and contrasted for appropriate management. There has been a significant improvement in the outcomes of these patients undergoing liver transplantation (LT). Survival post-LT for ALF and ACLF ranges between 90% and 95% and 80% and 90% at 1 year, futility criteria have been described in both ALF and ACLF where organ failures define survival. Plasma exchange and continuous renal replacement therapy may serve as bridging therapies. Identifying the futility of LT is as necessary as the utility of LT in patients with ALF and ACLF. The role of regenerative therapies such as granulocyte colony-stimulating factors in ACLF and hepatocyte and xenotransplantation in both conditions remains uncertain. Measures to increase the donor pool through increasing deceased donor transplants in Asian countries, living donations in Western countries, auxiliary liver transplants, and ABO-incompatible liver transplants are necessary to improve the survival of these patients. In this review, we discuss the similarities and differences in clinical characteristics and the timing and outcomes of LT for ALF and ACLF, briefly highlighting the role of bridging therapies and providing an overview of recent advances in the management of ALF and ACLF.
Collapse
Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, HUB Hôpital Erasme, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
| |
Collapse
|
10
|
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.
Collapse
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
| |
Collapse
|
11
|
Artru F, Trovato F, Morrison M, Bernal W, McPhail M. Liver transplantation for acute-on-chronic liver failure. Lancet Gastroenterol Hepatol 2024; 9:564-576. [PMID: 38309288 DOI: 10.1016/s2468-1253(23)00363-1] [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: 07/24/2023] [Revised: 10/02/2023] [Accepted: 10/13/2023] [Indexed: 02/05/2024]
Abstract
Acute-on-chronic liver failure (ACLF) occurs in the context of advanced liver disease and is associated with hepatic and extrahepatic organ failure, eventually leading to a major risk of short-term mortality. To date, there are very few effective therapeutic options for ACLF. In many cases, liver transplantation is the only life-saving treatment that has acceptable outcomes in carefully selected recipients. This Review addresses key aspects of the use of liver transplantation for patients with ACLF, providing an in-depth discussion of existing evidence regarding candidate selection, the optimal window for transplantation, potential prioritisation of liver grafts for this indication, and the global management of ACLF to bridge patients to liver transplantation.
Collapse
Affiliation(s)
- Florent Artru
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK; Liver Disease Unit, Rennes University Hospital, Rennes, France; Inerm 1241 NuMeCan, University of Rennes, Rennes, France
| | - Francesca Trovato
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK
| | - Maura Morrison
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK
| | - William Bernal
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK.
| | - Mark McPhail
- Liver Intensive Care Unit, Institute of Liver Studies, King's College Hospital, London, UK; Department of Inflammation Biology, School of Infection and Microbial Sciences, King's College London, London, UK
| |
Collapse
|
12
|
Kaplan A, Ladin K, Junna S, Lindenberger E, Ufere NN. Serious Illness Communication in Cirrhosis Care: Tools to Improve Illness Understanding, Prognostic Understanding, and Care Planning. GASTRO HEP ADVANCES 2024; 3:634-645. [PMID: 38873184 PMCID: PMC11175167 DOI: 10.1016/j.gastha.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
Patients with cirrhosis frequently experience an unpredictable illness trajectory, with frequent hospitalizations and complications. Along with the uncertain nature of the disease, the possibility of a lifesaving and curative transplant often makes prognostic discussions and future care decisions challenging. Serious illness communication (SIC) refers to supportive communication whereby clinicians assess patients' illness understanding, share prognostic information according to patients' preferences, explore patients' goals, and make recommendations for care that align with these goals. SIC includes 3 key components: (1) illness understanding; (2) prognostic understanding; and (3) care planning. In this piece, we explore current barriers to early implementation of SIC in cirrhosis care and share possible solutions, including adopting a multidisciplinary approach, delivering culturally competent care, and training clinicians in SIC core skills. By use of a case example, we aim to demonstrate SIC in action and to provide clinicians with tools and skills that can be used in practice.
Collapse
Affiliation(s)
- Alyson Kaplan
- Department of Gastroenterology, Department of Surgery, Transplant Institute, Tufts University Medical Center, Boston, Massachusetts
| | - Keren Ladin
- Department of Community Health, Tufts University, Boston, Massachusetts
| | - Shilpa Junna
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic, Cleveland, Ohio
| | - Elizabeth Lindenberger
- Department of Geriatrics and Palliative Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Nneka N. Ufere
- Department of Gastroenterology, Massachusetts General Hospital, Boston, Massachusetts
| |
Collapse
|
13
|
Duvoux C, Blaise L, Matimbo JJ, Mubenga F, Ngongang N, Hurtova M, Laurent A, Augustin J, Calderaro J, Reizine E, Luciani A, Habibi A, Bachir D, Vole G, Gellen-Dautremer J, Leroy V, Levesque E, Bartolucci P. The liver in sickle cell disease. Presse Med 2023; 52:104212. [PMID: 37981193 DOI: 10.1016/j.lpm.2023.104212] [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] [Indexed: 11/21/2023] Open
Abstract
Liver involvement in SCD patients is frequent but often misdiagnosed or underestimated, except in case of advanced liver diseases. Because of so far poorly recognized forms of chronic SCD-related vascular injury that can silently evolved towards end stages or facilitate ACLF, any persisting liver function tests abnormalities should be carefully investigated, following the above proposed algorithm. Work up and management must be considered multidisciplinary in relationship with a Hepatologist. Early SCD hepatopathy should prompt revision of SCD management to prevent further liver injury and decompensation, discussing transfusion exchanges and hydro urea when not yet initiated, and control for any cofactor of liver injury. The role of HSCT in early SCD hepatopathies also deserves evaluation. In advanced SCD hepatopathies, liver transplantation, which has been rarely performed so far, is the only therapeutic option associated with improved survival. It should definitely be discussed- either electively in case of decompensation in SCD cirrhosis or jaundice/recurrent cholangitis in cholestatic diseases, with excellent outcome, - or emergently in case of ALF or ACLF with more mitigate results. To improve knowledge and management of SCD liver diseases, creation of national and international registries, as well as longitudinal observational cohorts are encouraged.
Collapse
Affiliation(s)
- Christophe Duvoux
- Department of Hepatology and Medical Liver Transplant Unit, Henri Mondor Hospital-APHP, University Paris Est Créteil, France.
| | - Lorraine Blaise
- Department of Hepatology and Liver Oncology, Avicenne Hospital-APHP, Bobigny, France
| | - Jean-Jacques Matimbo
- Department of Hepatology and Medical Liver Transplant Unit, Henri Mondor Hospital-APHP, University Paris Est Créteil, France; Department of Hepatology and Liver Oncology, Avicenne Hospital-APHP, Bobigny, France; Department of Hepatology and Gastroenterology, Clinique Universitaire Kinshasa, Democratic Republic of Congo
| | | | - Norbert Ngongang
- Department of Hepatology and Medical Liver Transplant Unit, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Monika Hurtova
- Department of Hepatology and Medical Liver Transplant Unit, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Alexis Laurent
- Department of Digestive & HPB Surgery, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Jérémy Augustin
- Department of Pathology, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Julien Calderaro
- Department of Pathology, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Edouard Reizine
- Department of Radiology, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Alain Luciani
- Department of Radiology, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Anoosha Habibi
- UMGGR, Department of Internal Medicine, Sickle Cell National Referral Center, Henri Mondor-Hospital APHP, University Paris Est Créteil, France; IMRB, UPEC, INSERM, EFS, Team Pirenne. University Paris Est Créteil, France
| | - Dora Bachir
- UMGGR, Department of Internal Medicine, Sickle Cell National Referral Center, Henri Mondor-Hospital APHP, University Paris Est Créteil, France
| | - Geoffroy Vole
- UMGGR, Department of Internal Medicine, Sickle Cell National Referral Center, Henri Mondor-Hospital APHP, University Paris Est Créteil, France; IMRB, UPEC, INSERM, EFS, Team Pirenne. University Paris Est Créteil, France
| | | | - Vincent Leroy
- Department of Hepatology and Medical Liver Transplant Unit, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Eric Levesque
- Department of Anesthesia and Surgical Intensive Care-liver ICU, Henri Mondor Hospital-APHP, University Paris Est Créteil, France
| | - Pablo Bartolucci
- UMGGR, Department of Internal Medicine, Sickle Cell National Referral Center, Henri Mondor-Hospital APHP, University Paris Est Créteil, France; IMRB, UPEC, INSERM, EFS, Team Pirenne. University Paris Est Créteil, France
| |
Collapse
|
14
|
Ge J, Digitale JC, Fenton C, McCulloch CE, Lai JC, Pletcher MJ, Gennatas ED. Predicting post-liver transplant outcomes in patients with acute-on-chronic liver failure using Expert-Augmented Machine Learning. Am J Transplant 2023; 23:1908-1921. [PMID: 37652176 PMCID: PMC11018271 DOI: 10.1016/j.ajt.2023.08.022] [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: 03/03/2023] [Revised: 08/04/2023] [Accepted: 08/25/2023] [Indexed: 09/01/2023]
Abstract
Liver transplantation (LT) is a treatment for acute-on-chronic liver failure (ACLF), but high post-LT mortality has been reported. Existing post-LT models in ACLF have been limited. We developed an Expert-Augmented Machine Learning (EAML) model to predict post-LT outcomes. We identified ACLF patients who underwent LT in the University of California Health Data Warehouse. We applied the RuleFit machine learning (ML) algorithm to extract rules from decision trees and create intermediate models. We asked human experts to rate the rules generated by RuleFit and incorporated these ratings to generate final EAML models. We identified 1384 ACLF patients. For death at 1 year, areas under the receiver-operating characteristic curve were 0.707 (confidence interval [CI] 0.625-0.793) for EAML and 0.719 (CI 0.640-0.800) for RuleFit. For death at 90 days, areas under the receiver-operating characteristic curve were 0.678 (CI 0.581-0.776) for EAML and 0.707 (CI 0.615-0.800) for RuleFit. In pairwise comparisons, both EAML and RuleFit models outperformed cross-sectional models. Significant discrepancies between experts and ML occurred in rankings of biomarkers used in clinical practice. EAML may serve as a method for ML-guided hypothesis generation in further ACLF research.
Collapse
Affiliation(s)
- Jin Ge
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
| | - Jean C Digitale
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Cynthia Fenton
- Division of Hospital Medicine, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Charles E McCulloch
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Jennifer C Lai
- Division of Gastroenterology and Hepatology, Department of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - Mark J Pletcher
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| | - Efstathios D Gennatas
- Department of Epidemiology and Biostatistics, University of California-San Francisco, San Francisco, California, USA
| |
Collapse
|
15
|
Butt MF, Jalan R. Review article: Emerging and current management of acute-on-chronic liver failure. Aliment Pharmacol Ther 2023; 58:774-794. [PMID: 37589507 DOI: 10.1111/apt.17659] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 05/02/2023] [Accepted: 07/24/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a clinically and pathophysiologically distinct condition from acutely decompensated cirrhosis and is characterised by systemic inflammation, extrahepatic organ failure, and high short-term mortality. AIMS To provide a narrative review of the diagnostic criteria, prognosis, epidemiology, and general management principles of ACLF. Four specific interventions that are explored in detail are intravenous albumin, extracorporeal liver assist devices, granulocyte-colony stimulating factor, and liver transplantation. METHODS We searched PubMed and Cochrane databases for articles published up to July 2023. RESULTS Approximately 35% of hospital inpatients with decompensated cirrhosis have ACLF. There is significant heterogeneity in the criteria used to diagnose ACLF; different definitions identify different phenotypes with varying mortality. Criteria established by the European Association for the Study of the Liver were developed in prospective patient cohorts and are, to-date, the most well validated internationally. Systemic haemodynamic instability, renal dysfunction, coagulopathy, neurological dysfunction, and respiratory failure are key considerations when managing ACLF in the intensive care unit. Apart from liver transplantation, there are no accepted evidence-based treatments for ACLF, but several different approaches are under investigation. CONCLUSION The recognition of ACLF as a distinct entity from acutely decompensated cirrhosis has allowed for better patient stratification in clinical settings, facilitating earlier engagement with the intensive care unit and liver transplantation teams. Research priorities over the next decade should focus on exploring novel treatment strategies with a particular focus on which, when, and how patients with ACLF should be treated.
Collapse
Affiliation(s)
- Mohsin F Butt
- Centre for Neuroscience, Trauma and Surgery, Wingate Institute of Neurogastroenterology, The Blizard Institute, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- Liver Failure Group, University College London Medical School, Royal Free Hospital Campus, London, UK
- National Institute for Health Research, Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, University of Nottingham, Nottinghamshire, UK
| | - Rajiv Jalan
- Liver Failure Group, University College London Medical School, Royal Free Hospital Campus, London, UK
- European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium, Barcelona, Spain
| |
Collapse
|
16
|
Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
Collapse
Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
| |
Collapse
|