1
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Maiwall R, Kulkarni AV, Arab JP, Piano S. Acute liver failure. Lancet 2024; 404:789-802. [PMID: 39098320 DOI: 10.1016/s0140-6736(24)00693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
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2
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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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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4
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Acharya SK. Overview of acute liver failure in India. Indian J Gastroenterol 2024; 43:296-311. [PMID: 38722512 DOI: 10.1007/s12664-024-01589-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/08/2024] [Indexed: 05/28/2024]
Abstract
Acute liver failure (ALF) is an infrequent, but serious complication subsequent to severe acute liver injury (sALI) due to various hepatotoxic agents such as hepatotropic virus(es) and drugs such as anti-tubercular medications, paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), antibiotics and anti-cancer and anti-epileptic therapy and due to metabolic and autoimmune disease flares. ALF after sALI presents with encephalopathy associated with prolonged international normalized ratio (INR). Mortality in ALF is high and ranges between 50% and 80%. Due to severe liver damage, multiple sequels consequent to hepatic dysfunction result in complications such as hyperammonemia that culminates in encephalopathy associated with cerebral edema; innate immune paralysis resulting in increased frequency of infections and endotoxemia causing decrease in systemic vascular resistance (SVR) and tissue hypoperfusion and damage-associated molecular patterns (DAMPs) released from damaged hepatic parenchyma inducing pro-inflammatory cytokine storm, which may cause other organ dysfunctions. Certain etiologies such as hepatitis E virus and hepatitis A virus-related ALF or paracetamol-ALF (hyper-acute presentation) have better survival than remaining causes. In addition, if etiology-specific treatment (antivirals for ALF related to hepatitis B virus (HBV) or Herpes simplex virus (HSV) or N-acetylcysteine for paracetamol) is available, then the outcome with treatment is better. About half of the patients can be salvaged with medical therapy. All patients need intensive care and organ support to provide time for the liver to regenerate. Various prognostic models to predict high probability of mortality have been described, which should be used to select patient early during the disease for liver transplantation, which is associated with high long-term survival in these sick patients. The Indian National Association for Study of the Liver (INASL) recommends the ALF-Early Dynamic (ALFED) model as a preferred prognostic model in the Indian scenario, where hepatitis viruses are a dominant etiology of ALF and occur on a naïve liver with good regenerative capacity.
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Affiliation(s)
- Subrat Kumar Acharya
- Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751 024, India.
- Fortis Escorts Digestive and Liver Institute, Okhla, New Delhi, 110 025, India.
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5
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Popescu M, Bratu A, Agapie M, Borjog T, Jafal M, Sima RM, Orban C. The Use and Potential Benefits of N-Acetylcysteine in Non-Acetaminophen Acute Liver Failure: An Etiology-Based Review. Biomedicines 2024; 12:676. [PMID: 38540289 PMCID: PMC10967777 DOI: 10.3390/biomedicines12030676] [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: 02/11/2024] [Revised: 03/04/2024] [Accepted: 03/15/2024] [Indexed: 08/13/2024] Open
Abstract
Acute liver failure represents a life-threatening organ dysfunction with high mortality rates and an urgent need for liver transplantation. The etiology of the disease varies widely depending on various socio-economic factors and is represented mainly by paracetamol overdose and other drug-induced forms of liver dysfunction in the developed world and by viral hepatitis and mushroom poisoning in less developed countries. Current medical care constitutes either specific antidotes or supportive measures to ensure spontaneous recovery. Although it has been proven to have beneficial effects in paracetamol-induced liver failure, N-acetylcysteine is widely used for all forms of acute liver failure. Despite this, few well-designed studies have been conducted on the assessment of the potential benefits, dose regimens, or route of administration of N-acetylcysteine in non-acetaminophen liver failure. This review aims to summarize the current evidence behind the use of this drug in different forms of liver failure.
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Affiliation(s)
- Mihai Popescu
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Angelica Bratu
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mihaela Agapie
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Tudor Borjog
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mugurel Jafal
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Romina-Marina Sima
- Department of Obstetrics and Gynecology, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania;
| | - Carmen Orban
- Department of Anaesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (M.A.); (T.B.); (M.J.); (C.O.)
- Department of Anaesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
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6
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Schilsky ML, Emre SH. An abbreviated history of liver transplantation. Clin Liver Dis (Hoboken) 2024; 23:e0244. [PMID: 38952697 PMCID: PMC11216664 DOI: 10.1097/cld.0000000000000244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 04/25/2024] [Indexed: 07/03/2024] Open
Affiliation(s)
- Michael L. Schilsky
- Division of Digestive Diseases and Transplantation and Immunology, Department of Medicine and Surgery, Yale University Medical Center, New Haven, Connecticut, USA
| | - Sukru H. Emre
- Department of Surgery, İzmir University of Economics School of Medicine, Izmir, Turkiye
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7
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Turan C, Szigetváry CE, Kói T, Engh MA, Atakan I, Zubek L, Terebessy T, Hegyi P, Molnár Z. Hemoadsorption Therapy for Critically Ill Patients with Acute Liver Dysfunction: A Meta-Analysis and Systematic Review. Biomedicines 2023; 12:67. [PMID: 38255174 PMCID: PMC10813081 DOI: 10.3390/biomedicines12010067] [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: 11/16/2023] [Revised: 12/15/2023] [Accepted: 12/24/2023] [Indexed: 01/24/2024] Open
Abstract
Critically ill patients are at risk of developing acute liver dysfunction as part of multiorgan failure sequelae. Clearing the blood from toxic liver-related metabolites and cytokines could prevent further organ damage. Despite the increasing use of hemoadsorption for this purpose, evidence of its efficacy is lacking. Therefore, we conducted this systematic review and meta-analysis to assess the evidence on clinical outcomes following hemoadsorption therapy. A systematic search conducted in six electronic databases (PROSPERO registration: CRD42022286213) yielded 30 eligible publications between 2011 and 2023, reporting the use of hemoadsorption for a total of 335 patients presenting with liver dysfunction related to acute critical illness. Of those, 26 are case presentations (n = 84), 3 are observational studies (n = 142), and 1 is a registry analysis (n = 109). Analysis of data from individual cases showed a significant reduction in levels of aspartate transaminase (p = 0.03) and vasopressor need (p = 0.03) and a tendency to lower levels of total bilirubin, alanine transaminase, C-reactive protein, and creatinine. Pooled data showed a significant reduction in total bilirubin (mean difference of -4.79 mg/dL (95% CI: -6.25; -3.33), p = 0.002). The use of hemoadsorption for critically ill patients with acute liver dysfunction or failure seems to be safe and yields a trend towards improved liver function after therapy, but more high-quality evidence is crucially needed.
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Affiliation(s)
- Caner Turan
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (C.T.); (C.E.S.)
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
| | - Csenge Erzsébet Szigetváry
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (C.T.); (C.E.S.)
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
| | - Tamás Kói
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
- Department of Stochastics, Institute of Mathematics, Budapest University of Technology and Economics, 1111 Budapest, Hungary
| | - Marie Anne Engh
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
| | - Işıl Atakan
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
| | - László Zubek
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
| | - Tamás Terebessy
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
- Department of Orthopaedics, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
- Institute of Pancreatic Diseases, Semmelweis University, 1085 Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, 7623 Pécs, Hungary
| | - Zsolt Molnár
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (C.T.); (C.E.S.)
- Centre for Translational Medicine, Semmelweis University, 1085 Budapest, Hungary; (T.K.); (I.A.); (L.Z.); (T.T.); (P.H.)
- Department of Anesthesiology and Intensive Therapy, Poznan University of Medical Sciences, 60-806 Poznan, Poland
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8
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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9
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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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10
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Bio-Artificial Liver Support System: A Prospective Future Therapy. LIVERS 2023. [DOI: 10.3390/livers3010006] [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: 02/12/2023] Open
Abstract
Whether acute or chronic, liver failure is a state of liver dysfunction that can progress to multiorgan failure. Mortality in liver failure patients is approximately 80–90% and is caused by detoxification failure, which triggers other immediate complications, such as encephalopathy, coagulopathy, jaundice, cholestasis, and acute kidney failure. The ideal treatment for liver failure is liver transplantation, but the long waiting period for the right donor match causes unavoidable deaths in most patients. Therefore, new therapies, such as tissue engineering, hepatocyte transplantation, and stem cells, are now being studied to anticipate the patient’s condition while waiting for liver transplantation. This literature review investigated the effectiveness of some bio-artificial liver support systems using review methods systematically from international publication sites, including PubMed, using keywords, such as bio-artificial liver, acute and chronic liver failure, extracorporeal liver support system (ECLS), MARS, single-pass albumin dialysis (SPAD). Artificial and bioartificial liver systems can show specific detoxification abilities and pathophysiological improvements in liver failure patients but cannot reach the ideal criteria for actual liver function. The liver support system must provide the metabolic and synthetic function as in the actual liver while reducing the pathophysiological changes in liver failure. Aspects of safety, cost efficiency, and practicality are also considered. Identifying the technology to produce high-quality hepatocytes on a big scale is essential as a medium to replace failing liver cells. An increase in detoxification capacity and therapeutic effectiveness must also focus on patient survival and the ability to perform liver transplantation.
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11
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Ferrada P, Cannon JW, Kozar RA, Bulger EM, Sugrue M, Napolitano LM, Tisherman SA, Coopersmith CM, Efron PA, Dries DJ, Dunn TB, Kaplan LJ. Surgical Science and the Evolution of Critical Care Medicine. Crit Care Med 2023; 51:182-211. [PMID: 36661448 DOI: 10.1097/ccm.0000000000005708] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.
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Affiliation(s)
- Paula Ferrada
- Division of Trauma and Acute Care Surgery, Department of Surgery, Inova Fairfax Hospital, Falls Church, VA
| | - Jeremy W Cannon
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Rosemary A Kozar
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Eileen M Bulger
- Division of Trauma, Burn and Critical Care Surgery, Department of Surgery, University of Washington at Seattle, Harborview, Seattle, WA
| | - Michael Sugrue
- Department of Surgery, Letterkenny University Hospital, County of Donegal, Ireland
| | - Lena M Napolitano
- Division of Acute Care Surgery, Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Samuel A Tisherman
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Craig M Coopersmith
- Division of General Surgery, Department of Surgery, Emory University, Emory Critical Care Center, Atlanta, GA
| | - Phil A Efron
- Department of Surgery, Division of Critical Care, University of Florida, Gainesville, FL
| | - David J Dries
- Department of Surgery, University of Minnesota, Regions Healthcare, St. Paul, MN
| | - Ty B Dunn
- Division of Transplant Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Lewis J Kaplan
- Division of Trauma, Surgical Critical Care and Emergency Surgery, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Corporal Michael J. Crescenz VA Medical Center, Section of Surgical Critical Care, Surgical Services, Philadelphia, PA
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12
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Kim JD. [Acute Liver Failure: Current Updates and Management]. THE KOREAN JOURNAL OF GASTROENTEROLOGY = TAEHAN SOHWAGI HAKHOE CHI 2023; 81:17-28. [PMID: 36695063 DOI: 10.4166/kjg.2022.148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 12/25/2022] [Accepted: 12/29/2022] [Indexed: 01/26/2023]
Abstract
Acute liver failure (ALF) is a rare disease condition with a dynamic clinical course and catastrophic outcomes. Several etiologies are involved in ALF. Hepatitis A and B infections and indiscriminate use of untested herbs or supplemental agents are the most common causes of ALF in Korea. Noninvasive neurological monitoring tools have been used in patients with ALF in recent times. Ongoing improvements in intensive care, including continuous renal replacement therapy, therapeutic plasma exchange, vasopressor, and extracorporeal membrane oxygenation, have reduced the mortality rate of patients with ALF. However, liver transplantation is still the most effective treatment for patients with intractable ALF. There is a need for further research in the areas of better prognostication and precise selection of patients for emergency transplantation.
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Affiliation(s)
- Jin Dong Kim
- Department of Internal Medicine, Cheju Halla General Hospital, Jeju, Korea
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13
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Delgado-Coello B, Navarro-Alvarez N, Mas-Oliva J. The Influence of Interdisciplinary Work towards Advancing Knowledge on Human Liver Physiology. Cells 2022; 11:cells11223696. [PMID: 36429123 PMCID: PMC9688355 DOI: 10.3390/cells11223696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/11/2022] [Accepted: 11/13/2022] [Indexed: 11/23/2022] Open
Abstract
The knowledge accumulated throughout the years about liver regeneration has allowed a better understanding of normal liver physiology, by reconstructing the sequence of steps that this organ follows when it must rebuild itself after being injured. The scientific community has used several interdisciplinary approaches searching to improve liver regeneration and, therefore, human health. Here, we provide a brief history of the milestones that have advanced liver surgery, and review some of the new insights offered by the interdisciplinary work using animals, in vitro models, tissue engineering, or mathematical models to help advance the knowledge on liver regeneration. We also present several of the main approaches currently available aiming at providing liver support and overcoming organ shortage and we conclude with some of the challenges found in clinical practice and the ethical issues that have concomitantly emerged with the use of those approaches.
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Affiliation(s)
- Blanca Delgado-Coello
- Department of Structural Biology and Biochemistry, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
- Correspondence:
| | - Nalu Navarro-Alvarez
- Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
- Departament of Molecular Biology, Universidad Panamericana School of Medicine, Mexico City 03920, Mexico
- Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, USA
| | - Jaime Mas-Oliva
- Department of Structural Biology and Biochemistry, Instituto de Fisiología Celular, Universidad Nacional Autónoma de México, Mexico City 04510, Mexico
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14
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Saliba F, Bañares R, Larsen FS, Wilmer A, Parés A, Mitzner S, Stange J, Fuhrmann V, Gilg S, Hassanein T, Samuel D, Torner J, Jaber S. Artificial liver support in patients with liver failure: a modified DELPHI consensus of international experts. Intensive Care Med 2022; 48:1352-1367. [PMID: 36066598 DOI: 10.1007/s00134-022-06802-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 06/24/2022] [Indexed: 02/04/2023]
Abstract
The present narrative review on albumin dialysis provides evidence-based and expert opinion guidelines for clinicians caring for adult patients with different types of liver failure. The review was prepared by an expert panel of 13 members with liver and ntensive care expertise in extracorporeal liver support therapies for the management of patients with liver failure. The coordinating committee developed the questions according to their importance in the management of patients with liver failure. For each indication, experts conducted a comprehensive review of the literature aiming to identify the best available evidence and assessed the quality of evidence based on the literature and their experience. Summary statements and expert's recommendations covered all indications of albumin dialysis therapy in patients with liver failure, timing and intensity of treatment, efficacy, technical issues related to the device and safety. The panel supports the data from the literature that albumin dialysis showed a beneficial effect on hepatic encephalopathy, refractory pruritus, renal function, reduction of cholestasis and jaundice. However, the trials lacked to show a clear beneficial effect on overall survival. A short-term survival benefit at 15 and 21 days respectively in acute and acute-on-chronic liver failure has been reported in recent studies. The technique should be limited to patients with a transplant project, to centers experienced in the management of advanced liver disease. The use of extracorporeal albumin dialysis could be beneficial in selected patients with advanced liver diseases listed for transplant or with a transplant project. Waiting future large randomized controlled trials, this panel experts' statements may help careful patient selection and better treatment modalities.
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Affiliation(s)
- Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Center and Liver Transplant ICU, University Paris Saclay, INSERM Unit N°1193, Villejuif, France
| | - Rafael Bañares
- Gastroenterology and Hepatology Department, Hospital General Universitario Gregorio Marañón, IISGM, Madrid, Spain.,Facultad de Medicina, Universidad Complutense, Madrid, Spain.,CIBERehd, Madrid, Spain
| | - Fin Stolze Larsen
- Department of Hepatology and Gastroenterology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Alexander Wilmer
- Medical Intensive Care Unit, Department of General Internal Medicine, KU Leuven University Hospitals Leuven, Leuven, Belgium
| | - Albert Parés
- Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHD), University of Barcelona, Barcelona, Spain
| | - Steffen Mitzner
- Division of Nephrology and Fraunhofer Institute for Cell Therapy and Immunology, Department of Medicine, University Hospital Rostock, Rostock, Germany
| | - Jan Stange
- Center for Extracorporeal Organ Support, Nephrology, Internal Medicine, Rostock University Medical Center, Rostock, Germany.,Albutec GmbH, Rostock, Germany
| | - Valentin Fuhrmann
- Klinik für Innere Medizin, Heilig Geist-Krankenhaus, Cologne, Germany.,Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Gilg
- Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institute, Solna, Sweden.,Department of HPB Surgery, Karolinska University Hospital, Stockholm, Sweden
| | - Tarek Hassanein
- Southern California Liver Centers, 131 Orange Avenue, Suite 101, Coronado, CA, 92118, USA
| | - Didier Samuel
- AP-HP Hôpital Paul Brousse, Hepato-Biliary Center and Liver Transplant ICU, University Paris Saclay, INSERM Unit N°1193, Villejuif, France
| | | | - Samir Jaber
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, 9214, Montpellier Cedex 5, France. .,Département d'Anesthésie Réanimation B (DAR B), 80 Avenue Augustin Fliche, 34295, Montpellier, France.
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15
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Abstract
Abbreviated pathogenesis and clinical course of the acute liver failure syndrome. The pathogenesis and clinical course of the syndrome of acute liver failure (ALF) differs depending upon the etiology of the primary liver injury. In turn, the severity of the liver injury and resulting synthetic failure is often the primary determinant of whether a patient is referred for emergency liver transplantation. Injuries by viral etiologies trigger the innate immune system via pathogen-associated molecular patterns (PAMPs), while toxin-induced (and presumably ischemia-induced) injuries do so via damage-associated molecular patterns (DAMPs). The course of the clinical syndrome further depends upon the relative intensity and composition of cytokine release, resulting in an early proinflammatory phenotype (SIRS) and later compensatory anti-inflammatory response phenotype (CARS). The outcomes of overwhelming immune activation are the systemic (extrahepatic) features of ALF (cardiovascular collapse, cerebral edema, acute kidney injury, respiratory failure, sepsis) which ultimately determine the likelihood of death.Acute liver failure (ALF) continues to carry a high risk of mortality or the need for transplantation despite recent improvements in overall outcomes over the past two decades. Optimal management begins with identifying that liver failure is indeed present and its etiology, since outcomes and the need for transplantation vary widely across the different etiologies. Most causes of ALF can be divided into hyperacute (ischemia and acetaminophen) and subacute types (other etiologies), based on time of evolution of signs and symptoms of liver failure; the former evolve in 3 to 4 days and the latter typically in 2 to 4 weeks. Both involve intense release of cytokines and hepatocellular contents into the circulation with multiorgan effects/consequences.Management involves optimizing fluid balance and cardiovascular support, including the use of continuous renal replacement therapy, vasopressors, and pulmonary ventilation. Early evaluation for liver transplantation is advised particularly for acetaminophen toxicity, which evolves so rapidly that delay is likely to lead to death.Vasopressor support, high-grade hepatic encephalopathy, and unfavorable (subacute) etiologies heighten the need for urgent listing for liver transplantation. Prognostic scores such as Kings Criteria, Model for End-Stage Liver Disease, and the Acute Liver Failure Group prognostic index take these features into account and provide reasonable but imperfect predictive accuracy. Future treatments may include liver support devices and/or agents that improve hepatocyte regeneration.
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Affiliation(s)
- Shannan Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R. Todd Stravitz
- Section of Hepatology, Department of Internal Medicine, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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16
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Martí-Carvajal AJ, Gluud C, Gluud LL, Pavlov CS, Mauro E, Monge Martín D, Liu JP, Nicola S, Comunián-Carrasco G, Martí-Amarista CE. Liver support systems for adults with acute liver failure. Hippokratia 2022. [DOI: 10.1002/14651858.cd015059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Arturo J Martí-Carvajal
- Facultad de Ciencias de la Salud Eugenio Espejo; Universidad UTE (Cochrane Ecuador); Quito Ecuador
- Facultad de Medicina, Universidad Francisco de Vitoria (Cochrane Madrid); Madrid Spain
- Cátedra Rectoral de Medicina Basada en la Evidencia; Universidad de Carabobo; Valencia Venezuela
| | - Christian Gluud
- Cochrane Hepato-Biliary Group, Copenhagen Trial Unit, Centre for Clinical Intervention Research; The Capital Region, Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Department of Regional Health Research; The Faculty of Health Sciences, University of Southern Denmark; Odense Denmark
| | - Lise Lotte Gluud
- Gastrounit, Medical Division; Copenhagen University Hospital Hvidovre; Hvidovre Denmark
| | - Chavdar S Pavlov
- Cochrane Hepato-Biliary Group; Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet; Copenhagen Denmark
- Department of Therapy ; IM Sechenov First Moscow State Medical University; Moscow Russian Federation
- Department of Gastroenterology; Botkin Hospital; Moscow Russian Federation
| | - Ezequiel Mauro
- Liver Unit & Liver Transplant Unit; Hospital Italiano de Buenos Aires; Buenos Aires Argentina
| | - Diana Monge Martín
- Facultad de Medicina; Universidad Francisco de Vitoria (Cochrane Madrid); Madrid Spain
| | - Jian Ping Liu
- Centre for Evidence-Based Chinese Medicine; Beijing University of Chinese Medicine; Beijing China
| | - Susana Nicola
- Centro Asociado Cochrane Ecuador, Centro de Investigación en Salud Pública y Epidemiología Clínica (CISPEC); Universidad UTE; Quito Ecuador
| | - Gabriella Comunián-Carrasco
- Cátedra Rectoral de Medicina Basada en la Evidencia; Universidad de Carabobo; Valencia Venezuela
- Departamento de Obstetricia y Ginecología; Universidad de Carabobo; Valencia Venezuela
| | - Cristina Elena Martí-Amarista
- Division of General, Geriatric and Hospital Medicine; Stony Brook University, Renaissance School of Medicine HSC, Level 2, Rm 155; Stony Brook, 11794-8228 New York USA
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17
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Dandu H, Kumar V, Goel A, Khetan D, Chandra T, Bharti VR. A preliminary experience of plasma exchange in liver failure. Asian J Transfus Sci 2022; 16:209-213. [PMID: 36687541 PMCID: PMC9855211 DOI: 10.4103/ajts.ajts_115_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/01/2021] [Accepted: 12/25/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Plasma exchange (PLEX) is one of the experimental modalities of treatment for liver failure. We report our experience of PLEX in patients with acute-(ALF) or acute-on-chronic (ACLF) liver failure. METHODS Hemodynamically stable adult patients with ALF or ACLF, encephalopathy, model for end-stage liver disease (MELD) score ≥ 15, and clinical worsening/no improvement after 72-h of inpatient care were included. PLEX cycles repeated every 48 h, each of 2.5-4.0 h duration with 1-1.5 times of estimated plasma volume, were given. PLEX cycle was repeated till either of the end-points were achieved (i) MELD < 20 for 48 h or reaches below the baseline, whichever is lower, (ii) completed three PLEX cycles, (iii) hemodynamic instability, (iv) or outcome achieved. Outcome of interest was categorized as favorable (discharged in stable condition) or unfavorable (death or discharge in moribund condition). Data are expressed as median (interquartile range). RESULTS Sixteen patients (age 35 [27-48] years; male 8; ALF 5, ACLF 11; MELD 33 [27-37]; CLIF-SOFA 10 [8.5-12]) were included. Participants received 2 (1-3) cycles of PLEX during 13 (11-25) days of hospitalization. Overall, serum bilirubin, INR, creatinine, MELD, and CLIF-SOFA scores were significantly improved after PLEX. Five patients (5/16, 31%) had complete resolution of HE. Eight patients (50%) had a favorable outcome. Those with favorable outcome had significant improvement in serum bilirubin, INR, and CLIF-SOFA scores as compared to those with unfavorable outcome. CONCLUSION PLEX may be effective in patients with ALF or ACLF. More data are needed to establish its role in the management of liver failure.
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Affiliation(s)
- Himanshu Dandu
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Vivek Kumar
- Department of Internal Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Amit Goel
- Department of Gastro-Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Dheeraj Khetan
- Department of Transfusion Medicine, SGPGIMS, Lucknow, Uttar Pradesh, India
| | - Tulika Chandra
- Department of Transfusion Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
| | - Vipin Raj Bharti
- Department of Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India
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18
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Hazrati A, Malekpour K, Soudi S, Hashemi SM. Mesenchymal Stromal/Stem Cells and Their Extracellular Vesicles Application in Acute and Chronic Inflammatory Liver Diseases: Emphasizing on the Anti-Fibrotic and Immunomodulatory Mechanisms. Front Immunol 2022; 13:865888. [PMID: 35464407 PMCID: PMC9021384 DOI: 10.3389/fimmu.2022.865888] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/15/2022] [Indexed: 12/21/2022] Open
Abstract
Various factors, including viral and bacterial infections, autoimmune responses, diabetes, drugs, alcohol abuse, and fat deposition, can damage liver tissue and impair its function. These factors affect the liver tissue and lead to acute and chronic liver damage, and if left untreated, can eventually lead to cirrhosis, fibrosis, and liver carcinoma. The main treatment for these disorders is liver transplantation. Still, given the few tissue donors, problems with tissue rejection, immunosuppression caused by medications taken while receiving tissue, and the high cost of transplantation, liver transplantation have been limited. Therefore, finding alternative treatments that do not have the mentioned problems is significant. Cell therapy is one of the treatments that has received a lot of attention today. Hepatocytes and mesenchymal stromal/stem cells (MSCs) are used in many patients to treat liver-related diseases. In the meantime, the use of mesenchymal stem cells has been studied more than other cells due to their favourable characteristics and has reduced the need for liver transplantation. These cells increase the regeneration and repair of liver tissue through various mechanisms, including migration to the site of liver injury, differentiation into liver cells, production of extracellular vesicles (EVs), secretion of various growth factors, and regulation of the immune system. Notably, cell therapy is not entirely excellent and has problems such as cell rejection, undesirable differentiation, accumulation in unwanted locations, and potential tumorigenesis. Therefore, the application of MSCs derived EVs, including exosomes, can help treat liver disease and prevent its progression. Exosomes can prevent apoptosis and induce proliferation by transferring different cargos to the target cell. In addition, these vesicles have been shown to transport hepatocyte growth factor (HGF) and can promote the hepatocytes'(one of the most important cells in the liver parenchyma) growths.
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Affiliation(s)
- Ali Hazrati
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Kosar Malekpour
- Department of Immunology, School of Medicine, Iran University of Medical Sciences, Tehran, Iran
| | - Sara Soudi
- Department of Immunology, Faculty of Medical Sciences, Tarbiat Modares University, Tehran, Iran
| | - Seyed Mahmoud Hashemi
- Department of Immunology, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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19
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Hemoadsorption in 'Liver Indication'-Analysis of 109 Patients' Data from the CytoSorb International Registry. J Clin Med 2021; 10:jcm10215182. [PMID: 34768702 PMCID: PMC8584981 DOI: 10.3390/jcm10215182] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 11/01/2021] [Accepted: 11/03/2021] [Indexed: 12/26/2022] Open
Abstract
Background: Our aim is to report the results of the ‘liver indication’ subset of patients in the CytoSorb International Registry. Methods: Structured data were recorded. Treatment characteristics and changes from T1 (start of hemoadsorption) to T2 (termination) were evaluated with a special focus on bilirubin, C-reactive protein, procalcitonin, interleukin-6, platelet levels, SOFA scores, mortality, and subjective assessment by the attending physicians. Results: Until January 2021, from the total 1434 patients, 109 (age: 49.2 ± 17.1 years, 57.8% males) received treatment for hyperbilirubinemia. APACHE II-predicted mortality was 49.6 ± 26.8%. In the study, 91% of patients were alive at the termination of hemoadsorption and improvement was observed by the physicians in 75 cases. Overall, 65 (59.6%) patients died in the hospital, and 60 (55.0%) died in the ICU. Patients received a median of two treatments for a median of 43 h (interquartile range: 24–72 h) in total. Serum bilirubin levels reduced significantly to −4.6 (95% CI: −6.329 to −2.8) mg/dL. Thrombocytopenia was reported in four patients as an adverse event. Conclusions: We report the largest case series on hemoadsorption for ‘liver indication’ from the CytoSorb International Registry. The finding of significant bilirubin removal observed in our study could have substantial impact in designing and executing further studies on the effects of hemoadsorption in liver dysfunction, which are certainly warranted.
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20
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Zhang J, Li J, Ding M, Chen Y, Duan Z. Cortisol in Peripheral Blood Predicts the Severity and Prognosis in Patients with Liver Failure at 90 Days. Risk Manag Healthc Policy 2021; 14:4311-4319. [PMID: 34703342 PMCID: PMC8528544 DOI: 10.2147/rmhp.s327440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/23/2021] [Indexed: 12/25/2022] Open
Abstract
Objective To investigate the cortisol level in peripheral blood in evaluating the severity and prognosis of patients with liver failure. Methods A total of 211 inpatients with liver failure were enrolled in Beijing You ‘an Hospital affiliated with Capital Medical University, from September 2018 to January 2020. They were divided into three groups according to the severity of liver failure: early-stage liver failure, medium-stage liver failure and end-stage liver failure. In all patients, peripheral venous blood was gathered to detect the level of peripheral cortisol and related biochemical indexes. Logistic regression was used to screen the risk factors affecting the prognosis of patients at 90 days. A receiver operating curve (ROC) was used to reflect the value of cortisol on the prognosis of patients at 90 days. A model for end-stage liver disease (MELD) was accessed. Results Among these 211 patients with liver failure, aged from 19 to 70 years, the average level of cortisol was 351.26 ± 129.78 nmol/L for 101 cases with early-stage liver failure, 281.05 ± 81.31 nmol/L for 58 cases with medium-stage liver failure, and 189.21 ± 89.27 nmol/L for 52 cases with end-stage liver failure (P < 0.05). The level of cortisol in the survival group and the non-survival group was 339.26 ± 121.19 nmol/L and 192.71 ± 67.23 nmol/L, respectively (P < 0.05). The results of logistics regression analysis showed that the odds ratio (OR) and 95% confidence intervals (CI) of cortisol were 1.025 and 1.013–1.038 nmol/L (P < 0.05). MELD results showed that patients with higher MELD scores had lower cortisol content. Conclusion The level of cortisol is correlated with the severity of liver failure and decreases with the aggravation of liver failure, suggesting that the level of cortisol could be used as one of the indicators to evaluate the prognosis in patients with liver failure at 90 days.
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Affiliation(s)
- Jian Zhang
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Junfeng Li
- Department of Infectious Diseases, The First Hospital of Lanzhou University, Lanzhou, 730000, People's Republic of China
| | - Mei Ding
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Yu Chen
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, People's Republic of China
| | - Zhongping Duan
- Difficult & Complicated Liver Diseases and Artificial Liver Center, Beijing Youan Hospital, Capital Medical University, Beijing, 100069, People's Republic of China
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21
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Brar HS, Dadlani A, Ng AM. Successful High-Volume Plasmapheresis in Acute Liver Failure. Cureus 2021; 13:e16143. [PMID: 34354883 PMCID: PMC8328117 DOI: 10.7759/cureus.16143] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/03/2021] [Indexed: 01/15/2023] Open
Abstract
Acute liver failure carries a high mortality. At present, liver transplant is the definitive treatment along with standard medical support. In the absence of or as a bridge to liver transplant, several liver assist therapies have been derived. Some of the therapies have shown short-term mortality benefits and transplant-free survival over standard medical treatment alone. High volume plasmapheresis (HVP) is one of such therapies and is readily available in hospitals. We discuss the case of a 28-year-old female who presented with acute liver failure, did not qualify for the liver transplant and successfully underwent HVP. Various regimens of plasmapheresis have been described in the literature of which we used the HVP for pre-determined three days. Our case emphasizes the importance of early initiation of HVP in an acute liver failure patient who did not qualify for liver transplant, and adds to the existing evidence of the utility of this particular type of plasmapheresis over other regimens.
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Affiliation(s)
| | - Apaar Dadlani
- Internal Medicine, University of Louisville, Louisville, USA
| | - Alex M Ng
- Pulmonary and Critical Care, University of Louisville, Louisville, USA
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