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Sehrawat SS, Premkumar M. Critical care management of acute liver failure. Indian J Gastroenterol 2024; 43:361-376. [PMID: 38578565 DOI: 10.1007/s12664-024-01556-8] [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: 12/12/2023] [Accepted: 02/12/2024] [Indexed: 04/06/2024]
Abstract
The management of acute liver failure (ALF) in modern hepatology intensive care units (ICU) has improved patient outcomes. Critical care management of hepatic encephalopathy, cerebral edema, fluid and electrolytes; prevention of infections and organ support are central to improved outcomes of ALF. In particular, the pathogenesis of encephalopathy is multifactorial, with ammonia, elevated intra-cranial pressure and systemic inflammation playing a central role. Although ALF remains associated with high mortality, the availability of supportive care, including organ failure support such as plasma exchange, timely mechanical ventilation or continuous renal replacement therapy, either conservatively manages patients with ALF or offers bridging therapy until liver transplantation. Thus, appropriate critical care management has improved the likelihood of patient recovery in ALF. ICU care interventions such as monitoring of cerebral edema, fluid status assessment and interventions for sepsis prevention, nutritional support and management of electrolytes can salvage a substantial proportion of patients. In this review, we discuss the key aspects of critical care management of ALF.
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Affiliation(s)
- Surender Singh Sehrawat
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India.
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2
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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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3
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Sharma B, Bhateja A, Sharma R, Chauhan A, Bodh V. Acute kidney injury in acute liver failure: A narrative review. Indian J Gastroenterol 2024; 43:377-386. [PMID: 38578564 DOI: 10.1007/s12664-024-01559-5] [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: 12/30/2023] [Accepted: 02/23/2024] [Indexed: 04/06/2024]
Abstract
Acute kidney injury (AKI) is a frequent complication of acute liver failure (ALF) and it worsens the already worse prognoses of ALF. ALF is an uncommon disease, with varying etiologies and varying definitions in different parts of the world. There is limited literature on the impact of AKI on the outcome of ALF with or without transplantation. The multifaceted etiology of AKI in ALF encompasses factors such as hemodynamic instability, systemic inflammation, sepsis and direct nephrotoxicity. Indications of renal replacement therapy (RRT) for AKI in ALF patients extend beyond the conventional criteria for dialysis and continuous renal replacement therapy (CRRT) may have a role in transplant-free survival or bridge to liver transplantation (LT). LT is a life-saving option for ALF, so despite somewhat lower survival rates of LT in ALF patients with AKI, LT is not usually deferred. In this review, we will discuss the guidelines' recommended definition and classification of AKI in ALF, the impact of AKI in ALF, the pathophysiology of AKI and the role of CRRT and LT in ALF patients with AKI.
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Affiliation(s)
- Brij Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Anshul Bhateja
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Rajesh Sharma
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Ashish Chauhan
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India
| | - Vishal Bodh
- Department of Gastroenterology, Indira Gandhi Medical College, Shimla, 171 001, India.
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4
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Lenz D, Hørby Jørgensen M, Kelly D, Cardinale V, Geerts A, Gonçalves Costa I, Fichtner A, Garbade SF, Hegen B, Hilberath J, de Kleine R, Kupčinskas L, McLin V, Niesert M, Prado Gonzalez V, Sturm E, Staufner C, Tjwa E, Willemse J, Zecher BF, Larsen FS, Sebode M, Ytting H. Etiology and Outcome of Adult and Pediatric Acute Liver Failure in Europe. J Pediatr Gastroenterol Nutr 2023; 77:115-120. [PMID: 36930963 DOI: 10.1097/mpg.0000000000003777] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/19/2023]
Abstract
Acute liver failure (ALF) is rare but life-threatening. Common causes include intoxications, infections, and metabolic disorders. Indeterminate etiology is still frequent. No systematic data on incidence, causes, and outcome of ALF across Europe are available. Via an online survey we reached out to European Reference Network Centers on rare liver diseases. Numbers and etiology of ALF cases during 2020 were retrieved and diagnostic and treatment availabilities assessed. In total, 455 cases (306 adult, 149 pediatric) were reported from 36 centers from 20 countries. Intoxication was the most common cause in adult and pediatric care. The number of cases with indeterminate etiology is low. Diagnostic tools and specific treatment options are broadly available within this network. This is the first approach to report on etiology and outcome of ALF in the pediatric and adult population in Europe. High diagnostic yield and standard of care reflects the expert status of involved centers.
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Affiliation(s)
- Dominic Lenz
- From the Department of Pediatrics I, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Marianne Hørby Jørgensen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Department of Pediatrics and Adolescent Medicine, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Deirdre Kelly
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Liver Unit, Birmingham Women's and Children's Hospital, University of Birmingham, Birmingham, United Kingdom
| | - Vincenzo Cardinale
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Medical-Surgical and Biotechnologies Sciences, Polo Pontino, Sapienza University of Rome, Latina, Italy
| | - Anja Geerts
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Hepatology Research Unit, Department of Internal Medicine and Paediatrics, Liver Research Center Ghent, Ghent University, Ghent, Belgium
| | - Isabel Gonçalves Costa
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Unidade de Hepatologia e Transplantação Hepática Pediátrica, Hospital Pediátrico de Coimbra, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Alexander Fichtner
- From the Department of Pediatrics I, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Sven F Garbade
- From the Department of Pediatrics I, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Bianca Hegen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Hilberath
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Paediatric Gastroenterology/Hepatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Ruben de Kleine
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Limas Kupčinskas
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Institute for Digestive Research and Department of Gastroenterology, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Valérie McLin
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Swiss Pediatric Liver Center, Division of Pediatric Specialties, Department of Pediatrics, Gynecology and Obstetrics, University Hospitals Geneva and University of Geneva, Geneva, Switzerland
| | - Moritz Niesert
- From the Department of Pediatrics I, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Veronica Prado Gonzalez
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Ekkehard Sturm
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Paediatric Gastroenterology/Hepatology, University Hospital Tuebingen, Tuebingen, Germany
| | - Christian Staufner
- From the Department of Pediatrics I, Center for Pediatric and Adolescent Medicine, University Hospital Heidelberg, Heidelberg, Germany
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Eric Tjwa
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - José Willemse
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- Dutch Liver Patient Association (NLV), Hoogland, The Netherlands
| | - Britta F Zecher
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Fin Stolze Larsen
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Department of Gastroenterology and Hepatology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marcial Sebode
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the I. Department of Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Henriette Ytting
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
- the Gastro Unit, Medical Division, Hvidovre University Hospital, Copenhagen, Denmark
- the Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Jindal A, Sarin SK. Epidemiology of liver failure in Asia-Pacific region. Liver Int 2022; 42:2093-2109. [PMID: 35635298 DOI: 10.1111/liv.15328] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 05/26/2022] [Accepted: 05/27/2022] [Indexed: 02/13/2023]
Abstract
The global burden of deaths caused by liver failure is substantial. The Asia-Pacific region is home to more than half of the global population and accounted for 62.6% of global deaths because of liver diseases in 2015. The aetiology of liver failure varies in different countries at different times. Viruses (Hepatitis A, B and E), drugs (herbs and anti-tuberculous drugs), toxins (alcohol use) and autoimmune flares are mainly responsible of majority of liver failure in individuals with normal liver (acute liver failure; ALF); else these may precipitate liver failure in those with chronic liver disease (acute-on-chronic liver failure; ACLF). Concomitant increases in alcohol misuse and metabolic syndrome in recent years are concerning. Ongoing efforts to address liver failure-related morbidity and mortality require accurate contemporary estimates of epidemiology and outcomes. In light of the ever-changing nature of liver disease epidemiology, accurate estimates for the burden of liver failure across the countries are vital for setting clinical, research and policy priorities. In this review, we aimed to describe the current as well as changing epidemiological trends of common liver failure syndromes, ALF and ACLF in the Asia-Pacific region.
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Affiliation(s)
- Ankur Jindal
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Taher MK, Crispo JAG, Fortin Y, Moog R, McNair D, Bjerre LM, Momoli F, Mattison D, Krewski D. Systemic quinolones and risk of acute liver failure III: A nested case-control study using a US electronic health records database. J Gastroenterol Hepatol 2021; 36:2307-2314. [PMID: 33755266 PMCID: PMC8451826 DOI: 10.1111/jgh.15504] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 02/19/2021] [Accepted: 03/14/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND AIM Quinolones are globally popular antibiotics with proven potency, broad coverage, and reasonable safety. However, some concerns were raised as to their possible association with acute liver failure (ALF). The aim of this study is to assess ALF risk within 30 days of receiving a systemically administered quinolone antibiotic, in individuals with no history of liver/diseases. METHODS We conducted a nested case-control study using electronic health records from the Cerner Health Facts. The initial cohort (n = 35 349 943) included all patients who were admitted between 2000 and 2016, with no history of liver diseases, and had a minimum medical history of one year. Eligible cases were inpatients who were first diagnosed with ALF between 2010 and 2015. Using incidence density sampling, each case was matched with up to five unique controls by sex, race, age at index encounter, and period-at-risk. We used conditional logistic regression to calculate the odds ratio and 95% confidence interval for ALF risk, upon adjusting for exposure to other medications, and major confounders (diabetes mellitus and alcohol abuse). We used the STROBE Statement for reporting on our study. RESULTS We identified 3151 cases and 15 657 controls. Our primary analysis did not reveal an association between quinolones and ALF risk. However, some risk was identified among those with no or few comorbidities, those ≤ 60 years of age, women, men, African Americans, and Caucasians. CONCLUSION Although our study does not suggest an overall association between quinolones and ALF, elevated risks seen in some subgroups warrant further investigation.
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Affiliation(s)
- Mohamed Kadry Taher
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
| | - James A G Crispo
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,Department of NeurologyUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaPennsylvaniaUSA,Human Sciences DivisionNorthern Ontario School of MedicineSudburyOntarioCanada
| | - Yannick Fortin
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,Statistics CanadaOttawaOntarioCanada
| | - Ryan Moog
- Cerner CorporationKansas CityMissouriUSA
| | | | - Lise M Bjerre
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Department of Family MedicineUniversity of OttawaOttawaOntarioCanada,Institut du Savoir MontfortOttawaOntarioCanada
| | - Franco Momoli
- School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada,Children's Hospital of Eastern Ontario Research InstituteOttawaOntarioCanada
| | - Donald Mattison
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
| | - Daniel Krewski
- McLaughlin Centre for Population Health Risk Assessment, Faculty of MedicineUniversity of OttawaOttawaOntarioCanada,School of Epidemiology and Public HealthUniversity of OttawaOttawaOntarioCanada,Risk Sciences InternationalOttawaOntarioCanada
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Kumar R, Anand U, Priyadarshi RN. Liver transplantation in acute liver failure: Dilemmas and challenges. World J Transplant 2021; 11:187-202. [PMID: 34164294 PMCID: PMC8218344 DOI: 10.5500/wjt.v11.i6.187] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/17/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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Chowdhury D, Mahmood F, Edwards C, Taylor-Robinson SD. Five-day outcome of hepatitis E-induced acute liver failure in the ICU. EGYPTIAN LIVER JOURNAL 2021; 11:39. [PMID: 34804613 PMCID: PMC8591700 DOI: 10.1186/s43066-021-00098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatitis E virus (HEV) is an important cause of acute liver failure (ALF) in Bangladesh with pregnant mothers being more vulnerable. As HEV occurs in epidemics, it limits medical capabilities in this resource-poor country. Cerebral oedema, resulting in raised intracranial pressure (ICP), is an important cause of morbidity and mortality. Practical treatments are currently few. To study the baseline characteristics and clinical outcome of HEV-induced ALF in a recent HEV epidemicTo detect raised ICP clinically and observe response to mannitol infusion.This was a prospective cohort study from June until August 2018 of 20 patients admitted to the intensive care unit (ICU) of a major Bangladeshi Referral Hospital with HEV-induced ALF. We diagnosed HEV infection by detecting serum anti-HEV IgM antibody. All were negative for hepatitis B surface antigen and hepatitis A IgM antibody. Data were collected on 5-day outcome after admission to ICU, monitoring all patients for signs of raised ICP. An intravenous bolus of 20% mannitol was administered at a single time point to patients with raised ICP. RESULTS Twenty patients were included in the study. Ten (50%) patients, seven (70%) females, received mannitol infusion. HE worsened in eight (40%): seven female and three pregnant. Glasgow Coma scores deteriorated in six (30%): all (100%) females and three pregnant. Consciousness status was not significantly different between pregnant and non-pregnant subjects, nor between those who received mannitol and those who did not. Six patients met King's College Criteria for liver transplantation. CONCLUSIONS Female patients had a worse outcome, but pregnancy status was not an additional risk factor in our cohort. Mannitol infusion was also not associated with a significant difference in outcome.
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Affiliation(s)
- Debashis Chowdhury
- Department of Gastroenterology and Hepatology, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Farhana Mahmood
- Department of Medicine, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Cathryn Edwards
- Office of the President, British Society of Gastroenterology, St Andrew’s Place, London, UK
| | - Simon D. Taylor-Robinson
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, UK
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Kim A, Niu B, Woreta T, Chen PH. Clinical Considerations of Coagulopathy in Acute Liver Failure. J Clin Transl Hepatol 2020; 8:407-413. [PMID: 33447524 PMCID: PMC7782116 DOI: 10.14218/jcth.2020.00058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 08/08/2020] [Accepted: 08/31/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is the rapid onset of severe liver dysfunction, defined by the presence of hepatic encephalopathy and impaired synthetic function (international normalized ratio of ≥1.5) in the absence of underlying liver disease. The elevated international normalized ratio value in ALF is often misinterpreted as an increased hemorrhagic tendency, which can lead to inappropriate, prophylactic transfusions of blood products. However, global assessments of coagulopathy via viscoelastic tests or thrombin generation assay suggest a reestablished hemostatic, or even hypercoagulable, status in patients with ALF. Although the current versions of global assays are not perfect, they can provide more nuanced insights into the hemostatic system in ALF than the conventional measures of coagulopathy.
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Affiliation(s)
- Ahyoung Kim
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Bolin Niu
- Division of Gastroenterology & Hepatology, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Tinsay Woreta
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Po-Hung Chen
- Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Correspondence to: Po-Hung Chen, Division of Gastroenterology & Hepatology, Department of Medicine, Johns Hopkins University School of Medicine, 1830 E. Monument Street, Suite 429, Baltimore, MD 21287, USA. Tel: +1-410-614-3530, Fax: +1-410-550-7861, E-mail:
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10
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Rahim MN, Miquel R, Heneghan MA. Approach to the patient with acute severe autoimmune hepatitis. JHEP Rep 2020; 2:100149. [PMID: 32995712 PMCID: PMC7509236 DOI: 10.1016/j.jhepr.2020.100149] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 07/09/2020] [Accepted: 07/15/2020] [Indexed: 12/11/2022] Open
Abstract
Autoimmune hepatitis is associated with varied clinical presentations and natural history, as well as somewhat unpredictable treatment responses. Understanding how to stratify patients who require further escalation of therapy will help clinicians manage these patients. The presentation of acute severe autoimmune hepatitis (AS-AIH) is relatively uncommon, although its prevalence is potentially greater than currently perceived. Previous studies consist of small retrospective single-centre series and are not directly comparable due to the diversity of presentations, disease definitions and non-standardised treatment regimens. We define AS-AIH as those who present acutely with AIH and are icteric with an international normalised ratio ≥1.5 and no evidence of hepatic encephalopathy. Those with hepatic encephalopathy should be defined as having AS-AIH with acute liver failure. In this review, we provide a structured practical approach for diagnosing and managing this unique group of patients.
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Key Words
- ACLF, acute-on-chronic liver failure
- AIH, autoimmune hepatitis
- ALF, acute liver failure
- ALI, acute liver injury
- ALT, alanine aminotransferase
- ANA, anti-nuclear antibody
- AS-AIH, acute severe autoimmune hepatitis
- ASMA, anti-smooth muscle antibody
- AST, aspartate aminotransferase
- AUROC, analysis of area under the receiver operator characteristic curve
- Acute liver failure
- Acute severe presentation
- Autoimmune hepatitis
- CT, computed tomography
- Corticosteroids
- DILI, drug-induced liver injury
- EBV, Epstein-Barr virus
- HE, hepatic encephalopathy
- HLA, human leukocyte antigen
- IAIHG, International Autoimmune Hepatitis Group
- INR, international normalised ratio
- LT, liver transplantation
- Liver transplantation
- MELD, model for end-stage liver disease
- MELD-Na, model for end-stage liver disease-sodium
- MHN, massive hepatic necrosis
- NAC, N-acetylcysteine
- PT, prothrombin time
- UKELD, United Kingdom end-stage liver disease
- USALF, United States Acute Liver Failure
- anti-LC-1, anti-liver cytosol-1
- anti-LKM, anti-liver kidney microsomal
- anti-SLA/LP, anti-soluble liver antigen/liver pancreas
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Affiliation(s)
- Mussarat N. Rahim
- Institute of Liver Studies, King's College Hospital, London, SE5 9RS, UK
| | - Rosa Miquel
- Liver Histopathology Laboratory, King's College Hospital, London, SE5 9RS, UK
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Patterson J, Hussey HS, Silal S, Goddard L, Setshedi M, Spearman W, Hussey GD, Kagina BM, Muloiwa R. Systematic review of the global epidemiology of viral-induced acute liver failure. BMJ Open 2020; 10:e037473. [PMID: 32690747 PMCID: PMC7375632 DOI: 10.1136/bmjopen-2020-037473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The aetiology and burden of viral-induced acute liver failure remains unclear globally. It is important to understand the epidemiology of viral-induced ALF to plan for clinical case management and case prevention. PARTICIPANTS This systematic review was conducted to synthesize data on the relative contribution of different viruses to the aetiology of viral-induced acute liver failure in an attempt to compile evidence that is currently missing in the field. EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science were searched for relevant literature published from 2009 to 2019. The initial search was run on 9 April 2019 and updated via PubMed on 30 September 2019 with no new eligible studies to include. Twenty-five eligible studies were included in the results of this review. RESULTS This systematic review estimated the burden of acute liver failure after infection with hepatitis B virus, hepatitis A virus, hepatitis C virus, hepatitis E virus, herpes simplex virus/human herpesvirus, cytomegalovirus, Epstein-Barr virus and parvovirus B19. Data were largely missing for acute liver failure after infection with varicella-zostervirus, human parainfluenza viruses, yellow fever virus, coxsackievirus and/or adenovirus. The prevalence of hepatitis A-induced acute liver failur was markedly lower in countries with routine hepatitis A immunisation versus no routine hepatitis A immunisation. Hepatitis E virus was the most common aetiological cause of viral-induced acute liver failure reported in this review. In addition, viral-induced acute liver failure had poor outcomes as indicated by high fatality rates, which appear to increase with poor economic status of the studied countries. CONCLUSIONS Immunisation against hepatitis A and hepatitis B should be prioritised in low-income and middle-income countries to prevent high viral-induced acute liver failure mortality rates, especially in settings where resources for managing acute liver failure are lacking. The expanded use of hepatitis E immunisation should be explored as hepatitis E virus was the most common cause of acute liver failure. REGISTRATION PROSPERO registration number: CRD42017079730.
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Affiliation(s)
- Jenna Patterson
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Hannah Sophia Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Sheetal Silal
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Liz Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mashiko Setshedi
- Department of Medicine, Division of Gastroenterology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Wendy Spearman
- Department of Medicine, Division of Hepatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gregory D Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Benjamin M Kagina
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Rudzani Muloiwa
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Department of Pediatrics & Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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12
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Anand AC, Nandi B, Acharya SK, Arora A, Babu S, Batra Y, Chawla YK, Chowdhury A, Chaoudhuri A, Eapen EC, Devarbhavi H, Dhiman R, Datta Gupta S, Duseja A, Jothimani D, Kapoor D, Kar P, Khuroo MS, Kumar A, Madan K, Mallick B, Maiwall R, Mohan N, Nagral A, Nath P, Panigrahi SC, Pawar A, Philips CA, Prahraj D, Puri P, Rastogi A, Saraswat VA, Saigal S, Shalimar, Shukla A, Singh SP, Verghese T, Wadhawan M. Indian National Association for the Study of the Liver Consensus Statement on Acute Liver Failure (Part 1): Epidemiology, Pathogenesis, Presentation and Prognosis. J Clin Exp Hepatol 2020; 10:339-376. [PMID: 32655238 PMCID: PMC7335721 DOI: 10.1016/j.jceh.2020.04.012] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/12/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.
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Key Words
- ACLF, acute on chronic liver failure
- AFLP, acute fatty liver of pregnancy
- AKI, Acute kidney injury
- ALF, Acute liver failure
- ALFED, Acute Liver Failure Early Dynamic
- ALT, alanine transaminase
- ANA, antinuclear antibody
- AP, Alkaline phosphatase
- APTT, activated partial thromboplastin time
- ASM, alternative system of medicine
- ASMA, antismooth muscle antibody
- AST, aspartate transaminase
- ATN, Acute tubular necrosis
- ATP, adenosine triphosphate
- ATT, anti-TB therapy
- AUROC, Area under the receiver operating characteristics curve
- BCS, Budd-Chiari syndrome
- BMI, body mass index
- CBF, cerebral blood flow
- CBFV, cerebral blood flow volume
- CE, cerebral edema
- CHBV, chronic HBV
- CLD, chronic liver disease
- CNS, central nervous system
- CPI, clinical prognostic indicator
- CSF, cerebrospinal fluid
- DAMPs, Damage-associated molecular patterns
- DILI, drug-induced liver injury
- EBV, Epstein-Barr virus
- ETCO2, End tidal CO2
- GRADE, Grading of Recommendations Assessment Development and Evaluation
- HAV, hepatitis A virus
- HBV, Hepatitis B virus
- HELLP, hemolysis
- HEV, hepatitis E virus
- HLH, Hemophagocytic lymphohistiocytosis
- HSV, herpes simplex virus
- HV, hepatic vein
- HVOTO, hepatic venous outflow tract obstruction
- IAHG, International Autoimmune Hepatitis Group
- ICH, intracerebral hypertension
- ICP, intracerebral pressure
- ICU, intensive care unit
- IFN, interferon
- IL, interleukin
- IND-ALF, ALF of indeterminate etiology
- INDILI, Indian Network for DILI
- KCC, King's College Criteria
- LC, liver cirrhosis
- LDLT, living donor liver transplantation
- LT, liver transplantation
- MAP, mean arterial pressure
- MHN, massive hepatic necrosis
- MPT, mitochondrial permeability transition
- MUAC, mid-upper arm circumference
- NAPQI, n-acetyl-p-benzo-quinone-imine
- NPV, negative predictive value
- NWI, New Wilson's Index
- ONSD, optic nerve sheath diameter
- PAMPs, pathogen-associated molecular patterns
- PCR, polymerase chain reaction
- PELD, Pediatric End-Stage Liver Disease
- PPV, positive predictive value
- PT, prothrombin time
- RAAS, renin–angiotensin–aldosterone system
- SHF, subacute hepatic failure
- SIRS, systemic inflammatory response syndrome
- SNS, sympathetic nervous system
- TB, tuberculosis
- TCD, transcranial Doppler
- TGF, tumor growth factor
- TJLB, transjugular liver biopsy
- TLR, toll-like receptor
- TNF, tumor necrosis factor
- TSFT, triceps skin fold thickness
- US, ultrasound
- USALF, US Acute Liver Failure
- VZV, varicella-zoster virus
- WD, Wilson disease
- Wilson disease (WD)
- YP, yellow phosphorus
- acute liver failure
- autoimmune hepatitis (AIH)
- drug-induced liver injury
- elevated liver enzymes, low platelets
- sALI, severe acute liver injury
- viral hepatitis
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Affiliation(s)
- Anil C. Anand
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Bhaskar Nandi
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Anil Arora
- Institute of Liver Gastroenterology &Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sethu Babu
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad 500003, India
| | - Yogesh Batra
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
| | - Ashok Chaoudhuri
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Eapen C. Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
| | - RadhaKrishan Dhiman
- Department of Hepatology, Post graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Ajay Duseja
- Department of Hepatology, Post graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
| | | | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Mohamad S. Khuroo
- Department of Gastroenterology, Dr Khuroo’ S Medical Clinic, Srinagar, Kashmir, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology &Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kaushal Madan
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
| | - Bipadabhanjan Mallick
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Rakhi Maiwall
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the Medicity Hospital, Sector – 38, Gurgaon, Haryana, India
| | - Aabha Nagral
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Preetam Nath
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Sarat C. Panigrahi
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Ankush Pawar
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
| | - Cyriac A. Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682028, Kerala, India
| | - Dibyalochan Prahraj
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Pankaj Puri
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
| | - Amit Rastogi
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Sanjiv Saigal
- Department of Hepatology, Department of Liver Transplantation, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
| | - Akash Shukla
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Thomas Verghese
- Department of Gastroenterology, Government Medical College, Kozikhode, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
| | - The INASL Task-Force on Acute Liver Failure
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
- Institute of Liver Gastroenterology &Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad 500003, India
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Hepatology, Christian Medical College, Vellore, India
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
- Department of Hepatology, Post graduate Institute of Medical Education and Research, Chandigarh, 160 012, India
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
- Gleneagles Global Hospitals, Hyderabad, Telangana, India
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
- Department of Gastroenterology, Dr Khuroo’ S Medical Clinic, Srinagar, Kashmir, India
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the Medicity Hospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, 682028, Kerala, India
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
- Department of Hepatology, Department of Liver Transplantation, India
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
- Department of Gastroenterology, SCB Medical College, Cuttack, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
- Department of Gastroenterology, Government Medical College, Kozikhode, India
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
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Karna R, Hazam RK, Borkakoti J, Kumar A, Kar P. A 5-year Single-Center Experience of Hepatitis E Virus Infection During Pregnancy. J Clin Exp Hepatol 2020; 10:135-138. [PMID: 32189928 PMCID: PMC7067984 DOI: 10.1016/j.jceh.2019.09.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 09/15/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE The study was designed to examine the hypothesis whether the course and severity of hepatitis E virus (HEV)-related liver disease is worse during pregnancy. METHOD The prospective study included 1088 patients (550 pregnant; 538 nonpregnant) with clinically and biochemically confirmed acute viral hepatitis (AVH) or acute liver failure (ALF) and were subjected to a complete panel of hepatitis serology. RESULTS In the pregnant cohort, HEV was the cause of infection in 80.36% (442/550) of cases, whereas non-HEV accounted for 19.63 (108/550) of cases. In the ALF pregnant group, the prevalence of HEV was observed in 73.38% (102/139) of cases, whereas other viruses accounted for 26.61% (37/139) of illness. Ninety-eight of 129 (75.96%) cases of HEV-infected pregnant women died, whereas non-HEV infection was responsible for only 31 of 129 (24.04%) cases' death in comparison. Serum viral load in the ALF group was also significantly higher than that in the AVH group in the pregnant (24578.6 ± 12410.3 vs. 6821.9 ± 1832.7, respectively) cohort and nonpregnant cohort (583.6 ± 187.34 vs. 298.68 ± 65.77, respectively). CONCLUSION HEV infection has a higher incidence, more severe course, and greater mortality in the pregnant cohort than in the nonpregnant cohort.
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Affiliation(s)
- Rahul Karna
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi
| | - Rajib K. Hazam
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi
| | - Jayanta Borkakoti
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi
| | - Ashok Kumar
- Department of Obstetrics and Gynaecology, Maulana Azad Medical College, University of Delhi, New Delhi
| | - Premashis Kar
- Department of Medicine, Maulana Azad Medical College, University of Delhi, New Delhi
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14
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Toma D, Lazar O, Bontas E. Acute Liver Failure. LIVER DISEASES 2020. [PMCID: PMC7122204 DOI: 10.1007/978-3-030-24432-3_32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acute liver failure is a highly unpredictable disease that can evolve to a life-threatening situation within few hours. In a simplified manner, acute liver failure is the acute liver dysfunction with multiorgan damaging associated with numerous complications, and very poor prognosis, being caused by varied etiologies. Despite the numerous advances on pathophysiology, intensive care treatment, and transplantation techniques from the last decades, is still characterized by increased mortality. At present, the patients with acute liver failure should be managed in Intensive Care Unit where the therapy should be applied based on the specific etiology of the acute liver failure and it should be started as early as possible.
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15
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Wang X, Yang L, Wang J, Zhang Y, Dong R, Wu X, Yang CS, Zhang Z, Zhang J. A mouse model of subacute liver failure with ascites induced by step-wise increased doses of (-)-epigallocatechin-3-gallate. Sci Rep 2019; 9:18102. [PMID: 31792332 PMCID: PMC6888815 DOI: 10.1038/s41598-019-54691-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Accepted: 11/18/2019] [Indexed: 12/20/2022] Open
Abstract
Acute liver failure is divided into hyperacute, acute and subacute liver failure. Ascites is a common complication of subacute liver failure. Although animal models of acute liver failure have been established, the study of the pathogenesis of subacute liver failure with ascites complication is hampered by the lack of experimental animal model. The present study aimed at providing a mouse model of subacute liver failure with ascites complication. Kunming mice were intraperitoneally injected with (-)-epigallocatechin-3-gallate (EGCG), a redox-active polyphenol from green tea, for 32 consecutive days with step-wise increased dosage. The EGCG treatment resulted in liver failure as evidenced by extensive hepatocyte necrosis observed histologically along with significant elevation of serum alanine aminotransferase, aspartate aminotransferase, total bilirubin and direct bilirubin levels as well as significant reduction of serum albumin. Liver fibrosis was not observed by Masson staining and fibrosis-associated proteins were not increased. The mortality was less than 12% and the survival mice developed noticeable ascites. Hepatic thioredoxin and glutathione systems were activated by the EGCG. These adaptive responses might render most mice tolerable to the EGCG treatment. The EGCG treatment significantly up-regulated renal urea transporter A1 and promoted its trafficking to apical membrane. These alterations, known to increase water reabsorption, may be responsible, at least in part, for the formation of the ascites. Overall, the mice treated with gradually elevated doses of EGCG exhibits some of the features observed in patients with subacute liver failure, especially ascites. This mouse model is a useful tool for investigating the pathogenesis of subacute liver failure with ascites complication.
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Affiliation(s)
- Xiaoxiao Wang
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea & Food Science, Anhui Agricultural University, Hefei, Anhui, China
| | - Lumin Yang
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea & Food Science, Anhui Agricultural University, Hefei, Anhui, China
| | - Jiajia Wang
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea & Food Science, Anhui Agricultural University, Hefei, Anhui, China
| | - Yafei Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, P.R. China
| | - Ruixia Dong
- Department of Forestry and Technology, Lishui Vocational and Technical College, Lishui, Zhejiang, China
| | - Ximing Wu
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea & Food Science, Anhui Agricultural University, Hefei, Anhui, China
| | - Chung S Yang
- Department of Chemical Biology, Ernest Mario School of Pharmacy, Rutgers, The State University of New Jersey, Piscataway, NJ, USA
- International Joint Research Laboratory of Tea Chemistry and Health Effects, Anhui Agricultural University, Hefei, Anhui, China
| | - Zhenhua Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital, Anhui Medical University, Hefei, Anhui, China.
- School of Pharmacy, Anhui Medical University, Hefei, Anhui, P.R. China.
| | - Jinsong Zhang
- State Key Laboratory of Tea Plant Biology and Utilization, School of Tea & Food Science, Anhui Agricultural University, Hefei, Anhui, China.
- International Joint Research Laboratory of Tea Chemistry and Health Effects, Anhui Agricultural University, Hefei, Anhui, China.
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Shalimar, Sonika U, Kedia S, Mahapatra SJ, Nayak B, Yadav DP, Gunjan D, Thakur B, Kaur H, Acharya SK. Comparison of Dynamic Changes Among Various Prognostic Scores in Viral Hepatitis-Related Acute Liver Failure. Ann Hepatol 2019; 17:403-412. [PMID: 29735790 DOI: 10.5604/01.3001.0011.7384] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Multiple prognostic scores are available for acute liver failure (ALF). Our objective was to compare the dynamicity of model for end stage liver disease (MELD), MELD-sodium, acute liver failure early dynamic model (ALFED), chronic liver failure (CLIF)-consortium ACLF score and King's College Hospital Criteria (KCH) for predicting outcome in ALF. MATERIALS AND METHODS All consecutive patients with ALF at a tertiary care centre in India were included. MELD, MELD-Na, ALFED, CLIF-C ACLF scores and KCH criteria were calculated at admission and day 3 of admission. Area under receiver operator characteristic curves (AUROC) were compared with DeLong method. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), likelihood ratio (LR) and diagnostic accuracy (DA) were reported. RESULTS Of the 115 patients included in the study, 73 (63.5%) died. The discrimination of mortality with baseline values of prognostic scores (MELD, MELD-Na, ALFED, CLIF-C ACLF and KCH) was modest (AUROC: 0.65-0.77). The AUROC increased on day 3 for all scores, except KCH criteria. On day 3 of admission, ALFED score had the highest AUROC 0.95, followed by CLIF-C ACLF 0.88, MELD 0.81, MELD-Na 0.77 and KCH 0.52. The AUROC for ALFED was significantly higher than MELD, MELD-Na and KCH (P < 0.001 for all) and CLIF-C ACLF (P = 0.05). ALFED score ≥ 4 on day 3 had the best sensitivity (87.1%), specificity (89.5%), PPV (93.8%), NPV (79.1%), LR positive (8.3) and DA (87.9%) for predicting mortality. CONCLUSIONS Dynamic assessment of prognostic scores better predicts outcome. ALFED model performs better than MELD, MELD, MELD-Na, CLIF-C ACLF scores and KCH criteria for predicting outcome in viral hepatitis- related ALF.
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Affiliation(s)
- Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Ujjwal Sonika
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Saurabh Kedia
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Soumya J Mahapatra
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Baibaswata Nayak
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Dawesh P Yadav
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak Gunjan
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Bhaskar Thakur
- Department of Biostatistics, All India Institute of Medical Sciences, New Delhi, India
| | - Harpreet Kaur
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
| | - Subrat K Acharya
- Department of Gastroenterology and Human nutrition, All India Institute of Medical Sciences, New Delhi, India
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17
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Escorsell À, Castellote J, Sánchez-Delgado J, Charco R, Crespo G, Fernández J. Manejo de la insuficiencia hepática aguda grave. Documento de posicionamiento de la Societat Catalana de Digestologia. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 42:51-64. [DOI: 10.1016/j.gastrohep.2018.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 07/19/2018] [Accepted: 07/27/2018] [Indexed: 02/08/2023]
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18
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de Martino RB, Abdala E, Villegas FC, D’Albuquerque LAC, Song ATW. Liver transplantation for acute liver failure due to antitubercular drugs - a single-center experience. Clinics (Sao Paulo) 2018; 73:e344. [PMID: 30020340 PMCID: PMC6015261 DOI: 10.6061/clinics/2018/e344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 02/22/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Patients receiving treatment for tuberculosis are at risk of developing acute liver failure due to the hepatotoxicity of antitubercular drugs. We aimed to describe our experience with liver transplantation from deceased donors in this situation. METHODS We identified patients undergoing transplantation for acute liver failure due to antitubercular drugs in our prospectively maintained database. RESULTS Of 81 patients undergoing transplantation for acute liver failure, 8 cases were attributed to antitubercular drugs during the period of 2006-2016. Regarding the time of tuberculosis treatment until the onset of jaundice, patients were on antitubercular drugs for a mean of 64.7 days (21-155 days). The model for end-stage liver disease (MELD) score of patients ranged from 32 to 47 (median 38), and seven patients underwent transplantation under vasopressors. The 1-year survival was 50%. Three patients died during the week following transplantation due to septic shock (including a patient with acute liver failure due to hepatic/disseminated tuberculosis), and the remaining patient died 2 months after transplantation due to pulmonary infection. There were 2 cases of mild rejection and 1 case of moderate rejection. Of the surviving patients, all were considered cured of tuberculosis after alternative drugs were given. CONCLUSION Patients arrived very sick and displayed poor survival after deceased donor transplantation.
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Affiliation(s)
- Rodrigo Bronze de Martino
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Edson Abdala
- Laboratorio de Hepatite Virais – LIM-47, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Doencas Infecciosas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Felipe Castro Villegas
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Augusto Carneiro D’Albuquerque
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Transplante e Cirurgia de Figado - LIM-37, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alice Tung Wan Song
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Transplante e Cirurgia de Figado - LIM-37, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Buechter M, Gerken G, Hoyer DP, Bertram S, Theysohn JM, Thodou V, Kahraman A. Liver maximum capacity (LiMAx) test as a helpful prognostic tool in acute liver failure with sepsis: a case report. BMC Anesthesiol 2018; 18:71. [PMID: 29925334 PMCID: PMC6011251 DOI: 10.1186/s12871-018-0538-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 05/30/2018] [Indexed: 12/21/2022] Open
Abstract
Background Acute liver failure (ALF) is a life-threatening entity particularly when infectious complications worsen the clinical course. Urgent liver transplantation (LT) is frequently the only curative treatment. However, in some cases, recovery is observed under conservative treatment. Therefore, prognostic tools for estimating course of the disease are of great clinical interest. Since laboratory parameters sometimes lack sensitivity and specificity, enzymatic liver function measured by liver maximum capacity (LiMAx) test may offer novel and valuable additional information in this setting. Case presentation We here report the case of a formerly healthy 20-year old male caucasian patient who was admitted to our clinic for ALF of unknown origin in December 2017. Laboratory parameters confirmed the diagnosis with an initial MELD score of 28 points. Likewise, enzymatic liver function was significantly impaired with a value of 147 [> 315] μg/h/kg. Clinical and biochemical analyses for viral-, autoimmune-, or drug-induced hepatitis were negative. Liver synthesis parameters further deteriorated reaching a MELD score of 40 points whilst clinical course was complicated by septic pneumonia leading to severe hepatic encephalopathy grade III-IV, finally resulting in mechanical ventilation of the patient. Interestingly, although clinical course and laboratory data suggested poor outcome, serial LiMAx test revealed improvement of the enzymatic liver function at this time point increasing to 169 μg/h/kg. Clinical condition and laboratory data slowly improved likewise, however with significant time delay of 11 days. Finally, the patient could be dismissed from our clinic after 37 days. Conclusion Estimating prognosis in patients with ALF is challenging by use of the established scores. In our case, improvement of enzymatic liver function measured by the LiMAx test was the first parameter predicting beneficial outcome in a patient with ALF complicated by sepsis.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany.
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Dieter P Hoyer
- Department of General, Visceral, and Transplantation Surgery, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Stefanie Bertram
- Institute of Pathology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Viktoria Thodou
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Hufelandstr. 55, 45147, Essen, Germany
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Pievsky D, Rustgi N, Pyrsopoulos NT. Classification and Epidemiologic Aspects of Acute Liver Failure. Clin Liver Dis 2018; 22:229-241. [PMID: 29605063 DOI: 10.1016/j.cld.2018.01.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute liver failure is a rare condition with high short-term morbidity and mortality. The most widely accepted definition is an abnormality in coagulation with any degree of encephalopathy in a patient without cirrhosis and an illness duration of less than 26 weeks. Multiple classifications systems are currently in use to help categorize the condition. This article reviews the most commonly used systems. The epidemiologic aspects of the disease are also reviewed, including incidence, prevalence, demographics, geographic distribution, and racial and cultural factors and are discussed for the various subtypes of acute liver failure.
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Affiliation(s)
- Daniel Pievsky
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, University Hospital, 185 South Orange Avenue, Newark, NJ 07101-1709, USA
| | - Neil Rustgi
- Eastern Virginia Medical School, 825 Fairfax Avenue, Norfolk, VA 23507, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, University Hospital, 185 South Orange Avenue, Newark, NJ 07101-1709, USA.
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21
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Abstract
There is a strong imperative to develop valid and accurate prognostic modeling for acute liver failure (ALF). Despite the numerous clinical models that have been proposed thus far and the use of some such models, that is, King's College Criteria and Model for End-Stage Liver Disease, in clinical practice to aid decision-making, there is a significant need for improvement for determining patients' clinical course, survival, and requirement for liver transplantation. Future prognostic models shall need a stronger statistical foundation and accountability for time and variability in the clinical course of ALF and be applied for pretransplant and posttransplant outcomes.
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22
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Shalimar, Kedia S, Sharma H, Vasudevan S, Sonika U, Upadhyaya AD, Acharya SK. Predictors of infection in viral-hepatitis related acute liver failure. Scand J Gastroenterol 2017; 52:1413-1419. [PMID: 28875762 DOI: 10.1080/00365521.2017.1374449] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Infections are common and associated with complications and mortality in acute liver failure (ALF). The temporal relationship between ammonia and infection in ALF patients is unclear. We aimed to evaluate the predictors of infection and its relationship with arterial ammonia levels. MATERIALS AND METHODS Consecutive ALF patients hospitalized between January 2004 and December 2015, without signs of infection at/within 48 h of admission, were included. Occurrence of infection after 48 h was documented and ammonia levels were estimated for five consecutive days. Multivariate logistic regression analysis was used to assess factors associated with development of infection. Generalized estimating equations (GEE) were used to evaluate five-day time trend of ammonia in patients with and without infection. RESULTS Of 540 consecutive patients, 120 were infected at admission/within 48 h and were excluded. Of the rest 420 patients, 144 (34.3%) developed infection after 48 h and 276 (65.7%) remained non-infected. Infected patients had higher mortality than non-infected patients (61.8% vs 40.0%, p < .001). On multivariate analysis, presence of cerebral edema(HR 2.049; 95%CI, 1.30-3.23), ammonia level on day 3 of admission (HR 1.006; 95%CI, 1.003-1.008), and model for end stage liver disease (MELD) score (HR 1.051; 95%CI, 1.026-1.078) were associated with development of infection. GEE showed group difference in serial ammonia values between infected and non-infected patients indicating lack of ammonia decline in infected patients. CONCLUSIONS Cerebral edema, elevated ammonia on day 3, and higher MELD score predict the development of infection in ALF. Ammonia persists at high levels in infected patients, and elevated ammonia on day 3 is associated with complications and death.
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Affiliation(s)
- Shalimar
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Saurabh Kedia
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Hanish Sharma
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Sreejith Vasudevan
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ujjwal Sonika
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
| | - Ashish Dutt Upadhyaya
- b Department of Biostatistics , All India Institute of Medical Sciences , New Delhi , India
| | - Subrat K Acharya
- a Department of Gastroenterology and Human Nutrition , All India Institute of Medical Sciences , New Delhi , India
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Abstract
Acute liver failure (ALF) is a life-threatening condition of heterogeneous etiology. Outcomes are better with early recognition and prompt initiation of etiology-specific therapy, intensive care protocols, and liver transplantation (LT). Prognostic scoring systems include the King's College Criteria and Model for End-stage Liver Disease score. Cerebral edema and intracranial hypertension are reasons for high morbidity and mortality; hypertonic saline is suggested for patients with a high risk for developing intracranial hypertension, and when it does, mannitol is recommended as first-line therapy. Extracorporeal liver support system may serve as a bridge to LT and may increase LT-free survival in select cases.
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Affiliation(s)
- Chalermrat Bunchorntavakul
- Division of Gastroenterology and Hepatology, Department of Medicine, Rajavithi Hospital, College of Medicine, Rangsit University, Rajavithi Road, Ratchathewi, Bangkok 10400, Thailand; Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Department of Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA 19104, USA.
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24
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Sharma S, Kumar A, Kar P, Agarwal S, Ramji S, Husain SA, Prasad S, Sharma S. Risk factors for vertical transmission of hepatitis E virus infection. J Viral Hepat 2017; 24:1067-1075. [PMID: 28570034 DOI: 10.1111/jvh.12730] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Accepted: 04/24/2017] [Indexed: 01/10/2023]
Abstract
Hepatitis E virus (HEV) infection can be vertically transmitted, but the factors that transmit the disease to foetuses are still unclear. We studied a total of 144 pregnant women with HEV infection. Cord blood and newborn samples were taken for analysis. Nutritional factors were evaluated on the basis of anthropometric parameters and biochemical factors, and HEV viral load was quantified by real-time PCR. Sequencing of HEV-positive samples was performed. Approximately 14.63% (6/41) of pregnant patients with acute liver failure (ALF) died before delivery. Vertical transmission was observed in 46.09% (59/128) of HEV-IgM-positive mothers. Approximately 23.80% (10/42) of newborns in the acute viral hepatitis group and 29.41% (5/17) in the ALF group were positive for HEV-RNA. No significant difference was observed in the occurrence of vertical transmission in HEV groups. Viral load was found to be a significant predictor for vertical transmission of HEV infection adjusted with haemoglobin and folate in derivation cohort group. Incorporating these variables, a new score predicting vertical transmission of HEV was derived. Using these significant predictors, the probability for vertical transmission of HEV was well stratified in the validation group (P>.05). In conclusion, viral load was associated with vertical transmission of HEV infection. A valid prediction score model was generated that was verified in a validation cohort group.
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Affiliation(s)
- S Sharma
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - A Kumar
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - P Kar
- Department of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - S Agarwal
- Department of Biochemistry, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - S Ramji
- Department of Neonatology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - S A Husain
- Department of Biosciences, Jamia Millia Islamia, New Delhi, India
| | - S Prasad
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, India
| | - S Sharma
- National Institute of Cancer Prevention and Research (NICPR), Noida, India
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25
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Kumar A, Sharma S, Kar P, Agarwal S, Ramji S, Husain SA, Prasad S, Sharma S. Impact of maternal nutrition in hepatitis E infection in pregnancy. Arch Gynecol Obstet 2017; 296:885-895. [PMID: 28871471 DOI: 10.1007/s00404-017-4501-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Accepted: 08/23/2017] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND AIM The basis of host response in hepatitis E virus (HEV)-related liver disease during pregnancy-is still unclear. The study aims to evaluate anthropometric parameters and biochemical nutritional parameters in hepatitis E infection during pregnancy and correlate it with severity of the disease. METHODS A total of consecutive 267 pregnant women with jaundice were recruited. The jaundiced patients were classified as acute viral hepatitis (AVH) or acute liver failure (ALF). The study group included 144 pregnant women with HEV infection and 144 healthy asymptomatic age and gestational age-matched pregnant women as controls. Nutritional factors were evaluated on basis of anthropometric parameters and biochemical factors. Serum prealbumin and folate were assayed by ELISA kit. RESULTS All nutritional parameters were significantly lower in pregnant women with HEV infection as compared with healthy pregnant controls. Some of the nutritional parameters significantly lower in ALF pregnant patients compared to AVH pregnant patients in HEV group. Linear regression analysis of the AVH group showed that serum total protein and mid-upper arm circumference (MUAC) were significant predictors for bilirubin, body mass index (BMI) could significantly predict viral load level, and total protein, prealbumin, folate, and tricep skin fold thickness (TSFT) could significantly predict prothrombin time. In ALF group, serum prealbumin could significantly predict bilirubin levels and MUAC could significantly predict prothrombin time. CONCLUSION Malnutrition might confer a higher predisposition for HEV infection during pregnancy and is associated with increased severity of disease in terms of occurrence of ALF.
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Affiliation(s)
- Ashok Kumar
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India. .,, 13B, DDA Flats, Ber Sarai, New Delhi, 110016, India.
| | - Sheetal Sharma
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Premashish Kar
- Department of Medicine, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Sarita Agarwal
- Department of Biochemistry, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Siddhartha Ramji
- Department of Neonatology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Syed Akhtar Husain
- Department of Biosciences, Jamia Millia Islamia, Jamia Nagar, New Delhi, 110025, India
| | - Sudha Prasad
- Department of Obstetrics and Gynecology, Maulana Azad Medical College and Associated Lok Nayak Hospital, New Delhi, 110002, India
| | - Shashi Sharma
- National Institute of Cancer Prevention and Research (NICPR) ICMR, Sector-39, Noida, Uttar Pradesh, 201301, India
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Jin L, Gao H, Wang J, Yang S, Wang J, Liu J, Yang Y, Yan T, Chen T, Zhao Y, He Y. Role and regulation of autophagy and apoptosis by nitric oxide in hepatic stellate cells during acute liver failure. Liver Int 2017; 37:1651-1659. [PMID: 28508586 DOI: 10.1111/liv.13476] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2016] [Accepted: 05/08/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS We previously found that hepatic stellate cell activation induced by autophagy maintains the liver architecture to prevent collapse during acute liver failure. Nitric oxide has shown to induce hepatic stellate cell apoptosis. Whether and how nitric oxide is involved in acute liver failure and autophagy remains unclear. METHODS Acute liver failure patients were recruited to investigate the correlation between plasma nitric oxide levels and clinical features. Liver tissues were collected from chronic hepatitis patients by biopsy and from acute liver failure patients who had undergone liver transplantation. The expression of nitric oxide synthases and hepatic stellate cell activation (alpha-SMA), and autophagic activity (LC3) were investigated by immunohistochemistry. Autophagy and apoptosis were investigated by immunoblot analysis, confocal microscopy, and flow cytometry in hepatic stellate cells treated with nitric oxide donors. RESULTS Plasma nitric oxide level was significantly increased in patients with acute liver failure compared to those with cirrhosis (53.60±19.74 μM vs 19.40±9.03 μM, Z=-7.384, P<.001) and positively correlated with MELD-Na score (r=.539, P<.001), implicating nitric oxide in acute liver failure. At least some Nitric oxide was produced by overexpression of inducible nitric oxide synthases and endothelial nitric oxide synthases, but not neuronal nitric oxide synthases in the liver tissue. In vivo observation revealed that autophagy was inhibited in hepatic stellate cells based on decreased LC3 immunostaining, and in vitro experiments demonstrated that Nitric oxide can inhibit autophagy. Moreover, nitric oxide promoted hepatic stellate cell apoptosis, which was rescued by an autophagy inducer. CONCLUSIONS Increased nitric oxide synthases/ nitric oxide promotes apoptosis through autophagy inhibition in hepatic stellate cells during acute liver failure, providing a novel strategy for the treatment of patients with acute liver failure.
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Affiliation(s)
- Li Jin
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Heng Gao
- Xi'an Health School, Xi'an City, Shaanxi province, China
| | - JiuPing Wang
- Centre of Liver Diseases, Fourth Military Medical University, First Affiliated Teaching Hospital, Xi'an City, Shaanxi, China
| | - ShuJuan Yang
- Xi'an Eighth Hospital Affiliated to Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Jing Wang
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - JingFeng Liu
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Yuan Yang
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - TaoTao Yan
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Tianyan Chen
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Yingren Zhao
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
| | - Yingli He
- Institution of Hepatology, First Affiliated Teaching Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China.,Department of Infectious Diseases, First Affiliated Hospital, School of Medicine, Xi'an Jiaotong University, Xi'an City, Shaanxi province, China
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Wendon, J, Cordoba J, Dhawan A, Larsen FS, Manns M, Samuel D, Simpson KJ, Yaron I, Bernardi M. EASL Clinical Practical Guidelines on the management of acute (fulminant) liver failure. J Hepatol 2017; 66:1047-1081. [PMID: 28417882 DOI: 10.1016/j.jhep.2016.12.003] [Citation(s) in RCA: 495] [Impact Index Per Article: 70.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 12/07/2016] [Indexed: 02/06/2023]
Abstract
The term acute liver failure (ALF) is frequently applied as a generic expression to describe patients presenting with or developing an acute episode of liver dysfunction. In the context of hepatological practice, however, ALF refers to a highly specific and rare syndrome, characterised by an acute abnormality of liver blood tests in an individual without underlying chronic liver disease. The disease process is associated with development of a coagulopathy of liver aetiology, and clinically apparent altered level of consciousness due to hepatic encephalopathy. Several important measures are immediately necessary when the patient presents for medical attention. These, as well as additional clinical procedures will be the subject of these clinical practice guidelines.
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Abstract
Drug-induced acute liver failure (ALF) disproportionately affects women and nonwhites. It is most frequently caused by antimicrobials and to a lesser extent by complementary and alternative medications, antiepileptics, antimetabolites, nonsteroidals, and statins. Most drug-induced liver injury ALF patients have hepatocellular injury pattern. Cerebral edema and intracranial hypertension are the most serious complications of ALF. Other complications include coagulopathy, sepsis, metabolic derangements, and renal, circulatory, and respiratory dysfunction. Although advances in intensive care have improved outcome, ALF has significant mortality without liver transplantation. Liver-assist devices may provide a bridge to transplant or to spontaneous recovery.
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Affiliation(s)
- Shahid Habib
- Department of Medicine, Southern Arizona Veterans Affairs Healthcare System 3601 S 6th Avenue, Tucson, AZ 85723 USA
| | - Obaid S Shaikh
- Section of Gastroenterology, Department of Medicine, Veterans Affairs Pittsburgh Healthcare System, University Drive C, FU #112, Pittsburgh, PA 15240, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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29
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Brent J, Burkhart K, Dargan P, Hatten B, Megarbane B, Palmer R, White J. Toxicant-Induced Hepatic Injury. CRITICAL CARE TOXICOLOGY 2017. [PMCID: PMC7123957 DOI: 10.1007/978-3-319-17900-1_75] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The sudden failure of a previously healthy and functioning liver is a dramatic and devastating event. Acute liver failure is the common final pathway of a multitude of conditions and insults, all of which result in massive hepatic necrosis or loss of normal hepatic function. The ensuing multiorgan system failure frequently has a fatal outcome, with mortality rates in most series ranging from approximately 55% to 95% [1]. Acute liver failure (ALF, previously often referred to as fulminant hepatic failure (FHF)) knows no age boundaries, with many cases occurring in those younger than 30 years. Short of excellent intensive care unit (ICU) support and liver transplantation in selected cases, few viable treatment options are available. Over the past few decades, however, survival has been improved by anticipation, recognition, and early treatment of associated complications, as well as the application of prognostic criteria for early identification of patients requiring liver transplantation (along with improvement in the techniques and science of transplantation itself). The etiology of ALF varies from country to country and the incidence change over time. Paracetamol (acetaminophen) has now replaced viral hepatitis as the leading cause of ALF [2]. In a study from London including 310 patients with ALF in the period 1994–2004, 42% of the cases were caused by paracetamol [3], whereas this was only the cause in 2% of 267 patients in Spain from 1992 to 2000 [4]. However, less than 10% of all liver transplants are performed in patients with ALF [5, 6].
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Affiliation(s)
- Jeffrey Brent
- Department of Medicine, Division of Clinical Pharmacology and Toxicology, University of Colorado, School of Medicine, Aurora, Colorado USA
| | - Keith Burkhart
- FDA, Office of New Drugs/Immediate Office, Center for Drug Evaluation and Research, Silver Spring, Maryland USA
| | - Paul Dargan
- Clinical Toxicology, St Thomas’ Hospital, Silver Spring, Maryland USA
| | - Benjamin Hatten
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Bruno Megarbane
- Medical Toxicological Intensive Care Unit, Lariboisiere Hospital, Paris-Diderot University, Paris, France
| | - Robert Palmer
- Toxicology Associates, University of Colorado, School of Medicine, Denver, Colorado USA
| | - Julian White
- Toxinology Department, Women’s and Children’s Hospital, North Adelaide, South Australia Australia
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Bhatnagar G, Sharma S, Kumar A, Prasad S, Agarwal S, Kar P. Reduced glutathione in hepatitis E infection and pregnancy outcome. J Obstet Gynaecol Res 2016; 42:789-95. [DOI: 10.1111/jog.12986] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2015] [Revised: 01/07/2016] [Accepted: 01/31/2016] [Indexed: 12/27/2022]
Affiliation(s)
- Gunjan Bhatnagar
- Department of Obstetrics and Gynecology; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
| | - Sheetal Sharma
- Department of Obstetrics and Gynecology; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
| | - Ashok Kumar
- Department of Obstetrics and Gynecology; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
| | - Sudha Prasad
- Department of Obstetrics and Gynecology; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
| | - Sarita Agarwal
- Department of Biochemistry; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
| | - Premashish Kar
- Department of Medicine; Maulana Azad Medical College and associated Lok Nayak Hospital; New Delhi India
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He Y, Jin L, Wang J, Yan Z, Chen T, Zhao Y. Mechanisms of fibrosis in acute liver failure. Liver Int 2015; 35:1877-85. [PMID: 25388426 PMCID: PMC5024020 DOI: 10.1111/liv.12731] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/05/2014] [Indexed: 12/24/2022]
Abstract
BACKGROUND & AIMS Acute liver failure (ALF) is a condition with high mortality and morbidity. Fibrosis in chronic liver disease was extensively researched, whereas fibrosis and underlying mechanism in acute liver failure remains unclear. METHODS Hepatitis B virus related ALF patients were recruited to investigate if there was ongoing fibrosis by liver histology and liver stiffness measurement(LSM) analysis as well as fibrosis markers assay. Sera HMGB1 were kinetically detected in progression and remission stage of ALF. Hepatic stellate cell(HSC) activation by HMGB1 was explored by testing mRNA and protein level of α-SMA and collagen 1a1 by using qPCR and western blot. Autophagy induction by HMGB1 was explored by LC3-II conversion, autophagy flux and fluorescence. RESULTS Firstly, ongoing fibrosis in progression stage of ALF was confirmed by histological analysis, LS measurement as well as fibrosis markers detection. HSC activation and autophagy induction in explanted liver tissue also revealed. Next, kinetic monitoring sera HMGB1 revealed elevated HMGB1 in progression stage of ALF vs HBsAg carrier, and drop back to base level in remission stage. Thirdly, rHMGB1 dose dependently activated HSCs, as indicated by increased mRNA and proteins level in α-SMA and collagen 1a1. Moreover, autophagy was induced in HSC treated with rHMGB1, as illustrated by increased LC3 lipidation, elevated autophagy flux and GFP-LC3 puncta. CONCLUSIONS Acute liver failure is accompanied by ongoing fibrosis, HSC activation and autophagy induction. Increased HMGB1 activates HSC via autophagy induction. Those findings integrate HMGB1, HSCs activation, autophagy into a common framework that underlies the fibrosis in ALF.
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Affiliation(s)
- Yingli He
- Department of Infectious DiseasesFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi ProvinceChina
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
| | - Li Jin
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
| | - Jing Wang
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
| | - Zhi Yan
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
- Department of Infectious DiseasesSecond teaching hospital of ShanDong universityJinanShandong provinceChina
| | - Tianyan Chen
- Department of Infectious DiseasesFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi ProvinceChina
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
| | - Yingren Zhao
- Department of Infectious DiseasesFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi ProvinceChina
- Institution of HepatologyFirst Affiliated HospitalSchool of MedicineXi'an Jiaotong UniversityXi'anShaanxi provinceChina
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Approach to clinical syndrome of jaundice and encephalopathy in tropics. J Clin Exp Hepatol 2015; 5:S116-30. [PMID: 26041951 PMCID: PMC4442860 DOI: 10.1016/j.jceh.2014.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 05/14/2014] [Indexed: 12/12/2022] Open
Abstract
A large number of patients present with jaundice and encephalopathy in tropical country like India and acute liver failure is the usual cause. Clinical presentation like ALF is also a complication of many tropical infections, and these conditions may mimic ALF but may have subtle differences from ALF. Moreover, what hepatologists see as acute liver failure in tropics is different from what is commonly described in Western Textbooks. Paracetamol overdose, which is possibly the commonest cause of ALF in UK and USA, is hardly ever seen in India. Most common etiology here is viral hepatitis (hepatitis E > hepatitis B> hepatitis A). Apart from ALF, one may also come across subacute hepatic failure (SAHF) as well as acute-on-chronic liver failure (ACLF) due to viral hepatitis. Interestingly, a host of other conditions can mimic ALF because clinical presentation in these conditions can be dominated by jaundice and encephalopathy. Malarial hepatopathy is possibly the best-known condition out of these and is not an uncommon manifestation of severe malaria. A similar presentation can also be seen in other common infections in tropics such as dengue fever, typhoid fever, leptospirosis, scrub typhus, amoebic liver abscesses, tuberculosis and other bacterial and fungal infections with or without human immunodeficiency virus (HIV) related disease. In many of these conditions, liver failure may not be underlying pathophysiology. Some pregnancy related liver diseases could also present with jaundice and encephalopathy. This review summarizes the commonly seen presentations in tropical country like India, where jaundice and encephalopathy dominate the clinical picture.
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Shalimar, Acharya SK. Management in acute liver failure. J Clin Exp Hepatol 2015; 5:S104-15. [PMID: 26041950 PMCID: PMC4442864 DOI: 10.1016/j.jceh.2014.11.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2014] [Accepted: 11/26/2014] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is a rare, potentially fatal complication of severe hepatic illness resulting from various causes. In a clinical setting, severe hepatic injury is usually recognised by the appearance of jaundice, encephalopathy and coagulopathy. The central and most important clinical event in ALF is occurrence of hepatic encephalopathy (HE) and cerebral edema which is responsible for most of the fatalities in this serious clinical syndrome. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a central role in the pathogenesis. The role of newer ammonia lowering agents is still evolving. Liver transplant is the only effective therapy that has been identified to be of promise in those with poor prognostic factors, whereas in the others, aggressive intensive medical management has been documented to salvage a substantial proportion of patients. A small fraction of patients undergo liver transplant and the remaining are usually treated with medical therapy. Therefore, identification of the complications and causes of death in such patients, and use of appropriate prognostic models to identify those who need liver transplant and those who can be managed with medical treatment is a vital component of therapeutic strategy. In this review, we discuss the various pathogenetic mechanisms and treatment options available.
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Key Words
- AASLD, American Association For the Study of Liver
- ALF, Acute Liver Failure
- ALFED, Acute Liver Failure Early Dynamic Model
- BBB, Blood Brain Barrier
- BCAA, Branched Chain Amino acid
- CBF, Cerebral Blood Flow
- CPP, Cerebral Perfusion Pressure
- CVVHD, Continuous Veno-Venous Hemodialysis
- FFP, Fresh Frozen Plasma
- GM-CSF, Granulocyte Macrophage Colony Stimulating Factor
- HE, Hepatic Encephalopathy
- ICU, Intensive Care Unit
- IEI, Icterus Encephalopathy Interval
- IL-1β, Interleukin-1 beta
- IL6, Interlekin 6
- INR, International Normalized Ratio
- LOLA, l-Ornithine L Aspartate
- LOPA
- LOPA, l-Ornithine Phenyl Acetate
- MAP, Mean Arterial Pressure
- NAC, N-Acetyl Cysteine
- NO, Nitric Oxide
- OLT, Orthotopic Liver Transplantation
- PCWP, Pulmonary Capillary Wedge Pressure
- PEEP, Positive End Expiratory Pressure
- PT, Prothrombin Time
- SIMV, Synchronous Intermittent mandatory Ventilation
- SIRS, Systemic Inflammatory Response Syndrome
- SPEAR, Selective Parenteral and Enteral Antibiotic Regimen
- TNF-α, Tumor Necrosis Factor alfa
- UCD, Urea Cycle Disorder
- USALF, United States Acute liver Failure Study Group
- ammonia
- cerebral edema
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Affiliation(s)
| | - Subrat K. Acharya
- Address for correspondence: Subrat K. Acharya, Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India.
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Bagchi A, Kumar S, Ray PC, Das BC, Gumma PK, Kar P. Predictive value of serum actin-free Gc-globulin for complications and outcome in acute liver failure. J Viral Hepat 2015; 22:192-200. [PMID: 24774007 DOI: 10.1111/jvh.12259] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Accepted: 03/09/2014] [Indexed: 12/26/2022]
Abstract
This prospective study was designed to evaluate whether early changes in actin-free Gc-globulin levels were associated with complications and outcomes and to identify factors associated with persistent low actin-free Gc-globulin levels in acute liver failure (ALF). Thirty-two consecutive ALF patients admitted from October 2011 to December 2012 were followed up until death or complete recovery. All had serum actin-free Gc-globulin estimation at admission and at day three or expiry. Logistic regression analysis was performed to identify independent predictors of mortality. A receiver operating characteristic curve analysis was also performed. Nonsurvivors had significantly lower median actin-free Gc-globulin levels than survivors (87.32 vs 180 mg/L; P < 0.001). A receiver operating characteristic curve analysis revealed an area under curve (AUC) of 0.771 and showed that serum actin-free Gc-globulin level of ≤124 mg/L would predict mortality with 92% sensitivity and 71.4% specificity. Patients with lower serum actin-free Gc-globulin levels and decreasing trend in serum actin-free Gc-globulin levels were found to have more mortality and developed more complications. Logistic regression analysis showed that serum actin-free Gc-globulin, total leucocyte count and serum creatinine at admission were independent predictors of mortality. Incorporating these variables, a score predicting mortality risk at admission was derived. The scoring system was compared to MELD score and King's College Criteria as individual predictor of mortality. Serum actin-free Gc-globulin level at presentation is predictive of outcome and can be used for risk stratification. Its persistent low-level predicts mortality and is correlated with various complications.
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Affiliation(s)
- A Bagchi
- General Medicine, Maulana Azad Medical College, University of Delhi, New Delhi, India
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Komura T, Taniguchi T, Sakai Y, Yamashita T, Mizukoshi E, Noda T, Okajima M, Kaneko S. Efficacy of continuous plasma diafiltration therapy in critical patients with acute liver failure. J Gastroenterol Hepatol 2014; 29:782-6. [PMID: 24224755 DOI: 10.1111/jgh.12440] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/11/2013] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND AIMS Acute liver failure (ALF) is a critical illness with high mortality. Plasma diafiltration (PDF) is a blood purification therapy that is useful for ALF patients, but it is difficult to use when those patients have multiple organ failure or unstable hemodynamics. In these patients, symptoms are also likely to exacerbate immediately after PDF therapy. We developed continuous PDF (CPDF) as a new concept in PDF therapy, and assessed its efficacy and safety in ALF patients. METHODS Ten ALF patients (gender: M/F 6/4, Age: 47 ± 14) were employed CPDF therapy. The primary outcomes were altered liver function, measured by the model for end-stage liver disease (MELD) score, and total bilirubin and prothrombin time international normalized ratios (PT-INR), 5 days after CPDF therapy. Secondary outcomes included sequential organ failure assessment (SOFA) scores, 5 days after CPDF therapy, and the survival rate 14 days after this therapy. RESULTS The MELD score (34.5-28.0; P = 0.005), total bilirubin (10.9-7.25 mg/dL; P = 0.048), PT-INR (1.89-1.31; P = 0.084), and SOFA score (10.0-7.5; P < 0.039) were improved 5 days after CPDF therapy. Nine patients were alive, and one patient died because of acute pancreatitis, complicated by ALF. There were no major adverse events related to this therapy under hemodynamic stability. CONCLUSION In the present study, CPDF therapy safely supported liver function and generally improved the condition of critically ill patients with ALF.
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Affiliation(s)
- Takuya Komura
- Intensive Care Unit, Kanazawa University Hospital, Kanazawa, Japan; Disease Control and Homeostasis, Kanazawa University, Kanazawa, Japan
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Singh KK, Panda SK, Shalimar, Acharya SK. Patients with Diabetes Mellitus are Prone to Develop Severe Hepatitis and Liver Failure due to Hepatitis Virus Infection. J Clin Exp Hepatol 2013; 3:275-80. [PMID: 25755514 PMCID: PMC3940282 DOI: 10.1016/j.jceh.2013.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 11/04/2013] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Acute viral hepatitis (AVH) is usually a self-limiting illness. Diabetics are prone to develop liver diseases and liver regeneration is impaired in them. Natural course of AVH in diabetics has not been assessed and may be severe. DESIGN Observational prospective study to evaluate natural course of AVH in patients with and without diabetes mellitus. Consecutive patients with AVH were included and categorized in to those with or without diabetes. Etiology, complications, mortality and recovery parameters of AVH were identified and compared between two groups. RESULTS 131 consecutive AVH between March 2007 and March 2009 were evaluated; 12 diabetics and 83 non-diabetics (n = 95) were included for analysis. Hepatitis E was the commonest cause (n = 55, 57.89%) in the whole cohort. However, Hepatitis B virus (HBV) as the etiology was significantly higher among diabetics than in non-diabetics (58.33% vs. 25.3%, P = 0.02). In contrast, hepatitis E was the etiology in 61.44% of non-diabetics. Frequency of severe hepatitis was significantly higher in diabetics than in non-diabetics (5/12; 41.67% vs. 9/83; 10.64%, P < 0.005). 5 of 14 (36%) with severe hepatitis were diabetics. Liver failure and death occurred in 2 (16%) diabetics, while none among the non-diabetics had liver failure. Multiple variable logistic regression analysis revealed that acute hepatitis B (OR 4.7 (95% CI 1.34-16.47)) and diabetes (OR 4.0 (95% CI 0.96-16.47)) were associated with severe hepatitis. CONCLUSION Patients with diabetes are at risk to contact HBV infection and severe hepatitis.
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Affiliation(s)
- Kumar K. Singh
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Subrat K. Panda
- Department of Pathology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Shalimar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
| | - Subrat K. Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi 110029, India
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Shalimar, Acharya SK. Hepatitis e and acute liver failure in pregnancy. J Clin Exp Hepatol 2013; 3:213-24. [PMID: 25755503 PMCID: PMC3940148 DOI: 10.1016/j.jceh.2013.08.009] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2013] [Accepted: 08/19/2013] [Indexed: 12/12/2022] Open
Abstract
Hepatitis E virus is a positive strand RNA virus with three open reading frames which is transmitted predominantly through the fecal contamination of water and food. It is the most common cause of acute liver failure in endemic areas. Pregnant women especially from the Indian subcontinent and Africa are at increased risk of contracting acute HEV infection as well as developing severe complications including ALF. Transmission of HEV occurs from mother to unborn child. Both maternal and fetal complications may occur, including abortion, fetal demise, preterm labor and maternal or neonatal death. The precise reasons for increased susceptibility to HEV infection during pregnancy and associated severe disease are still an enigma. Management is supportive and termination of pregnancy is not recommended as a general rule. Prevention of infection is of vital importance, as availability of clean drinking water can reduce the burden of this disease in the community. There is a need for future research to focus on prevention of ALF in pregnancy and to study the disease pathogenesis, which is not explicitly understood at present. The availability of a vaccine may alter the natural course of the disease in this select population which is at risk.
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Key Words
- ALF, acute liver failure
- AVH, acute viral hepatitis
- CTL, cytotoxic T lymphocytes
- HEV, hepatitis E virus
- NANE, non A, non E
- NK, not known
- NP, non-pregnant
- NR, not reported
- OR, odds ratio
- ORF, open reading frame
- P, pregnant
- fetal transmission
- mortality
- pathogenesis
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Affiliation(s)
| | - Subrat K. Acharya
- Address for correspondence: Subrat K. Acharya, Professor and Head, Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi 110029, India. Tel.: +91 11 26594934.
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Management of acute liver failure in infants and children: Consensus statement of the pediatric gastroenterology chapter, Indian academy of pediatrics. Indian Pediatr 2013; 50:477-82. [DOI: 10.1007/s13312-013-0147-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Abstract
Autoimmune hepatitis frequently has an abrupt onset of symptoms, and it can present with acute liver failure. The abrupt presentation can indicate spontaneous exacerbation of a pre-existent chronic disease, newly created disease, a superimposed infectious or toxic injury, or new disease after viral infection, drug therapy, or liver transplantation. Deficiencies in the classical phenotype may include a low serum immunoglobulin G level and low or absent titers of the conventional autoantibodies. The original revised diagnostic scoring system of the International Autoimmune Hepatitis Group can guide the diagnostic evaluation, but low scores do not preclude the diagnosis. Liver tissue examination is valuable to exclude viral-related or drug-induced liver injury and support the diagnosis by demonstrating centrilobular necrosis (usually with interface hepatitis), lymphoplasmacytic infiltration, hepatocyte rosettes, and fibrosis. Conventional therapy with prednisone and azathioprine induces clinical and laboratory improvement in 68-75 % of patients with acute presentations, and high dose prednisone or prednisolone (preferred drug) is effective in 20-100 % of patients with acute severe (fulminant) presentations. Failure to improve or worsening of any clinical or laboratory feature within 2 weeks of treatment or worsening of a mathematical model of end-stage liver disease within 7 days justifies liver transplantation in acute liver failure. Liver transplantation for acute severe (fulminant) autoimmune hepatitis is as successful as liver transplantation for autoimmune hepatitis with a chronic presentation and other types of acute liver failure (patient survival >1 year, 80-94 %). Liver transplantation should not be delayed or superseded by protracted corticosteroid therapy or the empiric institution of nonstandard medications.
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Kumar R, Shalimar, Sharma H, Prakash S, Panda SK, Khanal S, Acharya SK. Persistent hyperammonemia is associated with complications and poor outcomes in patients with acute liver failure. Clin Gastroenterol Hepatol 2012; 10:925-31. [PMID: 22521861 DOI: 10.1016/j.cgh.2012.04.011] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 03/24/2012] [Accepted: 04/04/2012] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Patients admitted to the hospital with acute liver failure (ALF) and high arterial levels of ammonia are more likely to have complications and poor outcomes than patients with lower levels of ammonia. ALF is a dynamic process; ammonia levels can change over time. We investigated whether early changes (first 3 days after admission) in arterial levels of ammonia were associated with complications and outcomes and identified factors associated with persistent hyperammonemia. METHODS We performed a prospective observational study that measured arterial ammonia levels each day for 5 days in 295 consecutive patients with ALF. We analyzed associations of changes in ammonia levels during the first 3 days with complications and outcomes. RESULTS Patients with persistent arterial hyperammonemia (≥122 μmol/L for 3 consecutive days), compared with those with decreasing levels, had lower rates of survival (23% vs 72%; P < .001) and higher percentages of cerebral edema (71% vs 37%; P < .001), infection (67% vs 28%; P = .003), and seizures (41% vs 7.7%; P < .001). Patients with persistent hyperammonemia had greater mortality, with an odds ratio (OR) of 10.7, compared with patients with baseline levels of ammonia ≥122 μmol/L (OR, 2.4). Patients with persistent hyperammonemia were more likely to progress to and maintain advanced hepatic encephalopathy than those with decreasing levels. Patients with persistent, mild hyperammonemia (≥85 μmol/L for 3 days) were also more likely to have complications or die (P < .001) than patients with serial ammonia levels <85 μmol/L. Infections (OR, 4.17), renal failure (OR, 2.20), and decreased arterial pH (OR, 0.003) were independent predictors of persistent hyperammonemia. CONCLUSIONS Patients with ALF and persistent arterial hyperammonemia for 3 days after admission are more likely to develop complications and have greater mortality than patients with decreasing levels or high baseline levels. Infection, renal failure, and decreased arterial pH are independent predictors of persistent hyperammonemia.
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India
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Man Shrestha S, Shrestha S. Subacute Hepatic Failure: Its Possible Pathogenesis. Euroasian J Hepatogastroenterol 2012. [DOI: 10.5005/jp-journals-10018-1030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Acute liver failure in Japan: definition, classification, and prediction of the outcome. J Gastroenterol 2012; 47:849-61. [PMID: 22825549 PMCID: PMC3423565 DOI: 10.1007/s00535-012-0624-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 05/25/2012] [Indexed: 02/08/2023]
Abstract
Acute liver failure is a clinical syndrome characterized by hepatic encephalopathy and a bleeding tendency due to severe impairment of liver function caused by massive or submassive liver necrosis. Viral hepatitis is the most important and frequent cause of acute liver failure in Japan. The diagnostic criteria for fulminant hepatitis, including that caused by viral infections, autoimmune hepatitis, and drug allergy induced-liver damage, were first established in 1981. Considering the discrepancies between the definition of fulminant hepatitis in Japan and the definitions of acute liver failure in the United States and Europe, the Intractable Hepato-Biliary Disease Study Group established the diagnostic criteria for "acute liver failure" for Japan in 2011, and performed a nationwide survey of patients seen in 2010 to clarify the demographic and clinical features and outcomes of these patients. According to the survey, the survival rates of patients receiving medical treatment alone were low, especially in those with hepatic encephalopathy, despite artificial liver support, consisting of plasma exchange and hemodiafiltration, being provided to almost all patients in Japan. Thus, liver transplantation is inevitable to rescue most patients with hepatic encephalopathy. The indications for liver transplantation had, until recently, been determined according to the guideline published by the Acute Liver Failure Study Group in 1996. Recently, however, the Intractable Hepato-Biliary Disease Study Group established a scoring system to predict the outcomes of acute liver failure patients. Algorithms for outcome prediction have also been developed based on data-mining analyses. These novel guidelines need further evaluation to determine their usefulness.
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Gupta RK, Yadav SK, Rangan M, Rathore RKS, Thomas MA, Prasad KN, Pandey CM, Saraswat VA. Serum proinflammatory cytokines correlate with diffusion tensor imaging derived metrics and 1H-MR spectroscopy in patients with acute liver failure. Metab Brain Dis 2010; 25:355-61. [PMID: 20838864 DOI: 10.1007/s11011-010-9206-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2010] [Accepted: 07/14/2010] [Indexed: 01/03/2023]
Abstract
Hyperammonemia and inflammation are major contributing factors in the development of cerebral edema (CE) in acute liver failure (ALF). Aim of this study was to look for the relationship between proinflammatory cytokines with diffusion tensor imaging (DTI) derived metrics and (1)H-MR spectroscopy ((1)H-MRS) derived Glutamate/Glutamine (Glx). Fourteen patients with ALF and 14 age/sex matched controls were included in this study. All subjects had undergone clinical, biochemical, MR imaging and (1)H-MRS studies. Serum proinflammatory cytokines (IL-6 and TNF-α), blood ammonia level and Glx were computed for independent t-test and Pearson correlation. Serum proinflammatory cytokines, blood ammonia level and brain Glx were significantly increased in ALF patients as compared to controls. Blood ammonia level and Glx showed significant positive correlation with proinflammatory cytokines. Spectroscopy voxel derived spherical anisotropy (CS) showed positive correlation with Glx while mean diffusivity (MD) showed negative correlation. Proinflammatory cytokines showed positive correlation with CS and negative correlation with MD in various brain regions including spectroscopy voxel. Significant correlation of Glx, CS and MD with proinflammatory cytokines suggests that both DTI derived metrics and (1)H-MRS measure the synergistic effect of hyperammonemia and proinflammatory cytokines and may be used as non-invasive tools for understanding the pathogenesis of CE in ALF.
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Affiliation(s)
- Rakesh Kumar Gupta
- Department of Radiology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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Kumar R, Bhatia V, Khanal S, Sreenivas V, Gupta SD, Panda SK, Acharya SK. Antituberculosis therapy-induced acute liver failure: magnitude, profile, prognosis, and predictors of outcome. Hepatology 2010; 51:1665-74. [PMID: 20196116 DOI: 10.1002/hep.23534] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
UNLABELLED Antituberculosis therapy (ATT)-associated acute liver failure (ATT-ALF) is the commonest drug-induced ALF in South Asia. Prospective studies on ATT-ALF are lacking. The current study prospectively evaluated the magnitude, clinical course, outcome, and prognostic factors in ATT-ALF. From January 1986 to January 2009, 1223 consecutive ALF patients were evaluated: ATT alone was the cause in 70 (5.7%) patients. Another 15 (1.2%) had ATT and simultaneous hepatitis virus infection. In 44 (62.8%) patients, ATT was prescribed empirically without definitive evidence of tuberculosis. ATT-ALF patients were younger (32.87 [+/-15.8] years), and 49 (70%) of them were women. Most had hyperacute presentation; the median icterus encephalopathy interval was 4.5 (0-30) days. The median duration of ATT before ALF was 30 (7-350) days. At presentation, advanced encephalopathy and cerebral edema were present in 51 (76%) and 29 (41.4%) patients, respectively. Gastrointestinal bleed, seizures, infection, and acute renal failure were documented in seven (10%), five (7.1%), 26 (37.1%), and seven (10%) patients, respectively. Compared with hepatitis E virus (HEV) and non-A non-E-induced ALF, ATT-ALF patients had nearly similar presentations except for older age and less elevation of liver enzymes. The mortality rate among patients with ATT-ALF was high (67.1%, n = 47), and only 23 (32.9%) patients recovered with medical treatment. In multivariate analysis, three factors independently predicted mortality: serum bilirubin (>or=10.8 mg/dL), prothrombin time (PT) prolongation (>or=26 seconds), and grade III/IV encephalopathy at presentation. CONCLUSION ATT-ALF constituted 5.7% of ALF at our center and had a high mortality rate. Because the mortality rate is so high, determining which factors are predictors is less important. A high proportion of patients had consumed ATT empirically, which could have been prevented.
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Affiliation(s)
- Ramesh Kumar
- Departments of GastroenterologyAll India Institute of Medical Sciences, New Delhi, India
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Ascitic form of sporadic acute viral hepatitis in children: a distinct entity for recognition. J Pediatr Gastroenterol Nutr 2010; 50:184-7. [PMID: 19966578 DOI: 10.1097/mpg.0b013e3181aecb4c] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVES This study looked at the frequency and differences in presentation, laboratory parameters, and outcome between ascitic acute viral hepatitis (AAVH) and nonascitic acute viral hepatitis (NAVH) in children. METHODS Diagnosis of AVH was based on clinical features, >3-fold elevation of alanine aminotransferase, viral marker positivity (IgM antihepatitis A virus, IgM antihepatitis E virus, hepatitis B surface antigen, and IgM antihepatitis B core antigen) at presentation, absence of history of liver disease, and subsequent normalization within 6 months of clinical features and liver functions including sustained resolution of ascites in AAVH on follow-up. RESULTS A total of 139 children (121 children with NAVH and 18 with AAVH, 12.9%) were studied. Children with AAVH in comparison with those with NAVH were younger (median age 4 vs 8 years), had lower frequency of prodrome (22% vs 51%), lower serum albumin (median 2.8 vs 3.7 g/dL), low total serum protein (median 6.5 vs 7.4 g/dL), and prolongation of prothrombin time (median 4.8 vs 1.05 seconds); all P < 0.03. No significant differences were found in sex, height standard deviation scores, duration of symptoms, liver span or consistency, transaminases, alkaline phosphatase, and etiology of NAVH versus AAVH. Among the AAVH group clinically detectable ascites was present in 38.9% (7/18), spontaneous bacterial peritonitis in 11%, and diuretics had to be used in 44% of cases. Ascites resolved in all of the cases in 8 weeks (94.4% cases in <4 weeks) and liver functions normalized in 17%, 50%, and 33% cases in <4, 4 to 8, and >8 weeks duration, respectively. CONCLUSIONS We report AAVH as a distinct entity that affects younger children. This subgroup has compromised biosynthetic liver functions irrespective of viral etiology with total recovery.
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Singhal S, Chakravarty A, Das BC, Kar P. Tumour necrosis factor-alpha and soluble Fas ligand as biomarkers in non-acetaminophen-induced acute liver failure. Biomarkers 2009; 14:347-53. [PMID: 19505222 DOI: 10.1080/13547500903013664] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Cytokines as prognostic markers in acute liver failure (ALF) have not been evaluated in the Indian subcontinent with hepatitis E as the commonest aetiological agent. We investigated the clinical significance of proinflammatory/apoptotic cytokines soluble Fas ligand (sFasL) and tumour necrosis factor (TNF)-alpha in ALF of specific aetiology. METHODS A total of 82 cases, 37 ALF and 45 acute hepatitis (AH), and 60 healthy controls were recruited. Serum levels of sFasL and TNF-alpha were determined at admission and death/recovery. RESULTS Mean sFasL and TNF-alpha serum levels at admission were significantly higher (p < 0.001) in patients with ALF than AH, but no marked difference was observed between ALF-E (expired, n = 23) and ALF-S (survivors, n = 14), although the former had comparatively higher levels. ALF-E had higher than baseline TNF-alpha and sFasL concentrations at death, while in the ALF-S group the samples obtained from the patients as soon as they came out of encephalopathy, showed either lower or similar TNF-alpha and sFasL levels as found at admission. CONCLUSION The high levels of sFasL and TNF-alpha are associated with ALF. Following the trend of these cytokines can be useful in predicting death and timely referral to a transplant centre.
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Affiliation(s)
- Shashideep Singhal
- Division of Gastroenterology, Department of Medicine, Maulana Azad Medical College & Lok Nayak Hospital, University of Delhi, Delhi, India.
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Kitzberger R, Funk GC, Holzinger U, Miehsler W, Kramer L, Kaider A, Ferenci P, Madl C. Severity of organ failure is an independent predictor of intracranial hypertension in acute liver failure. Clin Gastroenterol Hepatol 2009; 7:1000-6. [PMID: 19465152 DOI: 10.1016/j.cgh.2009.05.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2008] [Revised: 04/05/2009] [Accepted: 05/13/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Ionized ammonia (NH(3)) and partial pressure of the gaseous ammonia (pNH(3)) are associated with hepatic encephalopathy and intracranial hypertension in patients with acute liver failure; NH(3) is also believed to contribute to extrahepatic organ failure. We investigated whether the severity of organ failure was associated with intracranial hypertension and evaluated the correlation between NH(3) and pNH(3) and grade of hepatic encephalopathy. METHODS In 87 patients with acute liver failure admitted to the intensive care unit, we simultaneously evaluated arterial ammonia, pNH(3), clinical grade of hepatic encephalopathy, the sequential organ failure assessment score (SOFA score), and evidence of intracranial hypertension. RESULTS In comparing patients with intracranial hypertension (n = 37) with patients without intracranial hypertension (n = 50), the highest NH(3) and pNH(3) levels and SOFA scores before onset of intracranial hypertension were independent predictors of intracranial hypertension (P < .001). Among patients with NH(3) levels less than 146 mumol/L, those with intracranial hypertension had a higher SOFA score than those without intracranial hypertension (median, 10 vs 5.5; P = .004), despite the patients' similar levels of NH(3). NH(3) (r = 0.68, P < .0001) and pNH(3) (r = 0.78, P < .0001) both correlated with grade of hepatic encephalopathy. However, in multiple regression analysis, only pNH(3) (P < .0001) was shown to be a significant independent parameter for predicting grade of hepatic encephalopathy (P = .27). CONCLUSIONS SOFA score and ammonia levels are independent predictors of intracranial hypertension. In patients with acute liver failure admitted to the intensive care unit, pNH(3) level is a better predictor of clinical grade of hepatic encephalopathy than arterial NH(3) level.
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Affiliation(s)
- Reinhard Kitzberger
- Department of Gastroenterology, Hepatology and Medical Intensive Care Medicine, Medical University Hospital Vienna, Vienna, Austria.
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Acharya SK, Bhatia V, Sreenivas V, Khanal S, Panda SK. Efficacy of L-ornithine L-aspartate in acute liver failure: a double-blind, randomized, placebo-controlled study. Gastroenterology 2009; 136:2159-68. [PMID: 19505424 DOI: 10.1053/j.gastro.2009.02.050] [Citation(s) in RCA: 116] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Revised: 01/09/2009] [Accepted: 02/10/2009] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS In acute liver failure (ALF), high blood ammonia levels have been documented that correlate with mortality and complications. L-ornithine L-aspartate (LOLA) reduces ammonia levels by increasing hepatic ammonia disposal and its peripheral metabolism. Present study evaluated efficacy and ammonia lowering effect of LOLA in ALF. METHODS This study was placebo-controlled and blinded. We randomized 201 patients with ALF between January 2005 and October 2007 to either placebo or LOLA infusions (30 g daily) for 3 days. Arterial ammonia was measured at baseline and daily for 6 days. The primary end point was improvement in survival. The study followed CONSORT guidelines and was registered at the ClinicalTrials.gov (Identifier: NCT00470314). RESULTS There was no reduction in mortality with LOLA treatment (mortality: 33.3% in placebo and 42.4% in LOLA; relative risk of death 1.27; 95% CI: 0.88-1.85; P = .204). By multivariate analysis, ammonia levels were an independent predictor of survival. There was significant decrease in ammonia levels in both groups with time (P < .001), but the levels of ammonia between the randomized groups at any time point, either during the 72 hours of LOLA infusion or during the follow-up were similar (P = .492). There was no difference between the 2 groups in the improvement in encephalopathy grade (P = .418), consciousness recovery time (P = .347), survival time (P = .612), or complications like seizures (P = .058) and renal failure (P = .615). The fetal outcome was also similar (P = .172). No adverse drug effect was noted. CONCLUSIONS LOLA infusion did not lower the ammonia or improved survival in ALF.
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Affiliation(s)
- Subrat Kumar Acharya
- Department of Gastroenterology, All India Institute of Medical Sciences (AIIMS), New Delhi, India.
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Kumar Mandal P, Kumar Yadav S, Anand Saraswat V, Kumar Singh J, Upreti P, Singh R, Kishore Singh Rathore R, Kumar Gupta R. Mammillary body atrophy in acute liver failure and acute-on-chronic liver failure of nonalcoholic etiology. Metab Brain Dis 2009; 24:361-71. [PMID: 19308712 DOI: 10.1007/s11011-009-9140-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2008] [Accepted: 01/29/2009] [Indexed: 11/30/2022]
Abstract
The most common cause of atrophy of mammillary bodies (MBs) is thiamine deficiency, which is very common in patients with alcoholic liver disease. The purpose of this study was to look for changes in MBs using brain magnetic resonance imaging (MRI) in patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and chronic liver failure (CLF) of non-alcoholic etiology. Volumes of MBs and caudate nuclei (CNs) were quantified in nine patients with ALF, 17 with ACLF, 18 with CLF and in 24 healthy controls. Volume of these structures was quantified again three weeks after clinical recovery in five patients with ALF who had survived their illness. Volume of left, right and both MBs was significantly decreased (p < 0.05) in patients with ALF and ACLF whereas there was no change in patients with CLF, when compared with healthy controls. However CN volumes did not change significantly compared to controls in any of the three patient groups. In the follow-up study significant recovery in volume of MBs was noted compared to baseline values in the ALF patients. We conclude that significant volume loss occurs in MBs in patients with ALF and ACLF of non-alcoholic etiology but not in CLF. This loss of MBs volume recovers substantially in patients with ALF who survive their illness.
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Affiliation(s)
- Pranav Kumar Mandal
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Uttar Pradesh, India
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