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Henderson D, Gupta A, Menon S, Deep A. Intraoperative kidney replacement therapy in acute liver failure. Pediatr Nephrol 2024; 39:2899-2910. [PMID: 38526761 PMCID: PMC11349816 DOI: 10.1007/s00467-023-06272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 03/27/2024]
Abstract
Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.
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Affiliation(s)
- Daniel Henderson
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Anish Gupta
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Shina Menon
- Division of Nephrology, Department of Paediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
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2
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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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3
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Trautman CL, Khan M, Baker LW, Aslam N, Fitzpatrick P, Porter I, Mao M, Wadei H, Ball CT, Hickson LJ. Kidney Outcomes Following Utilization of Molecular Adsorbent Recirculating System. Kidney Int Rep 2023; 8:2100-2106. [PMID: 37850016 PMCID: PMC10577361 DOI: 10.1016/j.ekir.2023.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Revised: 07/24/2023] [Accepted: 07/31/2023] [Indexed: 10/19/2023] Open
Abstract
Introduction Molecular adsorbent recirculating system (MARS) is an extracorporeal system combining conventional veno-venous hemodiafiltration and adsorption to provide rescue support in fulminant hepatic failure. Acute kidney injury (AKI) is common in patients with hepatic failure warranting continuous kidney replacement therapy (CKRT). Our primary aim was to characterize a cohort of patients who received MARS therapy and examine kidney events given the current paucity of available data. Methods Patients initiating MARS in a tertiary care setting from January 2014 through December 2020 were assessed for treatment indications, transplantation, CKRT, kidney recovery, and death. Data was collected using the REDCAP software. Results A total of 49 patients (67% female; 75% White) received MARS therapy with 29 patients (59%) requiring concomitant CKRT. Hepatic encephalopathy (HE) was the most common indication for MARS initiation (55%). In-hospital mortality was 41% (12/29) among patients who received CKRT versus 10% (2/20) among those not requiring CKRT (relative risk [RR] 4.15, 95% confidence interval [CI] 1.04 to 16.52, P = 0.044); this persisted following adjustment for prespecified patient characteristics (all RR ≥ 3.76, all P ≤ 0.060). One-year mortality post-MARS initiation was high overall but highest among the CKRT group (59% [17/29] vs. 25% [5/20] unadjusted RR 2.92, 95% CI 1.08 to 7.94, P = 0.035). Liver transplant after MARS occurred in 41% of patients (20/49). After CKRT, 39% of patients (9/29) recovered kidney function prior to hospital discharge. Conclusions Patients requiring MARS frequently have AKI warranting the use of concomitant CKRT, which is associated with a high rate of in-hospital and 1-year mortality.
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Affiliation(s)
- Christopher L. Trautman
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Mahnoor Khan
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Lyle W. Baker
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Nabeel Aslam
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Peter Fitzpatrick
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Ivan Porter
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Michael Mao
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
| | - Hani Wadei
- Department of Transplantation; Mayo Clinic Jacksonville, Florida, USA
| | - Colleen T. Ball
- Division of Biomedical Statistics and Informatics, Mayo Clinic Jacksonville, Florida, USA
| | - LaTonya J. Hickson
- Division of Nephrology and Hypertension, Department of Medicine; Mayo Clinic Jacksonville, Florida, USA
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4
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Price N, Wood AF. Acute kidney injury in the critical care setting. Nurs Stand 2023; 38:45-50. [PMID: 37458070 DOI: 10.7748/ns.2023.e12063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 07/18/2023]
Abstract
Acute kidney injury is a sudden reduction in renal function which impairs the kidneys' ability to maintain fluid, electrolyte and acid-base balance. The syndrome often develops secondary to severe illness and is associated with a significant increase in morbidity and mortality rate in critically ill patients. This article gives an overview of the pathophysiology and aetiology of acute kidney injury, as well as the associated complications and clinical diagnostic signs. The authors also describe some common causes of the syndrome in critically ill patients, specifically sepsis, liver failure and cardiac failure, and discuss patient management in the critical care setting, with a focus on haemodynamic support and continuous renal replacement therapy.
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Affiliation(s)
- Natasha Price
- division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
| | - Alison Fiona Wood
- programme lead for independent prescribing, division of nursing and paramedic science, school of health sciences, Queen Margaret University, Edinburgh, Scotland
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Amer K, Flikshteyn B, Lingiah V, Tafesh Z, Pyrsopoulos NT. Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2023; 27:563-579. [PMID: 37380283 DOI: 10.1016/j.cld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Kamal Amer
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Ben Flikshteyn
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Vivek Lingiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Zaid Tafesh
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 53, Newark, NJ 07101-1709, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 536, Newark, NJ 07101-1709, USA.
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6
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Mataya LA, Srinivasan V, Rand EB, Alcamo AM. Multiple organ involvement and ICU considerations for the care of acute liver failure (ALF) and acute on chronic liver failure (ACLF) in children. Transl Pediatr 2021; 10:2749-2762. [PMID: 34765498 PMCID: PMC8578785 DOI: 10.21037/tp-20-375] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 02/23/2021] [Indexed: 12/30/2022] Open
Abstract
Liver disease results in approximately 15,000 pediatric hospitalizations per year in the United States and is a significant burden to child health. Major etiologies of liver failure and indications for transplantation in children include: biliary atresia, metabolic/genetic conditions, toxins, infections, tumors, and immune-mediated liver/biliary injury. Children requiring transplantation are placed on the United Network of Organ Sharing waitlist including those with acute liver failure (ALF) and acute on chronic liver failure (ACLF). ALF is a clinical syndrome in which a previously healthy child develops rapid-onset hepatic dysfunction, and becomes critically ill with multiple organ dysfunction within days. ACLF, by contrast, is generally described as an acute decompensation of pre-existing chronic liver disease (CLD) brought on by a precipitating event, with higher risk of mortality. Children with ALF and ACLF receive multidisciplinary care in pediatric intensive care units (ICUs) due to multiple organ system involvement and high risk of decompensation in these patients. The care of these patients requires a holistic approach that addresses the complex interplay between hepatic and extra-hepatic organ systems. This review will define and describe ALF and ACLF in the pediatric population, and outline the effects of ALF and ACLF on individual organ systems with diagnostic and management considerations in the ICU while awaiting liver transplantation.
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Affiliation(s)
- Leslie A Mataya
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Vijay Srinivasan
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Elizabeth B Rand
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Pediatrics, University of Pennsylvania, Philadelphia, PA, USA
| | - Alicia M Alcamo
- Division of Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, USA
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7
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4-methylpyrazole protects against acetaminophen-induced acute kidney injury. Toxicol Appl Pharmacol 2020; 409:115317. [PMID: 33157119 DOI: 10.1016/j.taap.2020.115317] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 10/27/2020] [Accepted: 10/31/2020] [Indexed: 12/14/2022]
Abstract
Acetaminophen (APAP) hepatotoxicity is the most common cause of acute liver failure in the United States, and while a significant percentage of APAP overdose patients develop kidney injury, molecular mechanisms involved in APAP-induced nephrotoxicity are relatively unknown. We have shown that 4-methylpyrazole (4MP, Fomepizole) protects against APAP-induced liver injury by inhibiting reactive metabolite formation through Cyp2E1, and analysis of data from APAP overdose patients indicated that kidney dysfunction strongly correlated with severe liver injury. Since Cyp2E1 is also expressed in the kidney, this study explored protection by 4MP against APAP-induced nephrotoxicity. Male C57BL/6 J mice were treated with either 300 or 600 mg/kg APAP with or without 4MP for 2, 6 or 24 h, followed by measurement of APAP metabolism and tissue injury. Interestingly, levels of APAP and its non-oxidative metabolites were significantly higher in kidneys when compared to the liver. APAP-protein adducts were present in both tissues within 2 h, but were absent in kidney mitochondria, unlike in the liver. While GSH depletion was seen in both tissues, activation of c-jun N-terminal kinase and its translocation to the mitochondria, which is a critical feature of APAP-induced liver injury, was not detected in the kidney. Treatment with 4MP attenuated APAP oxidative metabolite generation, GSH depletion as well as kidney injury indicating its potential use in protection against APAP-induced nephrotoxicity. In conclusion, since reactive metabolite formation seems to be common in both liver and kidney, 4MP mediated inhibition of Cyp2E1 protects against APAP-induced nephrotoxicity. However, downstream mechanisms of APAP-induced nephrotoxicity seem distinct from the liver.
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Hamzagic N, Nikolic T, Jovicic BP, Canovic P, Jacovic S, Petrovic D. Acute Kidney Damage: Definition, Classification and Optimal Time of Hemodialysis. SERBIAN JOURNAL OF EXPERIMENTAL AND CLINICAL RESEARCH 2019. [DOI: 10.1515/sjecr-2017-0050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Acute damage to the kidney is a serious complication in patients in intensive care units. The causes of acute kidney damage in these patients may be prerenal, renal and postrenal. Sepsis is the most common cause of the development of acute kidney damage in intensive care units. For the definition and classification of acute kidney damage in clinical practice, the RIFLE, AKIN and KDIGO classifications are used. There is a complex link between acute kidney damage and other organs. Acute kidney damage is induced by complex pathophysiological mechanisms that cause acute damage and functional disorders of the heart (acute heart failure, acute coronary syndrome and cardiac arrhythmias), brain (whole body cramps, ischaemic stroke and coma), lung (acute damage to the lung and acute respiratory distress syndrome) and liver (hypoxic hepatitis and acute hepatic insufficiency). New biomarkers, colour Doppler ultrasound diagnosis and kidney biopsy have significant roles in the diagnosis of acute kidney damage. Prevention of the development of acute kidney damage in intensive care units includes maintaining an adequate haemodynamic status in patients and avoiding nephrotoxic drugs and agents (radiocontrast agents). The complications of acute kidney damage (hyperkalaemia, metabolic acidosis, hypervolaemia and azotaemia) are treated with medications, intravenous solutions, and therapies for renal function replacement. Absolute indications for acute haemodialysis include resistant hyperkalaemia, severe metabolic acidosis, resistant hypervolaemia and complications of high azotaemia. In the absence of an absolute indication, dialysis is indicated for patients in intensive care units at stage 3 of the AKIN/KDIGO classification and in some patients with stage 2. Intermittent haemodialysis is applied for haemodynamically stable patients with severe hyperkalaemia and hypervolaemia. In patients who are haemodynamically unstable and have liver insufficiency or brain damage, continuous modalities of treatment for renal replacement are indicated.
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Affiliation(s)
- Nedim Hamzagic
- Center of Hemodialysis , Medical Center Tutin , Tutin , Serbia
| | - Tomislav Nikolic
- Clinic of Urology, Nephrology and Dialysis , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Biljana Popovska Jovicic
- Clinic of Infectious Diseases , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Petar Canovic
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
| | - Sasa Jacovic
- Medicines and Medical Devices Agency of Serbia , Belgrade , Serbia
| | - Dejan Petrovic
- Clinic of Urology, Nephrology and Dialysis , Clinical center Kragujevac , Kragujevac , Serbia
- Faculty of Medical Sciences , University of Kragujevac , Kragujevac , Serbia
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9
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Yan Q, Zhao XM, Deng LJ, Fang YX, Lin JJ, Li AM. Human hepatocellular adenoma as a promising cell source for bioartificial liver systems. Exp Ther Med 2019; 18:1357-1365. [PMID: 31316625 DOI: 10.3892/etm.2019.7673] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 03/23/2019] [Indexed: 12/26/2022] Open
Abstract
The present study assessed human hepatocellular adenoma (HCA) as a potential source of biological material for bioartificial liver (BAL) systems. The histological characteristics of HCA tissues from 8 patients were examined using hematoxylin and eosin staining. The glycogen synthesis capacity of HCA cells was assessed using Periodic Acid-Schiff (PAS) staining and the expression of genes involved in liver function were examined using immunohistochemical staining (IHC) and reverse transcription-quantitative PCR analysis. Primary cells from HCA tissues were subsequently isolated and cultured in vitro. Cells within HCA tissues from 8 patients exhibited a polygonal shape, similar to that of cells in adjacent normal liver tissues. PAS staining of HCA tissues indicated the capacity of these cells to synthesize and store glycogen. Furthermore, IHC and PCR analyses revealed that the expression of liver function genes in HCA tissues were similar to those observed within normal adjacent liver tissues. Primary cells isolated from HCA tissues exhibited an irregular polygonal shape and positive in vitro growth. The current study demonstrated that HCA tissues exhibit histological and functional characteristics matching those of normal human liver tissue and may therefore be a promising alternative to hepatocytes as a source of biological material for BAL systems.
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Affiliation(s)
- Qun Yan
- Department of Gastroenterology, Longgang District People's Hospital of Shenzhen, Shenzhen, Guangdong 518116, P.R. China.,Department of Gastroenterology, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Xin-Mei Zhao
- Department of Gastroenterology, Longgang District People's Hospital of Shenzhen, Shenzhen, Guangdong 518116, P.R. China
| | - Li-Juan Deng
- Department of Gastroenterology, Zhuhai Hospital of Traditional Chinese and Western Medicine, Zhuhai, Guangdong 519000, P.R. China
| | - Yu-Xin Fang
- Department of Gastroenterology, Guangdong Provincial Key Laboratory of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, P.R. China
| | - Jian-Jiao Lin
- Department of Gastroenterology, Longgang District People's Hospital of Shenzhen, Shenzhen, Guangdong 518116, P.R. China
| | - Ai-Min Li
- Department of Gastroenterology, Longgang District People's Hospital of Shenzhen, Shenzhen, Guangdong 518116, P.R. China
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10
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Abstract
Pediatric acute liver failure (PALF) is a dynamic, life-threatening condition of disparate etiology. Management of PALF is dependent on intensive collaborative clinical care and support. Proper recognition and treatment of common complications of liver failure are critical to optimizing outcomes. In parallel, investigations to identify underlying cause and the implementation of timely, appropriate treatment can be life-saving. Predicting patient outcome in the era of liver transplantation has been unfulfilling and better predictive models must be developed for proper stewardship of the limited resource of organ availability.
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Affiliation(s)
- James E Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA.
| | - Patrick McKiernan
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
| | - Robert H Squires
- Department of Pediatric Gastroenterology and Hepatology, University of Pittsburgh School of Medicine, Children's Hospital of Pittsburgh, 4401 Penn Avenue, Pittsburgh, PA 15224, USA
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11
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Mastropietro CW, Valentine KM. Medical Management of Acute Liver Failure. PEDIATRIC CRITICAL CARE 2018. [PMCID: PMC7121299 DOI: 10.1007/978-3-319-96499-7_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Pediatric acute liver failure is a rapidly progressive, life-threatening, and devastating illness in children without preexisting liver disease. Due to the rarity and heterogeneity of this syndrome, there is a significant lack of data to guide evaluation and management of this disease. Most of our practice is extrapolated from adult literature and guidelines. This leads to significant controversies in medical management of acute liver failure in children. With advances in critical care, there has been a tremendous improvement in outcomes with decreased morbidity and mortality; however, there is a dire need for more research in this field. This chapter discusses challenges as well as controversies in diagnostic evaluation and management of this rare but potentially fatal disease. Latest developments in supportive care of liver failure, including advances in the area of liver support systems, are also discussed.
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Affiliation(s)
- Christopher W. Mastropietro
- grid.257413.60000 0001 2287 3919Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN USA
| | - Kevin M. Valentine
- grid.257413.60000 0001 2287 3919Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, IN USA
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12
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Abstract
Purpose of Review Pediatric acute liver failure is a rare, complex, rapidly progressing, and life-threatening illness. Majority of pediatric acute liver failures have unknown etiology. This review intends to discuss the current literature on the challenging aspects of management of acute liver failure. Recent Findings Collaborative multidisciplinary approach for management of patients with pediatric acute liver failure with upfront involvement of transplant hepatologist and critical care specialists can improve outcomes of this fatal disease. Extensive but systematic diagnostic evaluation can help to identify etiology and guide management. Early referral to a transplant center with prompt liver transplant, if indicated, can lead to improved survival in these patients. Summary Prompt identification and aggressive management of pediatric acute liver failure and related comorbidities can lead to increased transplant-free survival and improved post-transplant outcomes, thus decreasing mortality and morbidity associated with this potential fatal condition.
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Affiliation(s)
- Heli Bhatt
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN 46202 USA
| | - Girish S. Rao
- Section of Pediatric Gastroenterology, Hepatology and Nutrition, Riley Hospital for Children, Indiana University School of Medicine, Indiana University, 705 Riley Hospital Drive, ROC 4210, Indianapolis, IN 46202 USA
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13
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Krawitz S, Lingiah V, Pyrsopoulos NT. Acute Liver Failure: Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2018; 22:243-256. [PMID: 29605064 DOI: 10.1016/j.cld.2018.01.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute liver failure is accompanied by a pathologic syndrome common to numerous different etiologies of liver injury. This acute liver failure syndrome leads to potentially widespread devastating end-organ consequences. Systemic dysregulation and dysfunction is likely propagated via inflammation as well as underlying hepatic failure itself. Decoding the mechanisms of the disease process and multisystemic involvement of acute liver failure offers potential for targeted treatment opportunities and improved clinical outcomes in this sick population.
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Affiliation(s)
- Steven Krawitz
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-534, Newark, NJ 07103, USA.
| | - Vivek Lingiah
- Department of Medicine, Division of Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-530, Newark, NJ 07103, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers New Jersey Medical School, 185 South Orange Avenue, H-536, Newark, NJ 07103, USA
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14
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Abstract
Pediatric acute liver failure is rare but life-threatening illness that occurs in children without preexisting liver disease. The rarity of the disease, along with its severity and heterogeneity, presents unique clinical challenges to the physicians providing care for pediatric patients with acute liver failure. In this review, practical clinical approaches to the care of critically ill children with acute liver failure are discussed with an organ system-specific approach. The underlying pathophysiological processes, major areas of uncertainty, and approaches to the critical care management of pediatric acute liver failure are also reviewed.
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