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Serper M, Chafale A, Burdzy A, Kim M, Asrani SK, Yoshino Benavente J, Gershon R, Reese PP, Schaubel DE, Boike JR, Blanco MC, Wolf MS. Cognitive function, self-management, and outcomes among liver transplant recipients: LivCog, a multicenter, prospective study. Hepatol Commun 2023; 7:e0259. [PMID: 37916863 PMCID: PMC10545399 DOI: 10.1097/hc9.0000000000000259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/13/2023] [Indexed: 11/03/2023] Open
Abstract
Liver transplantation is a life-saving option for decompensated cirrhosis. Liver transplant recipients require advanced self-management skills, intact cognitive skills, and care partner support to improve long-term outcomes. Gaps remain in understanding post-liver transplant cognitive and health trajectories, and patient factors such as self-management skills, care partner support, and sleep. Our aims are to (1) assess pre-liver transplant to post-liver transplant cognitive trajectories and identify risk factors for persistent cognitive impairment; (2) evaluate associations between cognitive function and self-management skills, health behaviors, functional health status, and post-transplant outcomes; and (3) investigate potential mediators and moderators of associations between cognitive function and post-liver transplant outcomes. LivCog is a longitudinal, prospective observational study that will enroll 450 adult liver transplant recipients and their caregivers/care partners. The duration of the study is 5 years with 24 additional months of patient follow-up. Data will be collected from participants at 1, 3, 12, and 24 months post-transplant. Limited pre-liver transplant data will also be collected from waitlisted candidates. Data collection methods include interviews, surveys, cognitive assessments, and actigraphy/sleep diary measures. Patient measurements include sociodemographic characteristics, pretransplant health status, cognitive function, physical function, perioperative measures, medical history, transplant history, self-management skills, patient-reported outcomes, health behaviors, and clinical outcomes. Caregiver measures assess sociodemographic variables, health literacy, health care navigation skills, self-efficacy, care partner preparedness, nature and intensity of care, care partner burden, and community participation. By elucidating various health trajectories from pre-liver transplant to 2 years post-liver transplant, LivCog will be able to better characterize recipients at higher risk of cognitive impairment and compromised self-management. Findings will inform interventions targeting health behaviors, self-management, and caregiver supports to optimize outcomes.
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Affiliation(s)
- Marina Serper
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adwait Chafale
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alex Burdzy
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Minjee Kim
- Department of Neurology, Division of Neurocritical Care, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
- Department of Surgery, Northwestern University Transplant Outcomes Research Collaborative (NUTORC), Comprehensive Transplant Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Sumeet K. Asrani
- Department of Medicine, Baylor University Medical Center, Baylor Scott and White, Dallas, Texas, USA
| | - Julia Yoshino Benavente
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Richard Gershon
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Peter P. Reese
- Department of Medicine, Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Justin R. Boike
- Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maria C. Blanco
- Clinical Research Computing Unit (CRCU), The Center for Clinical Epidemiology and Biostatistics (CCEB), Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Michael S. Wolf
- Department of Medicine, Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Abstract
Acute liver failure is a rare and severe consequence of abrupt hepatocyte injury, and can evolve over days or weeks to a lethal outcome. A variety of insults to liver cells result in a consistent pattern of rapid-onset elevation of aminotransferases, altered mentation, and disturbed coagulation. The absence of existing liver disease distinguishes acute liver failure from decompensated cirrhosis or acute-on-chronic liver failure. Causes of acute liver failure include paracetamol toxicity, hepatic ischaemia, viral and autoimmune hepatitis, and drug-induced liver injury from prescription drugs, and herbal and dietary supplements. Diagnosis requires careful review of medications taken, and serological testing for possible viral exposure. Because of its rarity, acute liver failure has not been studied in large, randomised trials, and most treatment recommendations represent expert opinion. Improvements in management have resulted in lower mortality, although liver transplantation, used in nearly 30% of patients with acute liver failure, still provides a life-saving alternative to medical management.
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Affiliation(s)
- R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Digestive and Liver Diseases Division, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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Anand AC, Singh P. Neurological Recovery After Recovery From Acute Liver Failure: Is it Complete? J Clin Exp Hepatol 2019; 9:99-108. [PMID: 30765942 PMCID: PMC6363962 DOI: 10.1016/j.jceh.2018.06.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/11/2018] [Indexed: 12/12/2022] Open
Abstract
Neurologic dysfunction characterised by Hepatic Encephalopathy (HE) and cerebral oedema are the most dramatic presentations of Acute Liver Failure (ALF) and signify poor outcome. Improved critical care and wider availability of emergency Liver Transplantation (LT) has improved survivability in ALF. In most cases absence of clinically overt encephalopathy after spontaneous recovery from ALF or after LT is thought to indicate complete neurologic recovery. Recent data suggests that neurologic recovery may not always be complete. Instances of persistent neurologic dysfunction as well as neuropsychiatric abnormalities are now being recognised and warrant active follow up of these patients. Although evidences irreversible neurologic damage is uncommon after ALF, neuropsychiatric disturbances are not uncommon. Complex pathogenesis is involved in neurocognitive disorders seen after many other conditions including LT that require critical care. Structural damage and persistent neurological abnormalities seen after ALF are more likely to be related to cerebral edema, raised intracranial tension and cerebral hypoxemia, while neurocognitive dysfunctions may be a part of a wider spectrum of disorders commonly seen among those who recover from any critical illness.
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Key Words
- ALF, Acute Liver Failure
- APAP, Acetaminophen
- BBB, Blood Brain Barrier
- CARS, Compensatory Anti-Inflammatory Response Syndrome
- CVVH, Continuous Veno-Venous Hemodialysis
- DAMPS, Damage Associated Molecular Pattern
- DWI, Diffusion-Weighted Imaging
- EEG, Electroencephalography
- FLAIR, Fluid-Attenuated Inversion Recovery
- HE, Hepatic Encephalopathy
- LT, Liver Transplantation
- MPT, Mitochondrial Permeability Transition
- PET, Positron Emission Tomography
- SIRS, Systemic Inflammatory Response Syndrome
- acute liver failure
- cerebral oedema
- hepatic encephalopathy
- neurological dysfunction
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Affiliation(s)
- Anil C. Anand
- Address for correspondence: Anil C. Anand, Senior Consultant, Gastroenterology & Hepatology, Indraprastha Apollo Hospital, New Delhi 110076, India.
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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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5
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Fontana RJ, Ellerbe C, Durkalski VE, Rangnekar A, Reddy KR, Stravitz T, McGuire B, Davern T, Reuben A, Liou I, Fix O, Ganger DR, Chung RT, Schilsky M, Han S, Hynan LS, Sanders C, Lee WM. Two-year outcomes in initial survivors with acute liver failure: results from a prospective, multicentre study. Liver Int 2015; 35:370-80. [PMID: 25039930 PMCID: PMC4291312 DOI: 10.1111/liv.12632] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2014] [Accepted: 07/01/2014] [Indexed: 01/01/2023]
Abstract
BACKGROUND & AIMS The long-term clinical outcomes in initial survivors with acute liver failure (ALF) are not well known. The aim of this study was to provide an overview of the 2-year clinical outcomes among initial survivors and liver transplant (LT) recipients that were alive 3 weeks after enrolment in the Acute Liver Failure Study Group (ALFSG). METHODS Outcomes in adult ALFSG patients that were enrolled between 1998 and 2010 were reviewed. RESULTS Two-year patient survival was significantly higher in the 262 LT recipients (92.4%) compared to the 306 acetaminophen (APAP) spontaneous survivors (SS) (89.5%) and 200 non-APAP SS (75.5%) (P < 0.0001). The causes of death were similar in the three groups but the time to death was significantly longer in the LT recipients (P < 0.0001). Independent predictors of 2-year mortality in the APAP group were a high serum phosphate level and patient age (c-statistic = 0.65 (0.54, 0.76)), patient age and days from jaundice to ALF onset in the non-APAP group (c-statistic = 0.69 (0.60, 0.78)), and patient age, days from jaundice, and higher coma grade in the LT recipients (c-statistic = 0.74 (0.61, 0.87)). The LT recipients were significantly more likely to be employed and have a higher educational level (P < 0.05). CONCLUSIONS Two-year outcomes in initial survivors of ALF are generally good but non-APAP patients have a significantly lower survival which may relate to pre-existing medical comorbidities. Spontaneous survivors with APAP overdose experience substantial morbidity during follow-up from ongoing psychiatric and substance abuse issues.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109–0362
| | - Caitlyn Ellerbe
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Valerie E. Durkalski
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Amol Rangnekar
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109–0362
| | - K. Rajender Reddy
- Department of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Todd Stravitz
- Department of Medicine, Virginia Commonwealth University, Richmond, VA
| | - Brendan McGuire
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | | | - Adrian Reuben
- Medical University of South Carolina, Charleston, SC
| | - Iris Liou
- University of Washington, Seattle, WA
| | - Oren Fix
- University of California San Francisco, San Francisco, CA
| | - Daniel R Ganger
- Division of Gastroenterology, Northwestern University, Chicago, Il
| | | | - Mike Schilsky
- Section of Transplantation and Immunology, Yale University, New Haven, CT
| | - Steven Han
- University of California, Los Angeles, CA
| | - Linda S. Hynan
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Corron Sanders
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - William M. Lee
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
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Rangnekar AS, Ellerbe C, Durkalski V, McGuire B, Lee WM, Fontana RJ. Quality of life is significantly impaired in long-term survivors of acute liver failure and particularly in acetaminophen-overdose patients. Liver Transpl 2013; 19:991-1000. [PMID: 23780824 PMCID: PMC3775983 DOI: 10.1002/lt.23688] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2013] [Accepted: 05/22/2013] [Indexed: 12/13/2022]
Abstract
Functional outcomes for long-term survivors of acute liver failure (ALF) are not well characterized. The aim of this prospective study was to determine health-related quality of life in long-term adult ALF survivors. Acute Liver Failure Study Group registry participants completed the Centers for Disease Control and Prevention Health-Related Quality of Life 14 and Short Form 36 (SF-36) questionnaires at 1- and/or 2-year follow-up study visits. Responses were compared among ALF subgroups and to those for available general US population controls. Among the 282 adult ALF patients, 125 had undergone liver transplantation (LT), whereas 157, including 95 acetaminophen overdose (APAP) patients and 62 non-APAP patients, were spontaneous survivors (SSs). APAP SS patients reported significantly lower general health scores and more days of impaired mental and physical health, activity limitations due to poor health, pain, depression, and anxiety in comparison with the other groups (P ≤ 0.001). There were no significant differences in coma grade or in the use of mechanical ventilation or intracranial pressure monitoring among the patient groups during their ALF hospitalization, but APAP SSs had significantly higher rates of psychiatric disease and substance abuse (P < 0.001). In comparison with the general US population, a greater proportion of the combined SS patients reported fair or poor health and ≥14 days of impaired physical/mental health and activity limitations due to poor health. In addition, a greater proportion of LT recipients reported ≥14 days of impaired physical/mental health. Similar results were observed with the SF-36 across the 3 ALF subgroups and in comparison with population controls. In conclusion, long-term adult survivors of ALF reported significantly lower quality of life scores than US population controls. Furthermore, APAP SS patients reported the lowest quality of life scores, possibly because of higher rates of premorbid psychiatric and substance abuse disorders.
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Affiliation(s)
- Amol S. Rangnekar
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109-0362
| | - Caitlyn Ellerbe
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Valerie Durkalski
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Brendan McGuire
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - William M. Lee
- Division of Digestive & Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
| | - Robert J. Fontana
- Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, MI 48109-0362
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7
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Abstract
Acute liver failure (ALF) is a condition wherein the previously healthy liver rapidly deteriorates, resulting in jaundice, encephalopathy, and coagulopathy. There are approximately 2000 cases per year of ALF in the United States. Viral causes (fulminant viral hepatitis [FVH]) are the predominant cause of ALF in developing countries. Given the ease of spread of viral hepatitis and the high morbidity and mortality associated with ALF, a systematic approach to the diagnosis and treatment of FVH is required. In this review, the authors describe the viral causes of ALF and review the intensive care unit management of patients with FVH.
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MESH Headings
- Acetylcysteine/therapeutic use
- Adult
- Brain Edema/etiology
- Brain Edema/virology
- Developing Countries
- Female
- Hepatectomy
- Hepatitis, Viral, Human/complications
- Hepatitis, Viral, Human/drug therapy
- Hepatitis, Viral, Human/prevention & control
- Herpesviridae/pathogenicity
- Humans
- Hypothermia, Induced/adverse effects
- Hypothermia, Induced/standards
- Immunocompromised Host
- Intensive Care Units
- Intubation, Intratracheal
- Liver Failure, Acute/etiology
- Liver Failure, Acute/therapy
- Liver Failure, Acute/virology
- Liver Transplantation
- Pregnancy
- Pregnancy Complications, Infectious/virology
- Prognosis
- Viral Hepatitis Vaccines/administration & dosage
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Affiliation(s)
- Saumya Jayakumar
- Faculty of Medicine and Dentistry, Division of Gastroenterology, University of Calgary, TRW Building, 3280 Hospital Drive NW, Calgary, Alberta T2N 4Z6, Canada
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8
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Taylor RM, Tujios S, Jinjuvadia K, Davern T, Shaikh OS, Han S, Chung RT, Lee WM, Fontana RJ. Short and long-term outcomes in patients with acute liver failure due to ischemic hepatitis. Dig Dis Sci 2012; 57:777-85. [PMID: 21948394 PMCID: PMC5154383 DOI: 10.1007/s10620-011-1918-1] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2011] [Accepted: 09/06/2011] [Indexed: 12/15/2022]
Abstract
AIMS The purpose of this study is to describe the incidence and presenting features of patients with acute liver failure (ALF) due to ischemic hepatitis and the prognostic factors associated with short (three-week) and long-term outcomes. METHODS Retrospective cohort analysis of adult patients enrolled in the Acute Liver Failure Study Group between 1998 and 2008 with ALF due to ischemic hepatitis. Predictors of adverse outcomes three weeks after presentation were identified by univariate and multivariate analysis. RESULTS Ischemic hepatitis accounted for 51 (4.4%) of the 1147 ALF patients enrolled. Mean age was 50 years, 63% were female, and only 31% had known heart disease before presentation. However, a cardiopulmonary precipitant of hepatic ischemia was identified in 69%. Three-week spontaneous survival was 71%, two patients (4%) underwent liver transplantation, and the remaining 13 patients (25%) died of multi-organ failure. Adverse outcomes were more frequent in subjects with higher admission phosphate levels (HR 1.3, 95% CI 1.1-1.6, P = 0.008) and in subjects with grade 3/4 encephalopathy at presentation (HR: 8.4, 95% CI 1.1-66.5, P = 0.04). Nineteen of the 28 short-term survivors (68%) were still alive at a median follow-up of 3.7 years whereas nine (32%) others had died at a median follow-up of 2 months. CONCLUSIONS A higher admission serum phosphate level and more advanced encephalopathy are associated with a lower likelihood of short-term survival of hospitalized patients with ALF due to ischemic hepatitis. Long-term outcomes are largely determined by underlying cardiovascular morbidity and mortality.
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Affiliation(s)
- Ryan M. Taylor
- Department of Internal Medicine, University of Kansas, Kansas City, KS, USA
| | - Shannan Tujios
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109-0362, USA
| | - Kartik Jinjuvadia
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109-0362, USA
| | - Timothy Davern
- California Pacific Medical Center, San Francisco, CA, USA
| | - Obaid S. Shaikh
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Steve Han
- University of California Los Angeles, Los Angeles, CA, USA
| | | | - William M. Lee
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Robert J. Fontana
- Department of Internal Medicine, University of Michigan Medical School, University of Michigan Medical Center, 3912 Taubman Center, Ann Arbor, MI 48109-0362, USA
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Sundaram V, Shaikh OS. Acute liver failure: current practice and recent advances. Gastroenterol Clin North Am 2011; 40:523-39. [PMID: 21893272 DOI: 10.1016/j.gtc.2011.06.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
ALF is an important cause of liver-related morbidity and mortality. Advances in the management of ICH and SIRS, and cardiorespiratory, metabolic, and renal support have improved the outlook of such patients. Early transfer to a liver transplant center is essential. Routine use of NAC is recommended for patients with early hepatic encephalopathy, irrespective of the etiology. The role of hypothermia remains to be determined. Liver transplantation plays a critical role, particularly for those with advanced encephalopathy. Several detoxification and BAL support systems have been developed to serve as a bridge to transplantation or to spontaneous recovery. However, such systems lack sufficient reliability and efficacy to be applied routinely in clinical practice. Hepatocyte and stem cell transplantation may provide valuable adjunctive therapy in the future.
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Affiliation(s)
- Vinay Sundaram
- Department of Medicine, Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA
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10
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Mahajan A, Lat I. Correction of coagulopathy in the setting of acute liver failure. Crit Care Nurs Clin North Am 2010; 22:315-21. [PMID: 20691382 DOI: 10.1016/j.ccell.2010.02.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The depletion of vital coagulation factors and proteins in the setting of acute liver failure (ALF) is common and multifactorial. The management of critically ill patients with ALF is difficult and requires a multidisciplinary approach to effective treatment. Critical care nurses are essential in identifying potential sources of bleeding, monitoring for transfusion reactions, and staying vigilant for medication-related adverse reactions. Prevention and treatment of bleeding disorders is a priority because ineffective therapy can lead to hazardous consequences. Correction of coagulopathy for treatment of bleeding and reversal for invasive procedures should include a multifactorial therapeutic plan emphasizing the correction of all coagulation factors. The limitations of current knowledge in effective correction should serve as a stimulus for future research.
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Affiliation(s)
- Amit Mahajan
- Department of Medicine-Section of Pulmonary and Critical Care Medicine, University of Chicago Medical Center, 5841 South, Maryland Avenue, Chicago, IL 60637, USA
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11
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Abstract
Acute liver failure (ALF) is a syndrome of diverse etiology, in which patients without previously recognized liver disease sustain a liver injury that results in rapid loss of hepatic function. Depending on the etiology and severity of the insult, some patients undergo rapid hepatic regeneration and spontaneously recover. However, nearly 60% of patients with ALF in the US require and undergo orthotopic liver transplantation or die. Management decisions made by clinicians who initially assess individuals with ALF can drastically affect these patients' outcomes. Even with optimal early management, however, many patients with ALF develop a cascade of complications often presaged by the systemic inflammatory response syndrome, which involves failure of nearly every organ system. We highlight advances in the intensive care management of patients with ALF that have contributed to a marked improvement in their overall survival over the past 20 years. These advances include therapies that limit the extent of liver injury and maximize the likelihood of spontaneous recovery and approaches to enable prevention, recognition and early treatment of complications that lead to multi-organ-system failure, the most common cause of death. Finally, we summarize the role of orthotopic liver transplantation in salvage of the most severely affected patients.
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12
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Sotil EU, Gottstein J, Ayala E, Randolph C, Blei AT. Impact of preoperative overt hepatic encephalopathy on neurocognitive function after liver transplantation. Liver Transpl 2009; 15:184-92. [PMID: 19177446 DOI: 10.1002/lt.21593] [Citation(s) in RCA: 115] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
In the current Model for End-Stage Liver Disease allocation system, patients are at risk of suffering repeated episodes of hepatic encephalopathy (HE) while waiting for an orthotopic liver transplantation (OLT); the posttransplantation impact of these episodes has not been well explored. We evaluated the cognitive function and quality of life in a group of OLT recipients (n = 25) who had suffered from overt HE prior to their procedure (HE-PreLT group) and compared their performance to that of a similar group of patients (n = 14) without overt HE (No HE-PreLT group) as well as to controls. Patients were selected from a cohort of 280 patients who underwent OLT during this period; the presence of clinical confounders excluded many of the remaining subjects. Demographic and clinical characteristics were balanced among groups. At an average of 18 months after OLT, we administered 2 neuropsychological batteries [Psychometric Hepatic Encephalopathy Score (PHES) test battery and Repeatable Battery for the Assessment of Neuropsychological Status (RBANS)]; a pyschophysiological test (critical flicker frequency); and the SF-36 quality of life score. The HE-PreLT group scored below controls in 5 of 6 cognitive domains tested by RBANS, 3 of 6 PHES subtests, as well as the critical flicker frequency test. The No HE-PreLT group scored below the controls in 1 of the 6 cognitive domains tested by RBANS. The more severe neurocognitive abnormalities seen in the HE-PreLT group did not appear to affect quality of life, as lower values than normative data were only found in 1 of the 8 SF-36 scales. In conclusion, neurocognitive abnormalities were more severe in liver transplant recipients that had suffered from overt HE prior to OLT. Prospective studies of neurocognitive function pre-OLT and post-OLT are needed to fully determine the impact of such abnormalities.
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Affiliation(s)
- Eva U Sotil
- Division of Hepatology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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13
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Abstract
Acute liver failure (ALF) is a rare but challenging clinical syndrome with multiple causes; a specific etiology cannot be identified in 15% of adult and 50% of pediatric cases. The course of ALF is variable and the mortality rate is high. Liver transplantation is the only therapy of proven benefit, but the rapidity of progression and the variable course of ALF limit its use. Currently in the United States, spontaneous survival occurs in approximately 45%, liver transplantation in 25%, and death without transplantation in 30% of adults with ALF. Higher rates of spontaneous recovery (56%) and transplantation (31%) with lower rates of death (13%) occur in children. The outcome of ALF varies by etiology, favorable prognoses being found with acetaminophen overdose, hepatitis A, and ischemia (approximately 60% spontaneous survival), and poor prognoses with drug-induced ALF, hepatitis B, and indeterminate cases (approximately 25% spontaneous survival). Excellent intensive care is critical in management of patients with ALF. Nonspecific therapies are of unproven benefit. Future possible therapeutic approaches include N-acetylcysteine, hypothermia, liver assist devices, and hepatocyte transplantation. Advances in stem cell research may allow provision of cells for bioartificial liver support. ALF presents many challenging opportunities in both clinical and basic research.
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Affiliation(s)
- William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical School, Dallas, TX 75390-8887, USA.
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14
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Affiliation(s)
- William T Merritt
- Department of Anesthesiology/Critical Care Medicine, Johns Hopkins Medicine Center for Information Services, Johns Hopkins Hospital, Baltimore, MD 21287, USA
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15
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Abstract
The transplant recipient has traded a life-threatening illness for a chronically immunosuppressed state. Subsequent anesthetic management for non-transplant surgical procedures may be challenging. The anesthesia provider must be aware of the degree of post-transplant organ dysfunction and alter anesthesia techniques accordingly. This article reviews the anesthetic concerns for patients who have undergone a variety of organ transplants.
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Affiliation(s)
- Mark T Keegan
- Division of Critical Care, Department of Anesthesiology, Mayo Clinic College of Medicine, Rochester, MN 55905, USA
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16
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Youssef WI, Mullen KD. Liver transplantation in advanced liver failure: neurologic outcome in acute versus chronic liver disease. Liver Transpl 2002; 8:937-8. [PMID: 12360437 DOI: 10.1053/jlts.2002.35925] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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