Prediction value of model for end-stage liver disease scoring system on prognosis in the acute on chronic liver failure patients with plasma exchange treatment. ASAIO J. 2010;56:475-478. [PMID: 20613491 DOI: 10.1097/mat.0b013e3181e6bf13]

Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis

Plasma exchange (PE) is a promising therapeutic option in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). However, the impact of PE on patient survival in these syndromes is unclear. We aimed to systematically investigate the use of PE in patients with ALF and ACLF compared with standard medical therapy (SMT). We searched PubMed/Embase/Cochrane databases to include all studies comparing PE versus SMT for patients ≥ 18 years of age with ALF and ACLF. Pooled risk ratios (RR) with corresponding 95% CIs were calculated by the Mantel-Haenszel method within a random-effect model. The primary outcome was 30-day survival for ACLF and ALF. Secondary outcomes were overall and 90-day survival for ALF and ACLF, respectively. Five studies, including 343 ALF patients (n = 174 PE vs. n = 169 SMT), and 20 studies, including 5,705 ACLF patients (n = 2,856 PE vs. n = 2,849 SMT), were analyzed. Compared with SMT, PE was significantly associated with higher 30-day (RR 1.41, 95% CI 1.06-1.87, p = 0.02) and overall (RR 1.35, 95% CI 1.12-1.63, p = 0.002) survival in ALF patients. In ACLF, PE was also significantly associated with higher 30-day (RR 1.36, 95% CI 1.22-1.52, p < 0.001) and 90-day (RR 1.21, 95% CI 1.10-1.34, p < 0.001) survival. On subgroup analysis of randomized controlled trials, results remained unchanged in ALF, but no differences in survival were found between PE and SMT in ACLF. In conclusion, PE is associated with improved survival in ALF and could improve survival in ACLF. PE may be considered in managing ALF and ACLF patients who are not liver transplant (LT) candidates or as a bridge to LT in otherwise eligible patients. Further randomized controlled trials are needed to confirm the survival benefit of PE in ACLF.

A single center retrospective study: Comparison between centrifugal separation plasma exchange with ACD-A and membrane separation plasma exchange with heparin on acute liver failure and acute on chronic liver failure

The purpose of this retrospective study is to compare the efficacy and safety of the centrifugal separation therapeutic plasma exchange (TPE) using citrate anticoagulant (cTPEc) with membrane separation TPE using heparin anticoagulant (mTPEh) in liver failure patients. The patients treated by cTPEc were defined as cTPEc group and those treated by mTPEh were defined as mTPEh group, respectively. Clinical characteristics were compared between the two groups. Survival analyses of two groups and subgroups classified by the model for end-stage liver disease (MELD) score were performed by Kaplan-Meier method and were compared by the log-rank test. In this study, there were 51 patients in cTPEc group and 18 patients in mTPEh group, respectively. The overall 28-day survival rate was 76% (39/51) in cTPEc group and 61% (11/18) in mTPEh group (P > .05). The 90-day survival rate was 69% (35/51) in cTPEc group and 50% (9/18) in mTPEh group (P > .05). MELD score = 30 was the best cut-off value to predict the prognosis of patients with liver failure treated with TPE, in mTPEh group as well as cTPEc group. The median of total calcium/ionized calcium ratio (2.84, range from 2.20 to 3.71) after cTPEc was significantly higher than the ratio (1.97, range from 1.73 to 3.19) before cTPEc (P < .001). However, there was no significant difference between the mean concentrations of total calcium before cTPEc and at 48 h after cTPEc. Our study concludes that there was no statistically significant difference in survival rate and complications between cTPEc and mTPEh groups. The liver failure patients tolerated cTPEc treatment via peripheral vascular access with the prognosis similar to mTPEh. The prognosis in patients with MELD score < 30 was better than in patients with MELD score ≥ 30 in both groups. In this study, the patients with acute liver failure (ALF) and acute on chronic liver failure (ACLF) treated with cTPEc tolerated the TPE frequency of every other day without significant clinical adverse event of hypocalcemia with similar outcomes to the mTPEh treatment. For liver failure patients treated with cTPEc, close clinical observation and monitoring ionized calcium are necessary to ensure the patients' safety.

Non-Invasive Serum Biomarkers for the Diagnosis of Cirrhosis in Patients with Autoimmune Hepatitis (AIH) and AIH-Primary Biliary Cholangitis Overlap Syndrome (AIH-PBC): Red Cell Distribution Width to Platelet Ratio (RPR) Yielded the Most Promising Result

Several serum biomarkers for fibrosis assessment have been proposed in various liver diseases, but in autoimmune hepatitis (AIH) or overlap with primary biliary cholangitis (PBC; AIH-PBC) patients, the data are scarce. This retrospective cross-sectional study was conducted to validate six non-invasive biomarkers in the diagnosis of cirrhosis (F4 fibrosis) in such patients. We included adult patients diagnosed with AIH or AIH-PBC overlap syndrome who underwent a liver biopsy between 2011 and 2021. Laboratory data were collected to calculate the following scores: red cell distribution width to platelet ratio (RPR), aspartate aminotransferase/platelet ratio index (APRI), Fibrosis-4 index (FIB-4), aspartate aminotransferase (AST) to alanine aminotransferase (ALT) ratio (AAR), neutrophil-to-lymphocyte ratio (NLR), and lymphocyte-to-platelet ratio (LPR). A total of 139 patients were eligible (111 AIH and 28 AIH-PBC). The prevalence of cirrhosis was 35.3% (36% in AIH and 32.1% in AIH-PBC). The AUROCs of the RPR, FIB-4, APRI, AAR, LPR, and NLR in all patients were 0.742, 0.724, 0.650, 0.640, 0.609, and 0.585, respectively. RPR was significantly superior to APRI, NLR, and LPR. Moreover, RPR showed the highest AUROC (0.915) in the overlap AIH-PBC subgroup. In conclusion, RPR yielded the highest diagnostic accuracy to predict cirrhosis in AIH and AIH-PBC overlap syndrome patients, while FIB-4 was considerably optimal.

Combined Age with Mean Decrease Rates of Total Bilirubin and MELD Score as a Novel and Simple Clinical Predictor on 90-Day Transplant-Free Mortality in Adult Patients with Acute Liver Failure Undergoing Plasma Exchange: A Single-Center Retrospective Study

Background

Acute liver failure (ALF), previously known as fulminant hepatic failure, has become a common, rapidly progressive, and life-threatening catastrophic hepatic disease in intensive care unit (ICU) due to the continuous increase in drug abuse, viral infection, metabolic insult, and auto-immune cause. At present, plasma exchange (PE) is the main effective alternative treatment for ALF in ICU clinical practice, and high-volume plasma exchange (HVP) has been listed as a grade I recommendation for ALF management in the American Society for Apheresis (ASFA) guidelines. However, no existing models can provide a satisfactory performance for clinical prediction on 90-day transplant-free mortality in adult patients with ALF undergoing PE. Our study aims to identify a novel and simple clinical predictor of 90-day transplant-free mortality in adult patients with ALF undergoing PE.

Methods

This retrospective study contained adult patients with ALF undergoing PE from the Medical ICU (MICU) in the Second Affiliated Hospital of Harbin Medical University between January 2017 and December 2020. Baseline and clinical data were collected and calculated on admission to ICU before PE, including gender, age, height, weight, body mass index (BMI), etiology, total bilirubin, direct bilirubin, indirect bilirubin, prothrombin activity, model for end-stage liver disease (MELD) score, and sequential organ failure assessment (SOFA) score. Enrolled adult patients with ALF undergoing PE were divided into a survival group and a death group at discharge and 90 days on account of medical records and telephone follow-up. After each PE, decreased rates of total bilirubin and MELD score and increased rates of prothrombin activity were calculated according to the clinical parameters. In clinical practice, different patients underwent different times of PE, and thus, mean decrease rates of total bilirubin and MELD score and mean increase rate of prothrombin activity were obtained for further statistical analysis.

Results

A total of 73 adult patients with ALF undergoing 204 PE were included in our retrospective study, and their transplant-free mortality at discharge and 90 days was 6.85% (5/73) and 31.51% (23/73), respectively. All deaths could be attributed to ALF-induced severe and life-threatening complications or even multiple organ dysfunction syndrome (MODS). Most of the enrolled adult patients with ALF were men (76.71%, 56/73), with a median age of 48.77 years. Various hepatitis virus infections, unknown etiology, auto-immune liver disease, drug-induced liver injury, and acute pancreatitis (AP) accounted for 75.34%, 12.33%, 6.85%, 4.11%, and 1.37% of the etiologies in adult patients with ALF, respectively. Univariate analysis showed a significant difference in age, mean decrease rates of total bilirubin and MELD score mean increase rate of prothrombin activity, decrease rates of total bilirubin and MELD score, and increase rate of prothrombin activity after the first PE between the death group and survival group. Multivariate analysis showed that age and mean decrease rates of total bilirubin and MELD score were closely associated with 90-day transplant-free mortality in adult patients with ALF undergoing PE. The 90-day transplant-free mortality was 1.081, 0.908, and 0.893 times of the original value with each one-unit increase in age and mean decrease rates of total bilirubin and MELD score, respectively. The areas under the receiver operatingcharacteristic (ROC) curve of age, mean decrease rates of total bilirubin and MELD score, and the three combined were 0.689, 0.225, 0.123, and 0.912, respectively. The cut-off values of age, mean decrease rates of total bilirubin and MELD score, and the three combined were 61.50, 3.12, 1.21, and 0.33, respectively. The specificity and sensitivity of combined age with mean decrease rates of total bilirubin and MELD score for predicting 90-day transplant-free mortality in adult patients with ALF undergoing PE were 87% and 14%.

Conclusion

Combined age with mean decrease rates of total bilirubin and MELD score as a novel and simple clinical predictor can accurately predict 90-day transplant-free mortality in adult patients with ALF undergoing PE, which is worthy of application and promotion in clinical practice, especially in the identification of potential transplant candidates.

Efficiency and safety of total plasma exchange in critically ill cirrhotic patients with acute on chronic liver failure: A pilot study

BACKGROUND AND AIMS

Treatment of patients with acute on chronic liver failure (ACLF) admitted to the ICU is very limited. The aim of this pilot study was to evaluate the efficiency on liver function and safety of therapeutic plasma exchange (TPE) in critically ill cirrhotic patients admitted with ACLF in a liver ICU.

METHODS

This is a prospective cohort of patients with ACLF grade > 2 treated by TPE admitted to the ICU that was matched to a control group. TPE was performed using a plasma filter (TPE2000, BAXTER®) on a CRRT machine (Prismaflex®, Baxter®). Ratio and type of fluid replacement were 50 % with 5 % albumin solution followed by 50 % with fresh frozen plasma.

RESULTS

Seven patients with a mean age of 50.6 ± 7.8 years (all males) and 14 controls matched to age, sex, etiology and cause of decompensation were recruited. At ICU admission, mean MELD score was 39.1 ± 2.7, mean SOFA score was 11.6 ± 5.2 and mean CLIF SOFA score was 12.9 ± 2.6. The grade of ACLF was 3 for 3 patients (42.9 %) and 2 for 4 patients (57.1 %). The TPE group had significantly higher levels of bilirubin (392.3 ± 117.1μmol/l vs. 219 ± 185μmol/l , p = 0.04), and INR values (5.7 ± 3.4 vs. 3.5 ± 0.9, p < 0.005) compared to the control group. Patient survival was respectively 28.6 % and 14.3 % at 30 and 90 days in the TPE group and 35.7 % and 7.14 % in the control group respectively (HR: 1 (95 % CI 0.19- 5.2; p = 1). One patient in the TPE group had a liver transplantation 13 days after admission to ICU and is still alive and none in the control group. Two (28.6 %) patients died from complications related to the double lumen catheter used for TPE.

CONCLUSION

This pilot study of TPE in patients with ACLF grade 2 and 3 showed a marked but transient improvement in liver function tests. TPE worth to be evaluated in large trials in ACLF patients, with a liver transplant project, and less organ failure.

Therapeutic plasma-exchange improves short-term, but not long-term, outcomes in patients with acute-on-chronic liver failure: A propensity score-matched analysis

BACKGROUND

Acute-on-chronic liver failure (ACLF) is associated with a high short-term mortality rate in the absence of liver transplantation. The role of therapeutic plasma exchange (TPE) in improving the outcomes of ACLF and acute decompensation (AD) is unclear. In this retrospective analysis, we aimed to determine the impact of TPE on mortality in patients with ACLF.

METHODS

ACLF patients receiving TPE with standard medical treatment (SMT) were propensity score matched (PSM) with those receiving SMT alone (1:1) for sex, grades of ACLF, CLIF C ACLF scores, and the presence of hepatic encephalopathy. The primary outcomes assessed were mortality at 30 and 90 days. Survival analysis was performed using Kaplan Meier survival curves.

RESULTS

A total of 1151 patients (ACLF n = 864 [75%], AD [without organ failure] n = 287 [25%]) were included. Of the patients with ACLF (n = 864), grade 1, 2, and 3 ACLF was present in 167 (19.3%), 325 (37.6%), and 372 (43.0%) patients, respectively. Thirty-nine patients received TPE and SMT, and 1112 patients received only SMT. On PSM analysis, there were 38 patients in each group (SMT plus TPE vs SMT alone). In the matched cohort, the 30-days mortality was lower in the TPE arm compared to SMT (21% vs 50%, P = .008), however, the 90-day mortality was not significantly different between the two groups (36.8% vs 52.6%, P = .166); HR, 0.82 (0.44-1.52), P = .549.

CONCLUSION

TPE improves short-term survival in patients with ACLF, but has no significant impact on long-term outcomes. Randomized control trials are needed to obtain a robust conclusion in this regard.

Liver replacement therapy with extracorporeal blood purification techniques current knowledge and future directions

Clinically, it is highly challenging to promote recovery in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). Despite recent advances in understanding the underlying mechanisms of ALF and ACLF, standard medical therapy remains the primary therapeutic approach. Liver transplantation (LT) is considered the last option, and in several cases, it is the only intervention that can be lifesaving. Unfortunately, this intervention is limited by organ donation shortage or exclusion criteria such that not all patients in need can receive a transplant. Another option is to restore impaired liver function with artificial extracorporeal blood purification systems. The first such systems were developed at the end of the 20^th century, providing solutions as bridging therapy, either for liver recovery or LT. They enhance the elimination of metabolites and substances that accumulate due to compromised liver function. In addition, they aid in clearance of molecules released during acute liver decompensation, which can initiate an excessive inflammatory response in these patients causing hepatic encephalopathy, multiple-organ failure, and other complications of liver failure. As compared to renal replacement therapies, we have been unsuccessful in using artificial extracorporeal blood purification systems to completely replace liver function despite the outstanding technological evolution of these systems. Extracting middle to high-molecular-weight and hydrophobic/protein-bound molecules remains extremely challenging. The majority of the currently available systems include a combination of methods that cleanse different ranges and types of molecules and toxins. Furthermore, conventional methods such as plasma exchange are being re-evaluated, and novel adsorption filters are increasingly being used for liver indications. These strategies are very promising for the treatment of liver failure. Nevertheless, the best method, system, or device has not been developed yet, and its probability of getting developed in the near future is also low. Furthermore, little is known about the effects of liver support systems on the overall and transplant-free survival of these patients, and further investigation using randomized controlled trials and meta-analyses is needed. This review presents the most popular extracorporeal blood purification techniques for liver replacement therapy. It focuses on general principles of their function, and on evidence regarding their effectiveness in detoxification and in supporting patients with ALF and ACLF. In addition, we have outlined the basic advantages and disadvantages of each system.

Value of extracorporeal artificial liver support in pediatric acute liver failure: A single-center experience of over 10 years

PURPOSE

Acute liver failure (ALF) is a life-threatening disease characterized by rapid-onset liver dysfunction, coagulopathy, and encephalopathy in patients without chronic liver disease. Today, the combined application of continuous veno-venous hemodiafiltration (CVVHDF) and plasma exchange (PEX), which are forms of supportive extracorporeal therapy (SECT), with conventional liver therapy in ALF is recommended. This study aims to retrospectively analyze the effects of combined SECT in pediatric patients with ALF.

MATERIALS AND METHODS

We retrospectively analyzed 42 pediatric patients, followed in the liver transplantation intensive care unit. The patients had ALF and received PEX supportive therapy with combined CVVHDF. The biochemical lab values of the results for the patients before the first combined SECT and after the last combined SECT were analyzed comparatively.

RESULTS

Of the pediatric patients included in our study, 20 were girls and 22 were boys. Liver transplantation was performed in 22 patients, and 20 patients recovered without transplantation. After the discontinuation of combined SECT, all patients had significantly lower serum liver function test results (total bilirubin, alanine transaminase, aspartate transaminase), ammonia, and prothrombin time/international normalized ratio levels than the previous levels (p < 0.01). Hemodynamic parameters (i.e., mean arterial pressure) also improved significantly.

DISCUSSION AND CONCLUSION

Combined CVVHDF and PEX treatment significantly improved biochemical parameters and clinical findings, including encephalopathy, in pediatric patients with ALF. PEX therapy combined with CVVHDF is a proper supportive therapy for bridging or recovery.

Acute kidney injury defined by cystatin C may be superior for predicting the outcomes of liver cirrhosis with acute gastrointestinal bleeding

BACKGROUND & AIMS

Acute kidney injury (AKI) is conventionally evaluated by a dynamic change of serum creatinine (Scr). Cystatin C (CysC) seems to be a more accurate biomarker for assessing kidney function. This retrospective multicenter study aims to evaluate whether AKI re-defined by CysC can predict the in-hospital outcomes of patients with liver cirrhosis and acute gastrointestinal bleeding.

METHODS

Overall, 677 cirrhotic patients with acute gastrointestinal bleeding, in whom both Scr and CysC levels were detected at admissions, were screened. eGFR_Scr, eGFR_CysC, and eGFR_Scr-CysC were calculated. MELD-Na score and AKI were re-evaluated by CysC instead of Scr. Odds ratios (ORs) were calculated in the logistic regression analyses. The receiver operating characteristic (ROC) curve analyses were performed.

RESULTS

Univariate logistic regression analyses demonstrated that baseline Scr and CysC levels, eGFR_Scr, eGFR_CysC, eGFR_Scr-CysC, original MELD-Na score defined by Scr, MELD-Na score re-defined by CysC, and AKI re-defined by CysC, but not conventional AKI defined by Scr, were significantly associated with in-hospital death. ROC analyses showed that baseline CysC level, eGFR_Scr, eGFR_CysC, eGFR_Scr-CysC, original MELD-Na score defined by Scr, and MELD-Na score re-defined by CysC, but not baseline Scr level, could significantly predict the risk of in-hospital death.

CONCLUSIONS

AKI re-defined by CysC may be superior for predicting the in-hospital mortality of cirrhotic patients with acute gastrointestinal bleeding.

Plasma Exchange in Acute and Acute on Chronic Liver Failure

Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.

Therapeutic plasma exchange in liver failure

The multi-organ failure syndrome associated with acute and acute-on-chronic liver failure (ACLF) is thought to be mediated by overwhelming systemic inflammation triggered by both microbial and non-microbial factors. Therapeutic plasma exchange (TPE) has been proven to be an efficacious therapy in autoimmune conditions and altered immunity, with more recent data supporting its use in the management of liver failure. Few therapies have been shown to improve survival in critically ill patients with liver failure who are not expected to survive until liver transplantation (LT), who are ineligible for LT or who have no access to LT. TPE has been shown to reduce the levels of inflammatory cytokines, modulate adaptive immunity with the potential to lessen the susceptibility to infections, and reduce the levels of albumin-bound and water-bound toxins in liver failure. In patients with acute liver failure, high volume TPE has been shown to reduce the vasopressor requirement and improve survival, particularly in patients not eligible for LT. Standard volume TPE has also been shown to reduce mortality in certain sub-populations of patients with ACLF. TPE may be most favorably employed as a bridge to LT in patients with ACLF. In this review, we discuss the efficacy and technical considerations of TPE in both acute and acute-on-chronic liver failure.

Intensive care management of acute-on-chronic liver failure

The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.

Therapeutic plasma-exchange improves systemic inflammation and survival in acute-on-chronic liver failure: A propensity-score matched study from AARC

BACKGROUND AND AIM

Plasma-exchange (PE) has improved survival in acute liver failure by ameliorating systemic inflammatory response syndrome (SIRS). We evaluated PE and compared it to Fractional Plasma Separation and Adsorption (FPSA) and standard medical treatment (SMT) in a large multinational cohort of ACLF patients.

METHODS

Data were prospectively collected from the AARC database and analysed. Matching by propensity risk score (PRS) was performed. Competing risk survival analysis was done to identify deaths because of multiorgan failure (MOF). In a subset of 10 patients, we also evaluated the mechanistic basis of response to PE.

RESULTS

ACLF patients (n = 1866, mean age 44.3 ± 12.3 yrs, 93% males, 65% alcoholics) received either artificial liver support (ALS) (n = 162); [PE (n = 131), FPSA (n = 31)] or were continued on standard medical therapy (SMT) (n = 1704). In the PRS-matched cohort (n = 208, [ALS-119; PE-94, FPSA-25)], SMT-89). ALS therapies were associated with a significantly higher resolution of SIRS (Odd's ratio 9.23,3.42-24.8), lower and delayed development of MOF (Hazard ratio 7.1, 4.5-11.1), and lower liver-failure-related deaths as compared to FPSA and SMT (P < .05). PE cleared inflammatory cytokines, damage-associated molecular patterns, and endotoxin in all patients. Responders improved monocyte phagocytic function and mitochondrial respiration and increased the anti-inflammatory cytokine interleukin-1 receptor antagonist (IL-1RA) compared to non-responders. PE was associated with lesser adverse effects as compared to FPSA.

CONCLUSIONS

PE improves systemic inflammation and lowers the development of MOF in patients with ACLF. Plasma-exchange provides significant survival benefit over FPSA and could be a preferred modality of liver support for ACLF patients.

Sequential versus mono double plasma molecular adsorption system in acute-on-chronic liver failures: A propensity-score matched study

AIMS

Efficacy of sequential double plasma molecular adsorb system (DPMAS) and plasma exchange (PE) on patients with acute on chronic liver failure (ACLF) has been rarely reported. We hereby reported the outcomes of a consecutive cohort of ACLF patients treated with sequential and mono DPMAS.

METHOD

Patients treated with artificial liver support system between January 2011 and December 2016 in XiJing hospital were retrospectively reviewed. A toal of 125 ACLF patients either received mono (DPMAS only) or sequential DPMAS (PE followed by DPMAS) therapy. One to one propensity-score matching (PSM) was used to compare the effects of sequential and mono DPMAS on survival and liver function.

RESULTS

After PSM, 80 patients were included with 40 patients in each group. Sequential therapy achieved significantly higher removal of total bilirubin, alanine aminotransferase, glutamic oxaloacetic transaminase, and alkaline phosphatase than mono DPMAS, but stabilized international normalized ratio. The effects of both regimens on white blood cell, platelet, creatinine, and liver function scores were similar. Survival rate on 90-day was 50% in the sequential group and 47.5% in the mono group.

CONCLUSION

For ACLF patients, sequential DPMAS and PE seemed to have a better effect on liver function improvement but provided no survival benefit compared with mono DPMAS.

Ninety days transplant free survival with high volume plasma exchange in Wilson disease presenting as acute liver failure

OBJECTIVE

To study the efficacy and safety of high volume plasma exchange (HVPE) in Wilson disease presenting as acute liver failure (WD-ALF).

METHODS

An analysis of prospectively collected data of consecutively admitted WD-ALF cases was done and patients were divided into two groups: (i) high volume plasma exchange (HVPE) group- who received HVPE + standard medical therapy (SMT), and (ii) SMT group- received only SMT. Outcome measure was transplant free survival (TFS) at 90 days post enrollment, change in biochemical, hemodynamic parameters & incidence of organ dysfunction in HVPE as compared to SMT group, and HVPE related complications.

RESULTS

Out of the total 43 cases of WD-ALF reported in the study period, 37 were enrolled (median age 9 years, 62.2% males). All biochemical parameters and prognostic indices except blood ammonia and serum creatinine improved significantly at 72 to 96 hours after enrollment in the HVPE group. Overall, TFS at 90 days was present in 9/19 (47.3%) in HVPE group vs 3/18 (16.6%) in the SMT group (OR 2.84, 95% CI 0.91-8.8, P = .049). Kaplan Meier survival analysis revealed that HVPE group had significantly higher cumulative survival as per the Log Rank test (P = .027); median days of survival was 38 days (IQR 12-63) in HVPE group vs 14 (IQR 5-22) days in SMT group.

CONCLUSIONS

The present study indicates that in children with WD-ALF, HVPE not only acts as a bridging therapy to LT but may also improve proportion of the cases with TFS.

Red cell distribution width to platelet ratio predicts liver fibrosis in patients with autoimmune hepatitis

Noninvasive tests for the assessment of liver fibrosis are highly needed for the management of patients with autoimmune hepatitis (AIH). We aimed to investigate the accuracy of red cell distribution width to platelet ratio (RPR) in predicting liver fibrosis in AIH patients. One hundred nineteen AIH patients who underwent liver biopsy were enrolled. Liver fibrosis stage was diagnosed using the Scheuer scoring system. The diagnostic accuracy was evaluated by the area under the receiver operating characteristic curve (AUROC). RPR values in AIH patients with S2-S4 (0.10, interquartile range [IQR] 0.08-0.15), S3-S4 (0.10, IQR 0.09-0.14), and S4 (0.14, IQR 0.09-0.19) were significantly higher than patients with S0-S1 (0.07, IQR 0.06-0.08, P < .001), S0-S2 (0.08, IQR 0.06-0.12, P = .025) and S0-S3 (0.09, IQR 0.07-0.13, P = .014), respectively. The RPR was positively correlated with fibrosis stages (r = 0.412, P < .001), while aspartate transaminase to platelet ratio index (APRI) and fibrosis-4 score (FIB-4) were not significantly associated with fibrosis stages in AIH patients. The AUROCs of RPR in identifying significant fibrosis (S2-S4), advanced fibrosis (S3-S4), and cirrhosis (S4) were 0.780 (95% confidence interval [CI] 0.696-0.865), 0.639 (95% CI 0.530-0.748), and 0.724 (95% CI 0.570-0.878), respectively. The AUROCs of RPR were significantly higher than APRI and FIB-4 in diagnosing significant fibrosis, advanced fibrosis, and cirrhosis. Our study demonstrates that the RPR is a simple predictor of liver fibrosis and is superior to APRI and FIB-4 in identifying liver fibrosis in AIH patients.

Red blood cell distribution width: A promising index for evaluating the severity and long-term prognosis of hepatitis B virus-related diseases

BACKGROUND

We sought to explore the association of red blood cell distribution width (RDW) with the severity and long-term prognosis of chronic hepatitis B (CHB)-related liver diseases.

METHODS

1482 treatment-naïve CHB patients without liver cirrhosis (LC), 485 CHB-related LC (CHB-LC) patients and 325 healthy controls (HCs) were enrolled. The median follow-up time for CHB-LC patients was 33.9 months.

RESULTS

RDW was significantly higher in CHB-LC (15.0%) than CHB (12.7%) patients or HCs (12.5%). RDW was slightly higher in CHB patients than HCs (p < 0.001). Among CHB patients, the RDW of immune clearance and HBeAg negative hepatitis patients was significantly higher than immune-tolerant and low-replicative phase patients. RDW was positively correlated with Child-Turcotte-Pugh (r = 0.363; p < 0.001) and the model of end-stage liver disease scores (r = 0.218; p < 0.001). The areas under the receiver operating characteristic curve of RDW in predicting one-year, three-year, five-year and global mortality rates were 0.696, 0.668, 0.628 and 0.660, respectively. Through multivariable Cox regression analysis, RDW (p = 0.048) was identified as an independent predictor of liver-related mortality. Over a median follow-up of 33.9 months, CHB-LC patients with RDW ≥ 15.1% had significantly higher liver-related mortality than RDW < 15.1% patients (18.8% vs. 8.6%; p = 0.002).

CONCLUSIONS

RDW is positively associated with the severity of CHB and can independently predict the long-term prognosis of CHB-LC patients.

Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review

BACKGROUND

Acute liver failure (ALF) and acute-on-chronic liver (ACLF) carry high short-term mortality rate, and may result from a wide variety of causes. Plasma exchange has been shown in a randomized control trial to improve survival in ALF especially in patients who did not receive a liver transplant. Other cohort studies demonstrated potential improvement in survival in patients with ACLF.

AIM

To assess utility of plasma exchange in liver failure and its effect on mortality in patients who do not undergo liver transplantation.

METHODS

Databases MEDLINE via PubMed, and EMBASE were searched and relevant publications up to 30 March, 2019 were assessed. Studies were included if they involved human participants diagnosed with liver failure who underwent plasma exchange, with or without another alternative non-bioartificial liver assist device.

RESULTS

Three hundred twenty four records were reviewed, of which 62 studies were found to be duplicates. Of the 262 records screened, 211 studies were excluded. Fifty-one articles were assessed for eligibility, for which 7 were excluded. Twenty-nine studies were included for ALF only, and 9 studies for ACLF only. Six studies included both ALF and ACLF patients. A total of 44 publications were included. Of the included publications, 2 were randomized controlled trials, 14 cohort studies, 12 case series, 16 case reports. All of three ALF studies which looked at survival rate or survival days reported improvement in outcome with plasma exchange. In two out of four studies where plasma exchange-based liver support systems were compared to standard medical treatment (SMT) for ACLF, a biochemical improvement was seen. Survival in the non-transplanted patients was improved in all four studies in patients with ACLF comparing plasma exchange vs SMT. Using the aforementioned studies, plasma exchange based therapy in ACLF compared to SMT improved survival in non-transplanted patients at 30 and 90-d with a pooled OR of 0.60 (95%CI 0.46-0.77, P < 0.01).

CONCLUSION

The level of evidence for use of high volume plasma exchange in selected ALF cases is high. Plasma exchange in ACLF improves survival at 30-and 90-d in non-transplanted patients. Further well-designed randomized control trials will need to be carried out to ascertain the optimal duration and amount of plasma exchange required and assess if the use of high volume plasma exchange can be extrapolated to patients with ACLF.

Red blood cell distribution width for predicting significant liver inflammation in patients with autoimmune hepatitis

BACKGROUND

Red blood cell distribution width (RDW) was reported to be associated with the severity of liver diseases. We aimed to investigate the association between RDW and severity of liver inflammation in autoimmune hepatitis (AIH).

PATIENTS AND METHODS

Ninety-two consecutive AIH patients who underwent liver biopsy during 2016-2017 were included. Liver histology was evaluated using the Scheuer scoring system. Logistic regression analysis was used to analyze the risk factors for significant inflammation. The diagnostic accuracy was evaluated by the area under the receiver operating characteristic curve.

RESULTS

The RDW level was higher in AIH patients with significant inflammation (14.6%, interquartile range: 13.2-16.3%) than in patients with mild inflammation (13.2%, interquartile range: 12.6-13.8%). The RDW level was correlated positively with the grades of liver inflammation (r=0.356, P < 0.001). The area under the receiver operating characteristic curve of RDW in predicting significant inflammation was 0.739 (95% confidential interval: 0.634-0.843, P < 0.001), with 67.80% sensitivity and 75.76% specificity. The diagnostic performance of RDW for significant inflammation was better than alanine aminotransferase (P = 0.003) and immunoglobulin G (P = 0.049). RDW (odds ratio = 1.702, P = 0.001) was identified as an independent predictor for significant inflammation by logistic multivariable analysis.

CONCLUSION

The RDW level was correlated positively with the severity of liver inflammation in AIH patients. RDW can be a promising indicator for predicting significant liver inflammation in AIH.

Effects of therapeutic plasma exchange on liver function test and coagulation parameters in acute liver failure patients

Background

Currently the treatment of choice for critical liver failure is liver transplantation. Liver failure is treated conservatively until a matching liver donor becomes available. The therapeutic plasma exchange (TPE) plays an important role as a bridge to transplantation by removing accumulated toxins from patient plasma, as well as restoring the coagulation profile.

Method

This was a retrospective study on critically ill liver disease patients who underwent TPE from January 2012 to September 2015. The data were collected for the analyses of coagulation parameters, liver function tests, renal function tests, model for end-stage liver disease (MELD) scores, mortality, and hospital stay.

Results

In the study duration, a total of 45 patients with critical liver disease underwent therapeutic plasma exchange. The TPE resulted in a statistically significant reduction in the bilirubin level, aspartate aminotransferase (AST), alanine aminotransferase (ALT), prothrombin time (PT), international normalized ratio (INR), serum ferritin level and MELD scores. Higher MELD scores in both pre- and post-TPE were associated with higher mortality during the hospital stay.

Conclusion

The TPE is safe and well-tolerated, and it improves coagulation profile and liver function tests in critically ill liver disease patients, but the overall survival remains low.

Serum Cystatin C Predicts Mortality in HBV-Related Decompensated Cirrhosis

Background

Some studies have reported that renal dysfunction is associated with poor prognosis in cirrhotic patients. Serum cystatin C (CysC) is an accurate biomarker for early renal dysfunction. This study aimed to assess the prognostic value of serum CysC levels in patients with hepatitis B virus-related decompensated cirrhosis (HBV-DeCi).

Methods

This retrospective study included 75 subjects who had been diagnosed with HBV-DeCi. The association between serum CysC and prognosis was estimated by receiver operating characteristic curve analysis and a multivariable logistic regression model.

Results

Serum CysC levels were higher in nonsurvivors than in survivors and were positively correlated with model for end-stage liver disease (MELD) scores. In multivariate analysis, CysC and the MELD score were independent prognostic factors in all HBV-DeCi patients. However, only serum CysC was an independent factor predicting mortality in patients with normal creatinine levels.

Conclusions

These data suggest that high serum CysC levels can be considered an independent biomarker of 3-month mortality in patients with HBV-DeCi.

Prognostic factors and treatment effect of standard-volume plasma exchange for acute and acute-on-chronic liver failure: A single-center retrospective study

Patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) have a high risk of mortality. Few studies have reported prognostic factors for patients receiving plasma exchange (PE) for liver support. We conducted a retrospective analysis using data of 55 patients with severe ACLF (n = 45) and ALF (n = 10) who received standard-volume PE (1-1.5 plasma volume) in the ICU. Hepatitis B virus infection accounts for the majority of ACLF (87%) and ALF (50%) patients. PE significantly improved the levels of total bilirubin, prothrombin time and liver enzymes (P<0.05). Thirteen ACLF patients (29%) and one ALF patient (10%) underwent liver transplantation. Two ALF patients (20%) recovered spontaneously without transplantation. The overall in-hospital survival rates for ACLF and ALF patients were 24% and 30%, and the transplant-free survival rates were 0% and 20%, respectively. For the 14 transplanted patients, the one-year survival rate was 86%. Multivariate analysis showed that pre-PE hemoglobin (P = 0.008), post-PE hemoglobin (P = 0.039), and post-PE CLIF-C ACLF scores (P = 0.061) were independent predictors of survival in ACLF. The post-PE CLIF-C ACLF scores ≥59 were a discriminator predicting the in-hospital mortality (area under the curve = 0.719, P = 0.030). Cumulative survival rates differed significantly between patients with CLIF-C ACLF scores ≤ 58 and those with CLIF-C ACLF scores ≥ 59 after PE (P< 0.05). The findings suggest that PE is mainly a bridge for liver transplantation and spontaneous recovery is exceptional even in patients treated with PE. A higher improvement in the post-PE CLIF-C ACLF score is associated with a superior in-hospital survival rate.

Therapeutic plasma exchange: A prospective randomized trial to evaluate 2 strategies in patients with liver failure

OBJECTIVE

To compare two means of performing therapeutic plasma exchange (TPE) in patients with liver failure.

METHOD

This open-label monocentric randomized trial, conducted in a single prestigious general healthcare facility, recruited liver failure patients with an indication to receive artificial liver support therapy for TPE. All patients underwent TPE procedures and were administered in a random sequence: heparin-free or systemic heparinization with unfractionated heparin. The primary endpoint was completion of TPE sessions, and the secondary endpoints included the safety and efficacy.

RESULTS

In the period of the studying, there were 164 patients being recruited in and underwent total of 398 randomized TPEs: 168 with unfractionated heparin and 230 with heparin-free. In unfractionated heparin group, there were 3 cases (1.79%) being interrupted due to uncontrollable intraoperative pulmonary hemorrhages and gastrointestinal bleeding. In heparin-free group, 228 (99.13%) were completed successfully and 2 of them (0.87%) were switched from heparin-free to unfractionated heparin eventually. No significant differences were found between the two groups for either RRs or IRs (P > 0.05).

CONCLUSION

Heparin-free regimen is feasible and safer than systemic heparinization with unfractionated heparin in the process of TPEs in patients with liver failure.

Therapeutic plasma exchange versus double plasma molecular absorption system in hepatitis B virus-infected acute-on-chronic liver failure treated by entercavir: A prospective study

BACKGROUND

Therapeutic plasma exchange (TPE) and double plasma molecular absorption system (DPMAS) were two extracorporeal liver support systems. Few studies compared their efficacy profile.

OBJECTIVE

This study was to compare the efficacy of TPE and DPMAS on acute-on-chronic liver failure (ACLF) caused by hepatitis B virus (HBV-ACLF).

METHODS

60 HBV-ACLF patients were enrolled and prospectively studied. All patients received entecavir therapy, and were assigned to TPE group (n = 33) and DPMAS group (n = 27). Primary end-points were the effects of TPE and DPMAS on liver function and serum inflammatory markers.

RESULTS

Serum procalcitonin, interleukin (IL)-6, and high sensitive C-reactive protein (hsCRP) were significantly elevated in patients with HBV-ACLF. TPE achieved significantly higher removal rates of total bilirubin (TBIL, P = .002), direct bilirubin (DBIL, P = .006), and hsCRP (P = .010) than DPMAS, but DPMAS displayed lower loss rate of albumin (P = .000). TPE and DPMAS resulted in similarly increased serum IL-6 levels and comparable 12-week survivals (P > .05). Multivariate analysis showed that hospital stay (Relative Risk [RR]: 1.062, 95% Confidence Interval [CI]: 1.011-1.115, P = .016), prothrombin time (RR: 1.346, 95% CI: 1.077-1.726, P = .010), and international normalized ratio (RR: 0.013, 95% CI: 0.006-0.788, P = .041) were independent predictors for 12-week survival. Both TPE and DPMAS treatments were well-tolerated.

CONCLUSION

Compared to DPMAS, TPE was more efficient in eliminating TBIL, DBIL, and hsCRP, but it was associated with higher loss rate of albumin. TPE and DPMAS were similar in improving 12-week survivals in HBV-ACLF.

New concepts in acute-on-chronic liver failure: Implications for liver transplantation

Acute-on-chronic liver failure (ACLF) is a recently defined syndrome that occurs frequently in patients with cirrhosis and is associated with a poor short-term prognosis. Currently, management of patients with ACLF is mainly supportive. Despite medical progress, this syndrome frequently leads to multiorgan failure, sepsis, and, ultimately, death. The results of attempts to use liver transplantation (LT) to manage this critical condition have been poorly reported but are promising. Currently, selection criteria of ACLF patients for LT, instructions for prioritization on the waiting list, and objective indicators for removal of ACLF patients from the waiting list in cases of clinical deterioration are poorly defined. Before potential changes can be implemented into decisional algorithms, their effects, either on the benefits to individual patients or on global transplant outcomes, should be carefully evaluated using objective longterm endpoints that take into account ethical considerations concerning LT. Liver Transplantation 23 234-243 2017 AASLD.

Development and validation of a prognostic nomogram for acute-on-chronic hepatitis B liver failure

BACKGROUND AND AIM

Determining individual risk of short-term mortality in patients with acute-on-chronic hepatitis B liver failure (ACHBLF) is a difficult task. We aimed to develop and externally validate a prognostic nomogram for ACHBLF patients.

METHODS

The nomogram was built to estimate the probability of 30-day, 60-day, 90-day, and 60-month survival based on an internal cohort of 246 patients with ACHBLF. The predictive accuracy and discriminative ability of nomogram were determined by a concordance index (C-index), calibration curve, and time-dependent receiver operating characteristics (tdROC), comparing with model for end-stage liver disease (MELD) score. The results were validated using bootstrap resampling and an external cohort of 138 patients. Furthermore, we plotted decision curves to evaluate the clinical usefulness of nomogram.

RESULTS

Independent factors derived from multivariable Cox analysis of training cohort to predict mortality were age, total bilirubin, serum sodium, and prothrombin activity, which were all assembled into nomogram. The calibration curves for probability of survival showed optimal agreement between nomogram prediction and actual observation. The C-index of nomogram was higher than that of MELD score for predicting survival (30-day, 0.809 vs 0.717, P < 0.001; 60-day, 0.792 vs 0.685, P < 0.001; 90-day, 0.779 vs 0.678, P < 0.001; 6-month, 0.781 vs 0.677, P < 0.001). Additionally, tdROC and decision curves also showed that nomogram was superior to MELD score. The results were confirmed in validation cohort.

CONCLUSIONS

The prognostic nomogram provided an individualized risk estimate of short-term survival in patients with ACHBLF, offering to clinicians to improve their abilities to assess patient prognosis.

Serum C-reactive protein predicts early mortality in hospitalized patients with HBV-related decompensated cirrhosis

The serum C-reactive protein (CRP) is an inflammatory marker. The aim of the present study was to elucidate whether CRP could serve as a potential surrogate marker for 30-day mortality in hospitalized patients with HBV-related decompensated cirrhosis (HBV-DeCi).This was a retrospective cohort study that included 140 patients with HBV-DeCi. All patients were followed up for 1-month. A panel of clinical and biochemical variables were analyzed for potential associations with outcomes using multiple regression models.The serum CRP was significantly higher in nonsurviving patients than in surviving patients. Multivariate analysis demonstrated that CRP levels (odds ratio: 1.047, P = 0.002) and the model for end-stage liver disease score (odds ratio: 1.370, P = 0.001) were independent predictors for mortality.Serum CRP is a simple marker that may serve as an additional predictor of 1-month mortality in hospitalized patients with HBV-DeCi.

Lymphocyte-monocyte ratio at admission predicts possible outcomes in patients with acute-on-chronic liver failure

BACKGROUND

The lymphocyte-monocyte ratio (LMR) in the peripheral blood is suggested to be a potential biomarker for predicting the clinical outcomes of several diseases. We aimed to evaluate the relative efficiency of LMR for predicting 3-month mortality in patients with acute-on-chronic liver failure (AoCLF).

PATIENTS AND METHODS

In this study, 74 chronic hepatitis B patients, 90 AoCLF patients, and 70 healthy controls were followed up for 4 months. The primary endpoint was 3-month in-hospital mortality. Hematological and virological parameters as well as liver biochemistry were determined using blood samples ordered upon admission. A panel of clinical and biochemical variables were analyzed for potential associations with outcomes using Cox proportional hazards and multiple regression models.

RESULTS

A significantly lower LMR was detected in AoCLF patients than in healthy controls and chronic hepatitis B groups (both P=0.001). The LMR inversely correlated with model for end-stage liver disease scores, and a lower LMR was associated with increased 3-month mortality. Multivariate analysis suggested that both LMR and model for end-stage liver disease scores were independent predictors of 3-month mortality (P<0.01).

CONCLUSION

A low LMR measured at admission is predictive of a poor prognosis in AoCLF patients.

Plasma exchange-centered artificial liver support system in hepatitis B virus-related acute-on-chronic liver failure: a nationwide prospective multicenter study in China

BACKGROUND

Plasma exchange (PE)-centered artificial liver support system reduced the high mortality rate of hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). But the data were diverse in different medical centers. The present prospective nationwide study was to evaluate the effects of PE on patients with HBV-ACLF at different stages.

METHODS

From December 2009 to December 2011, we evaluated 250 patients at different stages of HBV-ACLF from 10 major medical centers in China. All the laboratory parameters were collected at admission, before and after PE.

RESULTS

Among the 250 patients who underwent 661 rounds of PE, one-month survival rate was 61.6%; 141 (56.4%) showed improvement after PE. Variables such as age (P=0.000), levels of total bilirubin (TB, P=0.000), direct bilirubin (P=0.000), total triglycerides (P=0.000), low-density lipoprotein (P=0.022), Na+ (P=0.014), Cl- (P=0.038), creatinine (Cr, P=0.007), fibrinogen (P=0.000), prothrombin time (PT, P=0.000), white blood cell (P=0.000), platelet (P=0.003) and MELD (P=0.000) were significantly related to prognosis. Multivariate logistic regression analysis showed that age, disease stage, TB, Cr and PT levels were independent risk factors of mortality among HBV-ACLF patients.

CONCLUSIONS

PE can improve the clinical outcome of patients with HBV-ACLF. Levels of TB, Cr and PT, age and disease stage help to predict prognosis.

AST to Platelet Ratio Index Predicts Mortality in Hospitalized Patients With Hepatitis B-Related Decompensated Cirrhosis

Aspartate aminotransferase to platelet ratio index (APRI) has originally been considered as a noninvasive marker for detecting hepatic fibrosis in patients with chronic hepatitis B and C. APRI has been used for predicting liver-related mortality in patients with chronic hepatitis C virus infection or alcoholic liver disease. However, whether APRI could be useful for predicting mortality in chronic hepatitis B virus (HBV) infection remains unevaluated. This study aims to address this knowledge gap. A total of 193 hospitalized chronic HBV-infected patients (cirrhosis, n = 100; noncirrhosis, n = 93) and 88 healthy subjects were retrospectively enrolled. All patients were followed up for 4 months. Mortality that occurred within 90 days of hospital stay was compared among patients with different APRI. APRI predictive value was evaluated by univariate and multivariate regression embedded in a Cox proportional hazards model. APRI varied significantly in our cohort (range, 0.16-10.00). Elevated APRI was associated with increased severity of liver disease and 3-month mortality in hospitalized patients with HBV-related cirrhosis. Multivariate analysis demonstrated that APRI (odds ratio: 1.456, P < 0.001) and the model for end-stage liver disease score (odds ratio: 1.194, P < 0.001) were 2 independent markers for predicting mortality. APRI is a simple marker that may serve as an additional predictor of 3-month mortality in hospitalized patients with HBV-related decompensated cirrhosis.

Neutrophil-to-Lymphocyte Ratio Predicts Early Mortality in Patients with HBV-Related Decompensated Cirrhosis

Background. The neutrophil-to-lymphocyte ratio (NLR) is an inflammation index that has been shown to independently predict poor clinical outcomes. We aimed to evaluate the clinical value of NLR in the prediction of 30-day mortality in patients with HBV-related decompensated cirrhosis (HBV-DeCi). Methods. This was a retrospective cohort study that included 148 patients with HBV-DeCi. Results. An elevated NLR was associated with increased severity of liver disease and mortality within 30 days. Multivariate analysis suggested that NLR, similar to the model for end-stage liver disease (MELD) score, is an additional independent predictor of 30-day mortality (P < 0.01). Conclusion. Our results suggest that a high NLR can be considered a new independent biomarker for predicting 30-day mortality in patients with HBV-DeCi.

Advanced therapeutic strategies for HBV-related acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is increasingly recognized as a distinct clinical entity and is associated with a high short-term mortality. The most common cause of ACLF is chronic hepatitis B worldwide. Currently, there is no standardized approach for the management of ACLF and the efficacy and safety of therapeutic modalities are uncertain.

DATA SOURCES

PubMed and Web of Science were searched for English-language articles. The search criteria focused on clinical trials and observational studies on the treatment of patients with HBV-related ACLF.

RESULTS

Therapeutic approaches for ACLF in patients with chronic hepatitis B included nucleos(t)ide analogues, artificial liver support systems, immune regulatory therapy, stem cell therapy and liver transplantation. All of these therapeutic approaches have shown the potential to improve liver function and increase patients' survival rate, but most of the studies were not randomized or controlled.

CONCLUSION

Substantial challenges for the treatment of HBV-related ACLF remain and further basic research and randomized controlled clinical trials are needed.

Prognostic value of the neutrophil-to-lymphocyte ratio in patients with acute-on-chronic liver failure

OBJECTIVES

The neutrophil-to-lymphocyte ratio (NLR) is a novel inflammation index that has been shown to independently predict poor clinical outcomes. We aimed to evaluate the role of NLR in the prediction of 3-month mortality in patients with acute-on-chronic liver failure (AoCLF).

METHODS

One hundred and twenty-seven patients, including 46 patients with chronic hepatitis B (CHB), 81 with AoCLF and 58 healthy controls (HCs), were enrolled in the study. All patients were followed up for 4 months. The primary end-point was in-hospital mortality at the end of 90 days. A blood sample was collected for all subjects at admission to examine liver function, renal function, international normalised ratio, C-reactive protein and neutrophil and lymphocyte counts, and NLRs were calculated. A total of six clinical chemistry and biochemical variables were analysed for potential associations with outcomes using Cox proportional hazards and multiple regression models.

RESULTS

Acute-on-chronic liver failure patients had significantly higher NLRs on admission compared with HCs and CHB patients (all p = 0.001). Patients with elevated NLRs were associated with increased severity of liver disease and 3-month mortality rates. According to multivariate analysis, only NLR was an independent predictor for mortality (p = 0.025).

CONCLUSIONS

The NLR measured at admission can serve as an independent predictor for 3-month mortality rate in AoCLF patients.

A single-center experience of non-bioartificial liver support systems among Chinese patients with liver failure

INTRODUCTION

Liver failure is one of the most deadly, prevalent, and costly diseases worldwide. Non-bioartificial liver support systems (NBALs) have been shown to be effective in improving the clinical symptoms and laboratory parameters of patients with liver failure. The main aim of this large case series analysis was to investigate the status of NBALs and their effectiveness in improving survival in liver-failure patients.

METHODS

In this retrospective study, 460 patients with liver failure who received NBAL treatment in addition to conventional medications were compared with 422 patients who were treated with conventional medications alone. Kaplan-Meier and life table analyses were used to estimate survival rates.

RESULTS

Clinical outcomes were improved after NBAL treatment. The 30-day survival rates of subacute liver failure (SALF) patients were 63% among those who received NBALs and 21% among those who did not receive NBALs (p < 0.01). Similarly, the 30-day survival rate of acute-on-chronic liver failure (ACLF) patients who received NBALs was 47%, significantly higher than that of the non-NBAL patients (p < 0.05). The survival rates of ACLF patients with low Model for End-Stage Liver Disease (MELD) scores (MELD ≤ 20) were 64% and 40% among whom received NBALs and those who did not, respectively (p < 0.01).

CONCLUSIONS

NBAL treatment is helpful to improve the survival of patients with ALF, SALF or ACLF. ACLF patients with lower MELD scores showed improved outcomes relative to those with higher MELD scores.

Neutrophil-lymphocyte ratio: a novel predictor for short-term prognosis in acute-on-chronic hepatitis B liver failure

Acute-on-chronic hepatitis B liver failure (ACHBLF) has a poor prognosis in patients with hepatitis B virus infection. The role of the neutrophil-lymphocyte ratio (NLR), which reflects the inflammatory status of the patient before treatment, has never been studied in this setting. To investigate the predictive value of NLR in patients with ACHBLF, a retrospective cohort with 216 patients and a prospective validation cohort with 73 patients were recruited. Multivariate analyses showed that total bilirubin (TBIL), NLR, age and model for end-stage liver disease (MELD) score had prognostic significance for survival. Both NLR (0.781) and MELD score (0.744) had higher ROC curves, which differed significantly from those for age (0.615) and TBIL (0.691), but not from each other (P = 0.94). NLR ≤ 2.36 predicted lower mortality (with 91.6% sensitivity and 86.0% negative predictive value), and NLR >6.12 was a warning sign for higher mortality risk (with 90.1% specificity and 80.3% positive predictive value). These results demonstrated that pretreatment NLR was associated with the prognosis of patients with ACHBLF, and elevated NLR predicted poor outcome within 8 weeks. We suggest that NLR cut-offs of ≤ 2.36 and >6.12 are powerful markers for predicting mortality in ACHBLF.

Clinical application of elevated platelet-activating factor acetylhydrolase in patients with hepatitis B

Background

The aim of this study was to investigate the variation of platelet-activating factor acetylhydrolase (PAF-AH) in patients with various stages of hepatitis B infection and evaluate the association between PAF-AH activity and chronic severe hepatitis B (CSHB) and mortality in patients with hepatitis B.

Methods

Serum PAF-AH activity was measured in 216 patients with hepatitis B and in 152 healthy controls using an automatic biochemical analysis system. Spearman correlation was used to investigate the correlation between PAF-AH activity and other biochemical indicators. The receiver operating characteristic (ROC) curve and multivariable logistic regression analysis were used to evaluate the ability of PAF-AH activity to predict CSHB and mortality in patients with hepatitis B.

Results

The PAF-AH activities in patients with CSHB (1320 ± 481 U/L) were significantly higher than those in healthy controls and in other hepatitis B groups (all P < 0.01). In patients with hepatitis B, PAF-AH activity correlated with total bilirubin (r = 0.633), total bile acid (r = 0.559), aspartate aminotransferase (r = 0.332), apolipoprotein B (r = 0.348), high-density lipoprotein cholesterol (r = −0.493), and apolipoprotein AI (r = −0.530). The areas under the ROC curves for the ability of PAF-AH activity to predict CSHB and mortality in patients with hepatitis B were 0.881 (95% confidence interval (CI): 0.824–0.937, P < 0.001) and 0.757 (95% CI: 0.677–0.837, P < 0.001), respectively. Multivariate logistic regression analysis showed PAF-AH activity to be an independent factor predicting CSHB with an odds ratio of 1.003 (95% CI: 1.002–1.005, P < 0.001).

Conclusion

Elevated PAF-AH in patients with hepatitis B was significantly associated with liver damage. Thus, serum PAF-AH could be used as a novel indicator for predicting CSHB and mortality in patients with hepatitis B. Further, PAF-AH activity was an independent factor predicting CSHB.

Serum ferritin concentration predicts mortality in patients with hepatitis B virus-related acute on chronic liver failure

BACKGROUND AND AIMS

This study was designed to investigate the association between serum ferritin concentration (SF) and hepatitis B virus infected patients with acute-on-chronic liver failure (AoCLF). In addition, we analyzed whether SF levels are associated with mortality in AoCLF patients.

METHODS

One hundred and seventeen patients, including 46 patients with chronic hepatitis B (CHB), 71 with AoCLF, and 55 healthy controls (HCs) were enrolled in this study. All patients were followed for 4 months. In all subjects, a blood sample was collected at admission to examine liver function, renal function, international normalized ratio, and SF levels. A total of six clinical chemistry and biochemical variables (e.g., model for end-stage liver disease [MELD] score, age, levels of SF, total protein, albumin, and alanine aminotransferase) were measured and analyzed for their association with outcomes by using Cox proportional hazards and multiple regression models.

RESULTS

AoCLF patients had significantly higher SF levels at admission compared to HCs and CHB (all p = 0.001). Elevated SF levels were associated with increased severity of liver disease and 3-month mortality rate. Multivariate analysis demonstrated that SF levels and MELD score were independent predictors for mortality (both p <0.001).

CONCLUSION

The SF measured at admission may serve as an independent predictor for 3-month mortality rate in AoCLF patients.

Nucleoside analogs prevent disease progression in HBV-related acute-on-chronic liver failure: validation of the TPPM model

PURPOSE

This study aimed to evaluate the efficacy and safety of entecavir, lamivudine and telbivudine for treating patients with HBV-ACLF and to validate the Tongji prognostic predictor model (TPPM) in these patients.

METHODS

In this retrospective study, we enrolled 283 patients with HBV-ACLF (100 treated with entecavir, 98 treated with lamivudine and 85 treated with telbivudine). There were no significant differences in baseline clinical and virological characteristics among patients treated with entecavir, telbivudine or lamivudine.

RESULTS

There were no significant differences in the 4- and 12-week survival rates of entecavir-, telbivudine- and lamivudine-treated patients (79.00, 81.18 and 86.73 %, respectively, at 4 weeks; 67.00, 65.88 and 73.47 %, respectively, at 12 weeks). Patients in all three groups achieved an improvement in the model for end-stage liver disease (MELD) score. Using the Hosmer-Lemeshow test, the validation of the TPPM score for HBV-ACLF demonstrated a good degree of fit with disease prognosis. Based on this unique group of patients, the TPPM score with an AUC of 0.787 was superior to the MELD score, which had an AUC of 0.736 in the prediction of 12-week mortality. The TPPM had an AUC of 0.733, and the MELD score had an AUC of 0.672 in the prediction of 4-week mortality. Using a cutoff value of 0.22 for 12-week mortality prediction by the TPPM, the positive predictive value was 49.66 %, with a negative predictive value of 89.55 %.

CONCLUSION

Treatment with nucleoside analogs including entecavir, lamivudine and telbivudine prevented disease progression and increased the survival of patients with HBV-ACLF. Validation of the established TPPM scoring system in this study confirmed its superior predictive value for HBV-ACLF patients when compared with the MELD system.

The association between circulating oestradiol levels and severity of liver disease in males with hepatitis B virus infection

BACKGROUND

Males have a strikingly increased risk of advanced liver disease. This study was designed to investigate the association between sex hormone levels and different disease states in hepatitis B virus (HBV)-infected male patients.

METHODS

Two hundred and fifty-two male patients, including 30 with acute hepatitis B (AHB), 127 with chronic hepatitis B (CHB) and 95 with chronic severe hepatitis B (CSHB), and 48 healthy controls (HCs) were enroled in this study. All patients were followed for 4 months. The primary end point was in-hospital mortality at the end of 90 days. At study entry, a blood sample was collected from all subjects to examine liver function, renal function and sex hormone levels (serum total testosterone and oestradiol). A total of nine clinical chemistry and biochemical variables were analyzed for possible association with outcomes by using Cox proportional hazards and multiple regression models.

RESULTS

We demonstrated that in CSHB and CHB patients, oestradiol levels were significantly increased compared with HCs and AHB patients, whereas no significant differences were observed in AHB patients and HCs. All male patients had normal levels of testosterone which were not significantly different compared with those of HCs. Increased oestradiol levels were clinically associated with severe liver disease, and increased 3-month mortality rate. Multivariate analysis demonstrated that oestradiol and the model for end-stage liver disease (MELD) score were independent predictors for mortality (both P < 0.001).

CONCLUSION

Oestradiol levels are significantly increased in male patients with hepatitis B, and were associated with the severity of liver disease. Moreover, elevation of oestradiol is an independent predictive factor for the 3-month mortality rate in male patients with hepatitis B.

Liver transplantation in acute-on-chronic liver failure patients with high model for end-stage liver disease (MELD) scores: a single center experience of 100 consecutive cases

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. However, there are little published data on risk factors and outcomes of LT for ACLF.

METHODS

The objective of this study was to analyze preoperative, intraoperative, postoperative, and overall survival data on 100 consecutive cases with ACLF in order to try to determine for which patients LT are futile.

RESULTS

One hundred consecutive patients with pathology-confirmed ACLF who underwent LT from June 2004 to September 2012 were enrolled. The preoperative data showed that all patients were in a serious condition with a median high model for end-stage liver disease (MELD) score of 32, total bilirubin of 440.20 umol/L, international normalized ratio (INR) of 3.012, and at least one organ dysfunction as assessed by a Sequential Organ Failure Assessment (SOFA) score of ≥9. The patients had either deceased or a living donor LT with an overall mortality of 20%. The 1-, 3-, and 5-year cumulative survival rates were 76.8%, 75.6%, and 74.1%, respectively, and graft 1-, 3-, and 5-y accumulative survival rates were 73.3%, 72.1%, and 70.6%, respectively. However, the area under receiver operating characteristic of SOFA score, MELD score, as well as Child-Pugh score were 0.552, 0.547, and 0.547, respectively.

CONCLUSIONS

Both deceased and living donor LT are effective therapeutic options for patients with ACLF and the short- and long-term survival rates are encouraging. It is important to conduct more prospective and multi-center studies to define preoperatively which patients would benefit from LT.

Serum vitamin B12 levels as indicators of disease severity and mortality of patients with acute-on-chronic liver failure

BACKGROUND

The study was designed to investigate the association between vitamin B12 levels and patients with acute-on-chronic liver failure (AoCLF). In addition, we analyzed whether B12 is associated with mortality in the AoCLF patients.

METHODS

One hundred five patients with AoCLF and 44 healthy controls (HCs) were prospectively studied. In all subjects, a blood sample was collected at admission to examine liver function, renal function, international normalized ratio and B12 levels. A total of 9 clinical chemistry and biochemical variables were analyzed for possible association with outcomes by using Cox proportional hazards and multiple regression models.

RESULTS

AoCLF patients had significantly higher B12 levels at admission compared with HCs (AoCLF patients vs HCs, median 1218 pg/ml, mean 1736.2 pg/ml, SD, 1294.6 vs 504 pg/ml, 529.8 ± 149.8 pg/ml, P<0.001). Elevated B12 levels were associated with increased severity of liver disease and 3-month mortality rate. Multivariate analysis demonstrated that B12 levels and the model for end-stage liver disease score were independent predictors for mortality (both P<0.001).

CONCLUSION

B12 levels were significantly higher in AoCLF patients than in HCs and elevated B12 were associated with increased severity of disease. Moreover, B12 levels are an independent predicting factor for the 3-month mortality rate in AoCLF patients.

Clinical usefulness of measuring red blood cell distribution width in patients with hepatitis B

Background

Red blood cell distribution width (RDW), an automated measure of red blood cell size heterogeneity (e.g., anisocytosis) that is largely overlooked, is a newly recognized risk marker in patients with cardiovascular diseases, but its role in persistent viral infection has not been well-defined. The present study was designed to investigate the association between RDW values and different disease states in hepatitis B virus (HBV)-infected patients. In addition, we analyzed whether RDW is associated with mortality in the HBV-infected patients.

Methodology/Principal Findings

One hundred and twenty-three patients, including 16 with acute hepatitis B (AHB), 61 with chronic hepatitis B (CHB), and 46 with chronic severe hepatitis B (CSHB), and 48 healthy controls were enrolled. In all subjects, a blood sample was collected at admission to examine liver function, renal function, international normalized ratio and routine hematological testing. All patients were followed up for at least 4 months. A total of 10 clinical chemistry, hematology, and biochemical variables were analyzed for possible association with outcomes by using Cox proportional hazards and multiple regression models. RDW values at admission in patients with CSHB (18.30±3.11%, P<0.001), CHB (16.37±2.43%, P<0.001) and AHB (14.38±1.72%, P<0.05) were significantly higher than those in healthy controls (13.03±1.33%). Increased RDW values were clinically associated with severe liver disease and increased 3-month mortality rate. Multivariate analysis demonstrated that RDW values and the model for end-stage liver disease score were independent predictors for mortality (both P<0.001).

Conclusion

RDW values are significantly increased in patients with hepatitis B and associated with its severity. Moreover, RDW values are an independent predicting factor for the 3-month mortality rate in patients with hepatitis B.

Downgrading MELD improves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure

Background

High score of model for end-stage liver diseases (MELD) before liver transplantation (LT) indicates poor prognosis. Artificial liver support system (ALSS) has been proved to effectively improve liver and kidney functions, and thus reduce the MELD score. We aim to evaluate whether downgrading MELD score could improve patient survival after LT.

Methodology/Principal Findings

One hundred and twenty-six LT candidates with acute-on-chronic hepatitis B liver failure and MELD score ≥30 were included in this prospective study. Of the 126 patients, 42 received emergency LT within 72 h (ELT group) and the other 84 were given ALSS as salvage treatment. Of the 84 patients, 33 were found to have reduced MELD score (<30) on the day of LT (DGM group), 51 underwent LT with persistent high MELD score (N-DGM group). The median waiting time for a donor was 10 for DGM group and 9.5 days for N-DGM group. In N-DGM group there is a significantly higher overall mortality (43.1%) than that in ELT group (16.7%) and DGM group (15.2%). N-DGM (vs. ECT and DGM) was the only independent risk factor of overall mortality (P = 0.003). Age >40 years and the interval from last ALSS to LT >48 h were independent negative influence factors of downgrading MELD.

Conclusions/Significance

Downgrading MELD for liver transplant candidates with MELD score ≥30 was effective in improving patient prognosis. An appropriate ALSS treatment within 48 h prior to LT is potentially beneficial.