Fulminant hepatic failure: a Portuguese experience

Changing epidemiology of acute liver failure in Italy: a single-center experience over 25 years

BACKGROUND

Acute liver failure (ALF) is a rare but often lethal syndrome. In Italy, recent data on its incidence and causes are lacking. We report here the epidemiological analysis of ALF cases observed in Campania, a Southern Italian region, over the last 25 years.

METHODS

Medical records of ALF cases hospitalized from 1992 to 2018 were retrospectively analyzed.

RESULTS

Two hundred ten ALF cases occurred during 1992-2018: 103 (49%) hepatitis B virus (HBV)-related (including 5 cases also infected with Delta virus), 39 (19%) from undetermined cause, 36 (17%) drug-induced, 11 (5%) Wilson's disease-associated, 8 (4%) hepatitis A virus (HAV)-related and 12 (6%) from other causes. Separate time-periods analysis of data showed a significant progressive decrease in ALF incidence mainly attributable to a decline of HBV and other viruses etiology. Already before 2010, HAV or Delta virus-related cases have no longer been observed. No hepatitis C or E virus-related ALF was detected through the study period. A progressive decrease in frequency of ALF due to undetermined causes or drug was also evident.

CONCLUSIONS

A decrease in ALF incidence and a changing in its etiology were observed in Campania during 1992-2018. Both results were likely mainly due to 1991 introduction of HBV universal vaccination and may be considered generalizable nationwide.

Epidemiological differences of common liver conditions between Asia and the West

Liver diseases form a heterogenous group of acute and chronic disorders of varying etiologies. Not only do they result in significant morbidity and mortality, but they also lead to a marked reduction in quality of life, together with a high socioeconomic burden globally. A better understanding of their global distribution is necessary to curb the massive health-care and socioeconomic burden that they entail. Notable differences and similarities have been described between common liver disease conditions occurring in Asia and the West (Europe and North America), giving rise to the need for an updated collective appraisal of this subject. In this review, the epidemiological differences of common liver conditions, specifically acute liver failure, drug-induced liver injury, acute-on-chronic liver failure, hepatocellular carcinoma, and non-alcoholic fatty liver disease, between Asia and the West are discussed.

Systematic review: non A-E, seronegative or indeterminate hepatitis; what is this deadly disease?

BACKGROUND

A significant proportion of cases of acute liver failure (ALF) do not have an identifiable cause; so called "non A-E," "non A, non B, non C," "seronegative" or "indeterminate" hepatitis. However, this entity is clinically not well described.

AIM

To collate the known incidence and outcomes in indeterminate hepatitis. This systematic review sought to identify potential aetiologies that ought to be considered, and identify likely future objectives in classification and treatment strategies for indeterminate hepatitis.

METHODS

Literature review to determine aetiological factors, prevalence and outcomes relating to indeterminate hepatitis.

RESULTS

There is significant heterogeneity within the reported cases of indeterminate hepatitis in the literature. Some of the potential infective aetiologies which are reviewed here include: parvovirus B19 (PVB19), herpes simplex virus (HSV), Toga-Like Virus and the Annelloviridae (including SEN-V). Interestingly, this condition predominately affects middle aged women, with subacute progression of the liver failure. In addition, the prognosis of indeterminate hepatitis is poor, with reduced spontaneous survival compared with other causes of acute liver failure and increased need for emergency liver transplantation.

CONCLUSIONS

Whilst various pathological processes have been implicated in the development of indeterminate hepatitis, the specific cause remains elusive. There is an urgent need for general consensus on a specific definition and exclusion of confounding aetiologies with coordinated multicentre investigation of this rare condition to identify aetiology and develop therapies to reduce the significant mortality and need for emergency liver transplantation associated with this condition.

Epidemiology of Acute Liver Failure from a Regional Liver Transplant Center in Portugal

Background and Aims

Acute liver failure (ALF) is a rare disease with potentially high mortality rates. We aimed to study the recent epidemiology of ALF in one of the Portuguese liver transplant (LT) regions.

Methods

We assessed a retrospective cohort including 34 consecutive patients with ALF admitted to the intensive care unit (ICU) of Curry Cabral Hospital (Lisbon, Portugal) between October 2013 and December 2016.

Results

The median age (IQR) was 49 (31-67) years, and 21 (62%) of the cohort were female. Non-paracetamol etiologies were found in 29 patients (85%). On ICU admission, grade 3-4 hepatic encephalopathy developed in 10 patients (29%); invasive mechanical ventilation, vasopressors, and renal replacement therapy were required for 8 (24%), 7 (21%), and 5 (15%) of the patients, respectively; the King's College criteria (KCC) were fulfilled by 16 patients (47%). Of the 15 (44%) nontransplanted patients, 11 (73%) died during their hospital stay. Of the 19 (56%) transplanted patients, 4 (21%) died during their hospital stay. KCC were not associated with hospital mortality (p = 0.97), but they were significantly associated with LT (p = 0.008).

Conclusions

In a Portuguese cohort of patients with ALF, non-paracetamol etiologies were predominant. Hospital mortality was much lower amongst transplanted patients.

Acute liver failure: An up-to-date approach

Acute liver failure is a rare but potentially devastating disease. Throughout the last few decades, acute liver failure outcomes have been improving in the context of the optimized overall management. This positive trend has been associated with the earlier recognition of this condition, the improvement of the intensive care unit management, and the developments in emergent liver transplantation. Accordingly, we aimed to review the current diagnostic and therapeutic approach to this syndrome, especially in the intensive care unit setting.

Changing etiology of liver failure in 3,916 patients from northern China: a 10-year survey

PURPOSE

To investigate the etiological characteristics of patients with liver failure in the past 10 years.

METHODS

Clinical and investigational data in hospitalized patients with liver failure admitted from 2002 to 2011 were retrospectively analyzed. Standard definitions and criteria were used to assess disease etiology.

RESULTS

Of these 3,916 patients, 3,429 (87.6 %) had acute-on-chronic liver failure (ACLF), 114 (2.9 %) acute liver failure (ALF), and 373 (9.5 %) subacute liver failure. Viral infection was the most common cause of liver failure in the 3,295 patients (84.1 %). Hepatitis of unknown etiology was deemed responsible for 371 cases of liver failure (9.5 %). Drug-induced liver injury, alcoholic hepatitis, and autoimmune hepatitis led to 120 cases (3.1 %), 109 cases (2.8 %), and 19 cases (0.5 %), respectively. The most common cause of ACLF was HBV infection (87.3 %), while the main causes of acute and subacute liver failure were hepatitis of unknown etiology (39.4 %), viral infection (36.6 %), and drug-induced liver injury (19.3 %). Our data showed that the incidence of liver failure caused by HBV gradually decreased from 86.5 % in 2002 to 69.2 % in 2011. However, the incidence of hepatitis of unknown etiology, drug-induced liver injury, and alcoholic hepatitis was increased.

CONCLUSIONS

HBV infection is the main cause of liver failure in China. However, the incidence of HBV-related liver failure has gradually decreased in the past 10 years. Hepatitis of unknown etiology has replaced HBV infection as the most common apparent cause of acute liver failure.

Acute liver failure in Scotland between 1992 and 2009; incidence, aetiology and outcome

AIM

To describe incidence, aetiology and outcome data for Scotland since the inception of the Scottish Liver Transplant Unit (SLTU) in 1992.

BACKGROUND

Acute liver failure (ALF) is a rare but frequently fatal condition. Few studies have adequate patient numbers to draw convincing conclusions over demographic features, aetiology and outcome.

DESIGN

Statistical analysis of prospectively collected data on aetiology, demographic, clinical and outcome of all admissions, including those with ALF, to the SLTU.

METHODS

Incidence data presented for admissions and ALF. Descriptive frequencies for aetiology, clinical, demographic and outcome data presented; including split analysis for paracetamol and non-paracetamol aetiologies. Univariate and multivariate analysis of admission factors predictive of outcome is described.

RESULTS

Nine hundred and forty-nine patients were admitted to the SLTU between 1992 and 2009. Five hundred and twenty-four patients had ALF. The annual incidence of ALF in the Scottish population is 0.62 per 100,000 and paracetamol overdose (POD) was the largest causative factor; responsible for 0.43 cases of ALF per 100,000 population per year. The odds ratio (OR) of transplantation or death was 0.47 in the POD group compared to other aetiologies; yet of not being a transplant candidate having met the Kings College Hospital poor prognostic criteria OR was 4.9. Of admissions listed for transplant 76.0% were transplanted. Of those listed and not transplanted mortality was approaching 100% and 76.1% of those transplanted survived to discharge.

CONCLUSION

This large, prospective, single centre study with a defined geographical area and well-recorded population provides accurate data regarding ALF between 1992 and 2009.

Epidemiology of liver failure

The etiology of fulminant hepatitis varies in different countries and at different times. The main causes of fulminant hepatitis are viruses, paracetamol, drugs (other than paracetamol), poisons and 15-30% remained of undetermined origin. The prevalence of these etiologies varies according to the geographic region and has changed over the past 10 years. Paracetamol has now overtaken viruses (particularly hepatitis B virus) as the leading cause of fulminant hepatitis. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation be eliminated.

[Fulminant and subfulminant hepatitis: causes and treatment]

Fulminant hepatitis is an emergency because within a few hours, the physician must find the cause of the hepatitis (not identified in 15 to 20% of cases), rule out any contraindication to liver transplantation, verify that it is indicated, and prevent and/or treat the complications associated with liver failure. Viruses (especially hepatitis viruses A and B), drugs, and toxic agents are the most common causes of fulminant hepatitis, with the proportions varying between countries. Hepatitis viruses, the leading cause through 1995-1996, have fallen behind drugs and in particular paracetamol, which is now the leading cause of this disease in Europe and in the United States. There are also other rarer causes: other viruses (e.g., herpes virus HSV1 or 2, hepatitis virus E, parvovirus B19, and chickenpox-herpes zoster), Wilson Disease, acute Budd-Chiari and Reyes syndromes, autoimmune hepatitis, neoplastic infiltration of the liver, hypoxic hepatitis, heatstroke, acute pregnancy-related steatosis, and the HELLP syndrome. Prognosis is essentially determined by neurological status, but is also affected very rapidly by damage to other organs. Liver transplantation has revolutionized the prognosis of fulminant hepatitis, causing survival to increase from 10-20% (all causes combined) to 75-80% at 1 year and 70% at 5 years. These patients can be treated only in specialized centers with access to liver transplantation and to different modern means of liver resuscitation (hypothermia, artificial liver support, albumin dialysis, monitoring intracranial pressure and cerebral perfusion, etc.) -all from the onset of the disease.

The utilization of liver transplantation in the management of acute liver failure: comparison between acetaminophen and non-acetaminophen etiologies

Liver transplantation (LT) may be life-saving in severe acute liver failure (ALF). The aim of this study was to compare the utilization of LT in acetaminophen and non-acetaminophen ALF. Between 1992 and 2006, 469 patients with ALF were admitted, and 104 underwent LT. Acetaminophen was the most common etiology, but LT proceeded more frequently in the non-acetaminophen cohort (acetaminophen: 45/326 patients received LT, 13.8%; non-acetaminophen: 59/143 patients received LT, 41.3%; P < 0.01). A retrospective analysis of the individual steps in the management of patients revealed more ALF patients in the non-acetaminophen cohort fulfilled the King's College Hospital poor prognostic criteria (non-acetaminophen: 91/143, 63.6%; acetaminophen: 165/326, 50.6%; P < 0.01), more patients had contraindications to LT in the acetaminophen cohort (acetaminophen: 99/165, 60%; non-acetaminophen: 21/91, 23.1%; P < 0.01), and survival on the LT waiting list was reduced in the acetaminophen cohort (acetaminophen: 45/66, 68.2%; non-acetaminophen: 59/70, 84.3%; P < 0.05). Post-LT survival was similar in the 2 groups. An analysis of cohorts admitted in 1993-1996 and 2002-2005 revealed that LT proceeded less commonly in acetaminophen ALF in the later cohort (1993-1996: 16/99 LT, 16.2%; 2002-2005: 4/81 LT, 5%; P < 0.01) in comparison with the non-acetaminophen cohort, in which transplantation proceeded more commonly in the later cohort (1993-1996: 11/34 LT, 32.4%; 2002-2005: 24/49 patients, 49.0%; P < 0.01). This was due to an increase in the number of patients with psychiatric contraindications to transplantation (predominantly resistant and severe alcohol dependence). In conclusion, at all decision steps between admission and emergency LT, LT is favored in non-acetaminophen patients, and nonoperative management is favored in acetaminophen ALF patients.

Etiology and prognosis of fulminant hepatitis in adults

1. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation can be eliminated. 2. The etiology of fulminant hepatitis varies in different countries and at different times. A viral etiology (in particular hepatitis B virus) is now less frequent, and paracetamol-induced fulminant hepatic failure is more common. 3. Many patients have miscellaneous causes of fulminant hepatitis. It is important to establish the main clinical and biological characteristics for specific management. 4. Assessment of the prognosis of fulminant hepatitis is important for distinguishing patients requiring liver transplantation from those whose will improve spontaneously. Prognosis depends on several factors, including the gold standard, the King's College Hospital criteria and Clichy's criteria.