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Stravitz RT, Fontana RJ, Karvellas C, Durkalski V, McGuire B, Rule JA, Tujios S, Lee WM. Future directions in acute liver failure. Hepatology 2023; 78:1266-1289. [PMID: 37183883 PMCID: PMC10521792 DOI: 10.1097/hep.0000000000000458] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Accepted: 04/20/2023] [Indexed: 05/16/2023]
Abstract
Acute liver failure (ALF) describes a clinical syndrome of rapid hepatocyte injury leading to liver failure manifested by coagulopathy and encephalopathy in the absence of pre-existing cirrhosis. The hallmark diagnostic features are a prolonged prothrombin time (ie, an international normalized ratio of prothrombin time of ≥1.5) and any degree of mental status alteration (HE). As a rare, orphan disease, it seemed an obvious target for a multicenter network. The Acute Liver Failure Study Group (ALFSG) began in 1997 to more thoroughly study and understand the causes, natural history, and management of ALF. Over the course of 22 years, 3364 adult patients were enrolled in the study registry (2614 ALF and 857 acute liver injury-international normalized ratio 2.0 but no encephalopathy-ALI) and >150,000 biosamples collected, including serum, plasma, urine, DNA, and liver tissue. Within the Registry study sites, 4 prospective substudies were conducted and published, 2 interventional ( N -acetylcysteine and ornithine phenylacetate), 1 prognostic [ 13 C-methacetin breath test (MBT)], and 1 mechanistic (rotational thromboelastometry). To review ALFSG's accomplishments and consider next steps, a 2-day in-person conference was held at UT Southwestern Medical Center, Dallas, TX, entitled "Acute Liver Failure: Science and Practice," in May 2022. To summarize the important findings in the field, this review highlights the current state of understanding of ALF and, more importantly, asks what further studies are needed to improve our understanding of the pathogenesis, natural history, and management of this unique and dramatic condition.
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Affiliation(s)
| | | | | | - Valerie Durkalski
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jody A. Rule
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Shannan Tujios
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - William M. Lee
- University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
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Michel C, Warming S, Neto AS, Abeygunawardana V, Fisher C, Kishore K, Warrillow S, Bellomo R. Early and prolonged continuous hypertonic saline infusion in patients with acute liver failure. J Crit Care 2023; 76:154289. [PMID: 36933387 DOI: 10.1016/j.jcrc.2023.154289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 02/15/2023] [Accepted: 03/09/2023] [Indexed: 03/18/2023]
Abstract
PURPOSE To study patient characteristics, physiological changes, and outcomes associated with prolonged continuous hypertonic saline (HTS) infusion in acute liver failure (ALF). MATERIALS AND METHODS Retrospective observational cohort study of adult patients with ALF. We collected clinical, biochemical, and physiological data six hourly for the first week, daily until day 30 or hospital discharge, and weekly, when documented, until day 180. RESULTS Of 127 patients, 85 received continuous HTS. Compared with non-HTS patients they were more likely to receive continuous renal replacement therapy (CRRT) (p < 0.001) and mechanical ventilation (p < 0.001). Median HTS duration was 150 (Interquartile range (IQR): 84-168) hours, delivering a median 2244 (IQR: 979-4610) mmol sodium load. Median peak sodium concentration was 149 mmol/L vs 138 mmol/L in non-HTS patients (p < 0.001). The median rate of sodium increase with infusion was 0.1 mmol/L/h and median rate of decrease during weaning was 0.1 mmol/L every 6 h. Median lowest pH value was 7.29 vs. 7.35 in non-HTS patients. Survival of HTS patients was 72.9% overall and 72.2% without transplantation. CONCLUSIONS In ALF patients, the prolonged administration of HTS infusion was not associated with severe hypernatremia or rapid shifts in serum sodium upon commencement, delivery, or weaning.
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Affiliation(s)
- Claire Michel
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Scott Warming
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | | | - Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Kartik Kishore
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia; Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Australia; Department of Critical Care, University of Melbourne, Melbourne, Australia.
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Gharib MS. Prediction of end-dialysis serum sodium concentration in severely hyponatremic kidney failure patients undergoing conventional hemodialysis using sodium kinetic equation. RENAL REPLACEMENT THERAPY 2023. [DOI: 10.1186/s41100-023-00463-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Abstract
Background and Objectives
Conventional hemodialysis (HD) for kidney failure patients with severe hyponatremia may be complicated by rapid correction of hyponatremia, which increases the risk of osmotic demyelination syndrome. A simple sodium kinetic equation was effective in prediction of end-dialysis serum Na+ in severely hyponatremic kidney failure patient treated with continuous venovenous hemofiltration, but was not tested in conventional HD. The aim of this study was to assess the validity of this equation when used in conventional HD.
Methods
Twenty conventional HD sessions were delivered to 12 kidney failure patients with severe hyponatremia (serum Na+ < 120 mEq/L). The target change in serum Na+ was 4 mEq/L. The DNa.t/V that obtained this change was predetermined according to the sodium kinetic equation and monitored in real time by online clearance monitoring software embedded in dialysis machine. The dialysis session was terminated once the target DNa.t/V was achieved.
Results
The mean observed and predicted serum Na+ were 119.80 ± 3.42 mEq/L and 119.45 ± 3.12 mEq/L, respectively. Bland–Altman plot analysis revealed a mean difference ± SD of 0.33 ± 1.26 mEq/L, and 95% limits of agreement of − 2.13 to 2.83. The imprecision in prediction of end-dialysis serum Na+ was 2.52 mEq/L. The small difference and clinically insignificant 95% limits of agreement indicate a good agreement between the observed and predicted serum Na+.
Conclusion
The sodium kinetic equation was effective in prediction of end-dialysis serum Na+ in kidney failure patients with severe hyponatremia.
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Wu H, Bai M, Li X, Xing Y, Sun S. Diagnosis and treatment of brain injury complicated by hypernatremia. Front Neurol 2022; 13:1026540. [PMID: 36518191 PMCID: PMC9743987 DOI: 10.3389/fneur.2022.1026540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 11/14/2022] [Indexed: 12/01/2023] Open
Abstract
Hypernatremia is a common electrolyte disorder in patients with brain injury. The mortality of brain injury patients with severe hypernatremia may be as high as 86.8%. The efficacy of conventional treatment for hypernatremia is limited. Continuous renal replacement therapy (CRRT) can slowly, controllably, and continuously reduce the blood sodium concentration and gradually become an important treatment for severe hypernatremia patients. This review aims to provide important information for clinicians and clinical researchers by describing the etiology, diagnosis, hazards, conventional treatment, and CRRT treatment of hypernatremia in patients with traumatic brain injury.
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Affiliation(s)
- Hao Wu
- Department for Postgraduate Students, Xi'an Medical University, Xi'an, China
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Xiayin Li
- Department for Postgraduate Students, Xi'an Medical University, Xi'an, China
| | - Yan Xing
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
| | - Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, China
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Abstract
Abbreviated pathogenesis and clinical course of the acute liver failure syndrome. The pathogenesis and clinical course of the syndrome of acute liver failure (ALF) differs depending upon the etiology of the primary liver injury. In turn, the severity of the liver injury and resulting synthetic failure is often the primary determinant of whether a patient is referred for emergency liver transplantation. Injuries by viral etiologies trigger the innate immune system via pathogen-associated molecular patterns (PAMPs), while toxin-induced (and presumably ischemia-induced) injuries do so via damage-associated molecular patterns (DAMPs). The course of the clinical syndrome further depends upon the relative intensity and composition of cytokine release, resulting in an early proinflammatory phenotype (SIRS) and later compensatory anti-inflammatory response phenotype (CARS). The outcomes of overwhelming immune activation are the systemic (extrahepatic) features of ALF (cardiovascular collapse, cerebral edema, acute kidney injury, respiratory failure, sepsis) which ultimately determine the likelihood of death.Acute liver failure (ALF) continues to carry a high risk of mortality or the need for transplantation despite recent improvements in overall outcomes over the past two decades. Optimal management begins with identifying that liver failure is indeed present and its etiology, since outcomes and the need for transplantation vary widely across the different etiologies. Most causes of ALF can be divided into hyperacute (ischemia and acetaminophen) and subacute types (other etiologies), based on time of evolution of signs and symptoms of liver failure; the former evolve in 3 to 4 days and the latter typically in 2 to 4 weeks. Both involve intense release of cytokines and hepatocellular contents into the circulation with multiorgan effects/consequences.Management involves optimizing fluid balance and cardiovascular support, including the use of continuous renal replacement therapy, vasopressors, and pulmonary ventilation. Early evaluation for liver transplantation is advised particularly for acetaminophen toxicity, which evolves so rapidly that delay is likely to lead to death.Vasopressor support, high-grade hepatic encephalopathy, and unfavorable (subacute) etiologies heighten the need for urgent listing for liver transplantation. Prognostic scores such as Kings Criteria, Model for End-Stage Liver Disease, and the Acute Liver Failure Group prognostic index take these features into account and provide reasonable but imperfect predictive accuracy. Future treatments may include liver support devices and/or agents that improve hepatocyte regeneration.
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Affiliation(s)
- Shannan Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - R. Todd Stravitz
- Section of Hepatology, Department of Internal Medicine, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, Virginia
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
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Mohiuddin N, Frinak S, Yee J. Sodium-based osmotherapy for hyponatremia in acute decompensated heart failure. Heart Fail Rev 2021; 27:379-391. [PMID: 34767112 DOI: 10.1007/s10741-021-10124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/25/2021] [Indexed: 10/19/2022]
Abstract
Acute decompensated heart failure (ADHF) accounts for more than 1 million hospital admissions annually and is associated with high morbidity and mortality. Decongestion with removal of increased total body sodium and total body water are goals of treatment. Acute kidney injury (AKI) or chronic kidney disease (CKD) is present in two-thirds of patients with ADHF. The pathophysiology of ADHF and AKI is bidirectional and synergistic. AKI and CKD complicate the management of ADHF by decreasing diuretic efficiency and excretion of sodium and water. Among patients hospitalized with ADHF, hyponatremia is the most common electrolyte abnormality and is classically encountered with volume overload. ADHF represents an additional therapeutic challenge particularly when oligoanuria is present. Predilution continuous venovenous hemofiltration with sodium-based osmotherapy can safely increase plasma sodium concentration without deleteriously increasing total body sodium. We present a detailed methodology that addresses the issue of hypervolemic hyponatremia in patients with ADHF and AKI.
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Affiliation(s)
- Naushaba Mohiuddin
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-510, Detroit, MI, 48202, USA
| | - Stanley Frinak
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-510, Detroit, MI, 48202, USA
| | - Jerry Yee
- Division of Nephrology and Hypertension, 2799 West Grand Blvd, CFP-514, Detroit, MI, 48202, USA.
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Yessayan LT, Szamosfalvi B, Rosner MH. Management of dysnatremias with continuous renal replacement therapy. Semin Dial 2021; 34:472-479. [PMID: 34218456 DOI: 10.1111/sdi.12983] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 03/17/2021] [Accepted: 04/05/2021] [Indexed: 11/28/2022]
Abstract
Disorders of serum sodium concentration are common in critically ill patients who may have concomitant acute kidney injury, chronic kidney disease, or end-stage kidney disease. Many of these patients may require customized serum sodium level management with dialysis which, if not strictly controlled, can lead to significant complications. Thus, controlled correction of the serum sodium level is necessary to avoid the development of osmotic demyelination syndrome in hyponatremic patients and dialysis disequilibrium syndrome in hypernatremic patients. Continuous renal replacement therapy offers unique benefits through the ability to slowly and safely correct dysnatremias that can be tailored to specific patient needs and should be considered in select patients.
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Affiliation(s)
- Lenar T Yessayan
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Balazs Szamosfalvi
- Division of Nephrology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Mitchell H Rosner
- Division of Nephrology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA
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Yee J, Mohiuddin N, Gradinariu T, Uduman J, Frinak S. Sodium-Based Osmotherapy in Continuous Renal Replacement Therapy: a Mathematical Approach. ACTA ACUST UNITED AC 2020; 1:281-291. [DOI: 10.34067/kid.0000382019] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Cerebral edema, in a variety of circumstances, may be accompanied by states of hyponatremia. The threat of brain injury from hypotonic stress-induced astrocyte demyelination is more common when vulnerable patients with hyponatremia who have end stage liver disease, traumatic brain injury, heart failure, or other conditions undergo overly rapid correction of hyponatremia. These scenarios, in the context of declining urinary output from CKD and/or AKI, may require controlled elevations of plasma tonicity vis-à-vis increases of the plasma sodium concentration. We offer a strategic solution to this problem via sodium-based osmotherapy applied through a conventional continuous RRT modality: predilution continuous venovenous hemofiltration.
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