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Kaliciński P, Grenda R, Szymczak M, Pietraszek E, Pawłowska J. Multidisciplinary management of children with acute liver failure - Report on 104 children treated in single center. Pediatr Transplant 2024; 28:e14654. [PMID: 37983943 DOI: 10.1111/petr.14654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/26/2023] [Accepted: 11/06/2023] [Indexed: 11/22/2023]
Abstract
BACKGROUND Pediatric acute liver failure (PALF) is one of the most demanding emergencies in hepatology, intensive care, and for transplant team. This report describes the clinical pattern, diagnostic and therapeutic modalities in children with ALF considered at risk of death without liver transplantation, basing on a long-term experience of the pediatric transplant center. MATERIALS AND METHODS Between 1990 and 2022, 104 children aged 7 days-17 years (median 8 years), with body weight 3.1 to 77 kg (median 32 kg), were qualified for LT due to ALF, and finally 81 (78%) of them were transplanted (9% of all 899 LT performed in children in the same period). RESULTS A total of 23 children were not transplanted: 15 (14.4%) died while awaiting transplantation. In 8 (7.7%) patients liver function recovered. Before transplantation 45 (43.3%) children developed circulatory failure, in 66 (63.5%) mechanical ventilation was necessary, 18 patients presented acute kidney injury (17.3%), and encephalopathy higher than stage I was present in 60 (57.7%) patients. In 63 children, various kidney/liver assist procedures were performed: CVVHD (continuous veno-venous hemodiafiltration in 22 (21.2%) patients, albumin dialysis (MARS; molecular adsorbent recirculating system) in 39 (37.5%) patients, therapeutic plasma exchange (TPE) in 13 (12.5%) patients. Twenty (24.7%) children died after LT including 15 (18.5%) in the early posttransplant period, and 5 (6.1%) in the late follow-up. CONCLUSIONS Treatment of children with ALF in the peritransplant period is very difficult and require an experienced, multidisciplinary team. Despite continued advances in the care of children with ALF, patient survival remains lower than for elective indications for liver transplantation, and timely qualification and transplantation still are the most important factors of survival of these children.
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Affiliation(s)
- Piotr Kaliciński
- Department of Pediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Ryszard Grenda
- Department of Nephrology, Kidney Transplantation and Hypertension, The Children's Memorial Health Institute, Warsaw, Poland
| | - Marek Szymczak
- Department of Pediatric Surgery and Organ Transplantation, The Children's Memorial Health Institute, Warsaw, Poland
| | - Elżbieta Pietraszek
- Department of Anaesthesiology and Intensive Care, The Children's Memorial Health Institute, Warsaw, Poland
| | - Joanna Pawłowska
- Department of Gastroenterology, Hepatology, Feeding Disorders and Pediatrics, The Children's Memorial Health Institute, Warsaw, Poland
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Khani S, Soheili A, Vahabi SM, Dara N, Sayyari A, Nilipour Y, Parvizi M, Hosseini A. Co-occurrence of celiac disease and glycogen storage disease in a five-year-old patient with diabetes mellitus; a case report. Clin Case Rep 2023; 11:e7804. [PMID: 37614289 PMCID: PMC10442470 DOI: 10.1002/ccr3.7804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 06/05/2023] [Accepted: 07/08/2023] [Indexed: 08/25/2023] Open
Abstract
A patient presented with edema, ascites and jaundice. Histologic report was consistent with Celiac Disease. Liver biopsy commensurate with Glycogen storage disease III, which was confirmed by genetic testing. A gluten-free diet was initiated. After 2 months, ascites was relieved, hepatic function was improved, and hepatic size reduced.
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Affiliation(s)
- Sina Khani
- Medical Student Research Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | - Amirali Soheili
- Medical Student Research Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
| | | | - Naghi Dara
- Pediatric Gastroentrology, Hepatology and Nutrition Research Center Research Institute for Children's HealthShahid Beheshti University of Medical sciencesTehranIran
| | - Aliakbar Sayyari
- Pediatric Gastroentrology, Hepatology and Nutrition Research Center Research Institute for Children's HealthShahid Beheshti University of Medical sciencesTehranIran
| | - Yalda Nilipour
- Pediatric Pathology Research Center, Research Institute for children's HealthShahid Beheshti University of Medical SciencesTehranIran
| | - Maryam Parvizi
- Pediatric Pathology Research Center, Research Institute for children's HealthShahid Beheshti University of Medical SciencesTehranIran
| | - Amirhossein Hosseini
- Pediatric Gastroentrology, Hepatology and Nutrition Research Center Research Institute for Children's HealthShahid Beheshti University of Medical sciencesTehranIran
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Pediatric acute liver failure in Saudi Arabia: prognostic indicators, outcomes and the role of genetic testing. Eur J Gastroenterol Hepatol 2023; 35:420-430. [PMID: 36574286 DOI: 10.1097/meg.0000000000002499] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
OBJECTIVE The objective of this study was to determine the etiologies, outcomes, prognostic indicators and the role of genetic testing in children with acute liver failure (ALF). METHODS This retrospective study included 46 patients with pediatric acute liver failure (PALF) according to the PALF study group definition, admitted to King Fahad Specialist Hospital-Dammam, Saudi Arabia, between January 2014 and December 2021. Patients who survived with supportive therapy were designated as the recovery group, whereas those who died or underwent liver transplantation were designated as the death/transplant group. RESULTS There were 26 (56.5%) patients in the recovery group and 20 (43.5%) patients in the death/transplant group. Four patients (8.7%) underwent liver transplantation. After indeterminate causes (45.6%), genetic-metabolic diseases and drug-induced liver injury (DILI) were the most common cause with 15.2 and 13%, respectively. Genetic testing had a high yield of (6/31) in identifying monogenic disease associated with ALF. Younger age, lower Glasgow Coma Scale and higher international normalized ratio (INR) on admission were predictors for poor prognosis. The death/transplant group had longer intensive care unit stay ( P < 0.001), and on admission they had more advanced hepatic encephalopathy ( P < 0.005), more prolonged prothrombin time ( P < 0.001), higher lactate ( P < 0.006), higher total and direct bilirubin ( P < 0.008) and ( P < 0.001), respectively. CONCLUSION Genetic, metabolic and DILI causes constituted the most common cause of PALF after indeterminate causes. The use of genetic testing can improve diagnostic rates in special cases, but we could not assess the effect of genetic testing on prognosis. The overall survival rate in our study was 65.2%. Younger age, higher admission INR and lower Glasgow coma scale were indicators of poor prognosis.
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Hadžić N, Molnar E, Height S, Kovács G, Dhawan A, Andrikovics H, Worth A, Gilmour KC. High Prevalence of Hemophagocytic Lymphohistiocytosis in Acute Liver Failure of Infancy. J Pediatr 2022; 250:67-74.e1. [PMID: 35835228 DOI: 10.1016/j.jpeds.2022.07.006] [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] [Received: 03/25/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVES To investigate the prevalence of hemophagocytic lymphohistiocytosis (HLH) syndrome in pediatric acute liver failure (PALF) of infancy and assess the diagnostic role of rapid immunologic tests, genotype/phenotype correlations, and clinical outcomes. STUDY DESIGN We retrospectively analyzed 78 children with PALF aged <24 months referred over almost 2 decades. The studied patients with a phenotype of HLH syndrome had a comprehensive immunologic workup, including additional genetic analysis for primary immunologic causes. RESULTS Thirty of the 78 children had the HLH phenotype and underwent genetic assessment, which demonstrated positive findings in 19 (63.3%), including 9 (30%) with biallelic primary HLH mutations and 10 (33.3%) with heterozygous mutations and/or polymorphisms. The most common form of primary HLH was familial hemophagocytic lymphohistiocytosis (FHL)-2, diagnosed in 6 children, 4 of whom had a c.50delT (p.Leu17ArgfsTer34) mutation in the PRF1 gene. Three patients with primary HLH received genetic diagnoses of FHL-3, Griscelli syndrome, and LRBA (lipopolysaccharide-responsive vesicle trafficking, beach- and anchor-containing) protein deficiency. Overall mortality in the series was 52.6% (10 of 19), and mortality in children with a documented biallelic pathogenic HLH mutation (ie, primary HLH) was 66.6% (6 of 9). Two children underwent liver transplantation, and 4 children underwent emergency hematopoietic stem cell transplantation; all but 1 child survived medium term. CONCLUSIONS Primary HLH can be diagnosed retrospectively in approximately one-third of infants with indeterminate PALF (iPALF) who meet the clinical criteria for HLH, often leading to their death. The most common HLH type in iPALF is FHL-2, caused by biallelic mutations in PRF-1. The clinical relevance of observed heterozygous mutations and variants of uncertain significance requires further investigation. Prompt hematopoietic stem cell transplantation could be life-saving in infants who survive the liver injury.
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Affiliation(s)
- Nedim Hadžić
- Paediatric Liver Service, King's College Hospital, London, United Kingdom.
| | - Emese Molnar
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom; Department of Rheumatology and Clinical Immunology, Semmelweis University, Budapest, Hungary
| | - Sue Height
- Department of Haematology, King's College Hospital, London, United Kingdom
| | - Gabor Kovács
- Department of Physiology, Semmelweis University, Budapest, Hungary
| | - Anil Dhawan
- Paediatric Liver Service, King's College Hospital, London, United Kingdom
| | - Hajnalka Andrikovics
- Laboratory of Molecular Genetics, Central Hospital of Southern Pest, Budapest, Hungary
| | - Austen Worth
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom
| | - Kimberly C Gilmour
- Department of Immunology, Camelia Bothnar Laboratories, Great Ormond Street Hospital, London, United Kingdom
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Etiology, outcome and prognostic indicators of acute liver failure in Asian children. Hepatol Int 2022; 16:1390-1397. [PMID: 36131224 DOI: 10.1007/s12072-022-10417-5] [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] [Received: 05/26/2022] [Accepted: 08/24/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Outcome of pediatric acute liver failure (PALF) in countries with limited availability of LT is not well described. We evaluated the outcome and prognostic indicators of PALF in Malaysia where emergency LT for ALF is limited. METHODS In this retrospective review on children < 18 years with PALF, we compared clinical and laboratory parameters between survival after supportive treatment and after LT or succumbed without LT. The predictive values of Liver Injury Unit (LIU; peak laboratory values for international normalized ratio [INR], ammonia, total bilirubin) and upon admission (aLIU) on outcome of PALF was evaluated using receiver operator characteristic (ROC) curves. RESULTS Of 77 children (39 males [51%]; median age 2.8 years) with PALF, the overall survival was 55% (n = 42); 52% (n = 40) survived with supportive management, 2.6% (n = 2) after LT. As compared to children who survived without LT, children who had LT/died had lower hemoglobin, aspartate transferase, γ-glutamyl transpeptidase (GGT), and higher serum bilirubin, alkaline phosphatase, ammonia, and serum sodium (p < 0.05). On multivariate analysis, significant independent predictor for death or LT were peak bilirubin > 452 μmol/L and peak GGT < 96 IU/L. The C-index of LIU and aLIU score were 0.79 and 0.68, respectively, indicating that LIU score was a good model in predicting outcome of PALF. CONCLUSIONS Overall survival of PALF remained poor. High peak bilirubin and low GGT predict poor outcome of PALF. LIU score is a good model in predicting outcome of PALF and maybe useful in selecting children for emergency LT.
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Mullapudi B, Hendrickson R. Pediatric liver transplantation. Semin Pediatr Surg 2022; 31:151191. [PMID: 35725050 DOI: 10.1016/j.sempedsurg.2022.151191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Bhargava Mullapudi
- Department of Surgery, Section of Transplant Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Richard Hendrickson
- Department of Surgery, Section of Transplant Surgery, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA
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Jagadisan B, Dhawan A. Emergencies in paediatric hepatology. J Hepatol 2022; 76:1199-1214. [PMID: 34990749 DOI: 10.1016/j.jhep.2021.12.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 12/17/2021] [Accepted: 12/21/2021] [Indexed: 12/12/2022]
Abstract
The aetiology of several liver diseases in children is age specific and many of these conditions have significant and potentially long-term clinical repercussions if not diagnosed early and managed in a timely fashion. We address 5 clinical scenarios that cover most of the diagnostic and therapeutic emergencies in children: infants with liver disease; acute liver failure; management of bleeding varices; liver-based metabolic disorders; and liver tumours and trauma. A wide spectrum of conditions that cause liver disease in infants may present as conjugated jaundice, which could be the only symptom of time-sensitive disorders - such as biliary atresia, metabolic disorders, infections, and haematological/alloimmune disorders - wherein algorithmic multistage testing is required for accurate diagnosis. In infantile cholestasis, algorithmic multistage tests are necessary for an accurate early diagnosis, while vitamin K, specific milk formulae and disease-specific medications are essential to avoid mortality and long-term morbidity. Management of paediatric acute liver failure requires co-ordination with a liver transplant centre, safe transport and detailed age-specific aetiological work-up - clinical stabilisation with appropriate supportive care is central to survival if transplantation is indicated. Gastrointestinal bleeding may present as the initial manifestation or during follow-up in patients with portal vein thrombosis or chronic liver disease and can be managed pharmacologically, or with endoscopic/radiological interventions. Liver-based inborn errors of metabolism may present as encephalopathy that needs to be recognised and treated early to avoid further neurological sequelae and death. Liver tumours and liver trauma are both rare occurrences in children and are best managed by a multidisciplinary team in a specialist centre.
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Affiliation(s)
- Barath Jagadisan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK
| | - Anil Dhawan
- Pediatric Liver GI and Nutrition Centre and MowatLabs, King's College Hospital, London, UK.
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Massabki LHP, Sandy NS, De Tommaso AMA, Brandão MAB, Hessel G, Lomazi EA. Pediatric Acute Liver Failure as Presentation of Autoimmune Hepatitis: Learning from a Fatal Case. JPGN REPORTS 2022; 3:e151. [PMID: 37168764 PMCID: PMC10158326 DOI: 10.1097/pg9.0000000000000151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/28/2021] [Indexed: 05/13/2023]
Abstract
Severe acute liver failure (SALF) is a rare condition in children. Up to 50% of the cryptogenic causes of SALF are associated with autoimmune hepatitis (AIH). This report presents a 5-year-old girl with progressive jaundice for 10 days. Her 1999 AIH diagnostic score totaled 11 points, compatible with probable AIH. She fulfilled the SALF criteria and the King's College criteria for liver transplantation, despite treatment with corticosteroids, and underwent the transplant, but died in the immediate postoperative period due to massive bleeding. Subsequently, the liver-kidney microsome type 1 result was 1:80, increasing the AIH score to 13 points. The final diagnosis was probable AIH type 2, associated with SALF. The biopsy of the explanted liver was compatible with fulminant hepatitis. This report highlights the difficult diagnosis of AIH in SALF, limitations of the diagnostic criteria for SALF in indications for emergency transplantation, and the uncertain therapeutic response produced by corticosteroids.
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Affiliation(s)
- Lilian H. P. Massabki
- From the Pediatric Gastroenterology, Hepatology and Nutrition at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Natascha S. Sandy
- Pediatric Gastroenterology, Hepatology and Nutrition at The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Adriana M. A. De Tommaso
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Maria A. B. Brandão
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Gabriel Hessel
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
| | - Elizete A. Lomazi
- Department of Pediatrics at University of Campinas, School of Medical Sciences, Campinas, São Paulo, Brazil
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Pop TL, Aldea CO, Delean D, Bulata B, Boghiţoiu D, Păcurar D, Ulmeanu CE, Grama A. The Role of Predictive Models in the Assessment of the Poor Outcomes in Pediatric Acute Liver Failure. J Clin Med 2022; 11:432. [PMID: 35054127 PMCID: PMC8778932 DOI: 10.3390/jcm11020432] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/05/2022] [Accepted: 01/13/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES In children, acute liver failure (ALF) is a severe condition with high mortality. As some patients need liver transplantation (LT), it is essential to predict the fatal evolution and to refer them early for LT if needed. Our study aimed to evaluate the prognostic criteria and scores for assessing the outcome in children with ALF. METHODS Data of 161 children with ALF (54.66% female, mean age 7.66 ± 6.18 years) were analyzed based on final evolution (32.91% with fatal evolution or LT) and etiology. We calculated on the first day of hospitalization the PELD score (109 children), MELD, and MELD-Na score (52 children), and King's College Criteria (KCC) for all patients. The Nazer prognostic index and Wilson index for predicting mortality were calculated for nine patients with ALF in Wilson's disease (WD). RESULTS PELD, MELD, and MELD-Na scores were significantly higher in patients with fatal evolution (21.04 ± 13.28 vs. 13.99 ± 10.07, p = 0.0023; 36.20 ± 19.51 vs. 20.08 ± 8.57, p < 0.0001; and 33.07 ± 8.29 vs. 20.08 ± 8.47, p < 0.0001, respectively). Moreover, age, bilirubin, albumin, INR, and hemoglobin significantly differed in children with fatal evolution. Function to etiology, PELD, MELD, MELD-Na, and KCC accurately predicted fatal evolution in toxic ALF (25.33 vs. 9.90, p = 0.0032; 37.29 vs. 18.79, p < 0.0001; 34.29 vs. 19.24, p = 0.0002, respectively; with positive predicting value 100%, negative predicting value 88.52%, and accuracy 89.23% for King's College criteria). The Wilson index for predicting mortality had an excellent predictive strength (100% sensibility and specificity), better than the Nazer prognostic index. CONCLUSIONS Prognostic scores may be used to predict the fatal evolution of ALF in children in correlation with other parameters or criteria. Early estimation of the outcome of ALF is essential, mainly in countries where emergency LT is problematic, as the transfer to a specialized center could be delayed, affecting survival chances.
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Affiliation(s)
- Tudor Lucian Pop
- 2nd Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
| | - Cornel Olimpiu Aldea
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Dan Delean
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Bogdan Bulata
- Pediatric Nephrology, Dialysis and Toxicology Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania; (C.O.A.); (D.D.); (B.B.)
| | - Dora Boghiţoiu
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Daniela Păcurar
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Coriolan Emil Ulmeanu
- Department of Pediatrics, Carol Davila University of Medicine and Pharmacy, 020021 Bucharest, Romania; (D.B.); (D.P.); (C.E.U.)
- Department of Pediatrics, Grigore Alexandrescu Emergency Clinical Hospital for Children, 011743 Bucharest, Romania
| | - Alina Grama
- 2nd Pediatric Discipline, Department of Mother and Child, Iuliu Hatieganu University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania;
- Center of Expertise in Pediatric Liver Rare Disorders, 2nd Pediatric Clinic, Emergency Clinical Hospital for Children, 400177 Cluj-Napoca, Romania
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Amatya P, Kapalavai SK, Deep A, Sankaranarayanan S, Krupanandan R, Sadasivam K, Ramachandran B. Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings. Front Pediatr 2022; 10:956699. [PMID: 36120651 PMCID: PMC9478462 DOI: 10.3389/fped.2022.956699] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 08/12/2022] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure. MATERIALS AND METHODS This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled. RESULTS Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation. CONCLUSION Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.
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Affiliation(s)
- Puja Amatya
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Sudeep Kumar Kapalavai
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Akash Deep
- Department of Pediatric Critical Care, King's College Hospital, London, United Kingdom
| | | | - Ravikumar Krupanandan
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Kalaimaran Sadasivam
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
| | - Bala Ramachandran
- Department of Pediatric Critical Care, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, India
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Di Giorgio A, Bartolini E, Calvo PL, Cananzi M, Cirillo F, Della Corte C, Dionisi-Vici C, Indolfi G, Iorio R, Maggiore G, Mandato C, Nebbia G, Nicastro E, Pinon M, Ranucci G, Sciveres M, Vajro P, D'Antiga L. Diagnostic Approach to Acute Liver Failure in Children: A Position Paper by the SIGENP Liver Disease Working Group. Dig Liver Dis 2021; 53:545-557. [PMID: 33775575 DOI: 10.1016/j.dld.2021.03.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/28/2021] [Accepted: 03/04/2021] [Indexed: 02/06/2023]
Abstract
Acute liver failure (ALF) is a clinical condition characterized by the abrupt onset of coagulopathy and biochemical evidence of hepatocellular injury, leading to rapid deterioration of liver cell function. In children, ALF has been characterized by raised transaminases, coagulopathy, and no known evidence of pre-existing chronic liver disease; unlike in adults, the presence of hepatic encephalopathy is not required to establish the diagnosis. Although rare, ALF has a high mortality rate without liver transplantation (LT). Etiology of ALF varies with age and geographical location, although it may remain indeterminate in a significant proportion of cases. However, identifying its etiology is crucial to undertake disease-specific management and evaluate indication to LT. In this position statement, the Liver Disease Working Group of the Italian Society of Gastroenterology, Hepatology and Nutrition (SIGENP) reviewed the most relevant studies on pediatric ALF to provide recommendations on etiology, clinical features and diagnostic work-up of neonates, infants and children presenting with ALF. Recommendations on medical management and transplant candidacy will be discussed in a following consensus conference.
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Affiliation(s)
- A Di Giorgio
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy.
| | - E Bartolini
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - P L Calvo
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - M Cananzi
- Unit of Pediatric Gastroenterology and Hepatology, Dpt. of Women's and Children's Health, University Hospital of Padova, Italy
| | - F Cirillo
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - C Della Corte
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Dionisi-Vici
- Division of Metabolic Diseases, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - G Indolfi
- Department Neurofarba, University of Florence and Liver Unit, Meyer Children's University Hospital, Florence, Italy
| | - R Iorio
- Paediatric Liver Unit, Department of Translational Medical Science, University of Naples Federico II, Naples, Italy
| | - G Maggiore
- Paediatric Gastroenterology, Hepatology, Nutrition and Liver Transplantation, IRCCS Bambino Gesù Paediatric Hospital, Rome, Italy
| | - C Mandato
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - G Nebbia
- Pediatric Liver Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - E Nicastro
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
| | - M Pinon
- Paediatric Gastroenterology Unit, Regina Margherita Children's Hospital Azienda Ospedaliera-Universitaria Citta della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - G Ranucci
- Department of Pediatrics, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - M Sciveres
- Paediatric Department and Transplantation, Ismett, Palermo, Italy
| | - P Vajro
- Department of Medicine, Surgery and Dentistry "Scuola Medica Salernitana" Section of Pediatrics, University of Salerno, Baronissi (Salerno), Italy
| | - L D'Antiga
- Paediatric Liver, GI and Transplantation, ASST-Hospital Papa Giovanni XXIII, Piazza OMS1, Bergamo 24127, Italy
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12
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Hou Y, Wang X, Yang H, Zhong S. Survival and Complication of Liver Transplantation in Infants: A Systematic Review and Meta-Analysis. Front Pediatr 2021; 9:628771. [PMID: 33996682 PMCID: PMC8116516 DOI: 10.3389/fped.2021.628771] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Accepted: 03/17/2021] [Indexed: 01/16/2023] Open
Abstract
Background: Modern surgical techniques and scientific advancements have made liver transplant (LT) in infants feasible. However, there are only a small number of studies examining the short- as well as long-term outcomes of LT in this vulnerable subset of children. Methods: Comprehensive searches were done systematically through the PubMed, Scopus, and Google scholar databases. Studies that were retrospective record based or adopted a cohort approach and reported either patient survival rates or graft survival rates or complications of LT in infants were included in the meta-analysis. Statistical analysis was done using STATA version 13.0. Results: A total of 22 studies were included in the meta-analysis. The overall pooled patient survival rate at 1 year, >1-5 years, and >5 years post-transplantation was 85% (95% CI: 78--92%), 71% (95% CI: 59-83%), and 80% (95% CI: 69-91%), respectively. The overall pooled graft survival rate at 1 year, >1-5 years, and >5 years post-transplantation was 72% (95% CI: 68-76%), 62% (95% CI: 46-78%), and 71% (95% CI: 56-86%), respectively. The overall pooled rate for vascular complications, need for re-transplantation, biliary complications, and infection/sepsis was 12% (95% CI: 10-15%), 16% (95% CI: 12-20%), 15% (95% CI: 9-21%), and 50% (95% CI: 38-61%), respectively. Conclusion: The current meta-analysis showed modest patient and graft survival rates for infant liver transplantation. However, the complication rates related to infection/sepsis were high. More comprehensive evidence is required from studies with larger sample sizes and a longer duration of follow-up.
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Affiliation(s)
- Yifu Hou
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Xiaoxiao Wang
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Hongji Yang
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
| | - Shan Zhong
- Department of Organ Transplantation, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu, China.,Chinese Academy of Sciences Sichuan Translational Medicine Research Hospital, Chengdu, China
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13
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Getsuwan S, Lertudomphonwanit C, Tanpowpong P, Thirapattaraphan C, Tim-Aroon T, Wattanasirichaigoon D, Treepongkaruna S. Etiologies, Prognostic Factors, and Outcomes of Pediatric Acute Liver Failure in Thailand. Pediatr Gastroenterol Hepatol Nutr 2020; 23:539-547. [PMID: 33215025 PMCID: PMC7667225 DOI: 10.5223/pghn.2020.23.6.539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 05/31/2020] [Accepted: 06/23/2020] [Indexed: 01/01/2023] Open
Abstract
PURPOSE Pediatric acute liver failure (PALF) is a serious condition; however, data on PALF in developing countries are sparse, particularly concerning molecular diagnosis and liver transplantation (LT). This study aimed to determine the causes, outcomes, and prognostic factors of PALF. METHODS We retrospectively reviewed the medical records of children (age <15 years) with PALF diagnosed using the American Association for the Study of Liver Diseases criteria at our center from 2011 to 2016. The collected data included laboratory results, complications, outcomes, and potential factors associated with death and LT. RESULTS We included a total of 27 patients, with a median age of 2 years (interquartile range, 3 months to 4 years). Viral infection was the most common etiology (n=8, 30%), predominantly dengue infection (n=4). A total of 16 patients (59%) died and 11 patients survived (3 patients with LT). The prognostic factors associated with death or LT requirement were grade IV hepatic encephalopathy (p<0.01), hypotension (p=0.02), gastrointestinal bleeding (p=0.03), increased intracranial pressure (p=0.04), and higher peak serum lactate level (p=0.01). Peak serum lactate ≥6 mmoL/L had a sensitivity of 79% and a specificity of 88% for predicting mortality or the necessity of LT. CONCLUSION Viral infection was the most common cause of PALF. The mortality rate remained high, and a considerable number of patients required LT. In addition to several clinical factors, peak serum lactate could be a potential marker for predicting poor outcomes in PALF.
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Affiliation(s)
- Songpon Getsuwan
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chatmanee Lertudomphonwanit
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pornthep Tanpowpong
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chollasak Thirapattaraphan
- Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Division of Pediatric Surgery, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Thipwimol Tim-Aroon
- Division of Genetics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Duangrurdee Wattanasirichaigoon
- Division of Genetics, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suporn Treepongkaruna
- Division of Gastroenterology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand.,Ramathibodi Excellence Center for Organ Transplantation, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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14
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Patterson J, Hussey HS, Silal S, Goddard L, Setshedi M, Spearman W, Hussey GD, Kagina BM, Muloiwa R. Systematic review of the global epidemiology of viral-induced acute liver failure. BMJ Open 2020; 10:e037473. [PMID: 32690747 PMCID: PMC7375632 DOI: 10.1136/bmjopen-2020-037473] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The aetiology and burden of viral-induced acute liver failure remains unclear globally. It is important to understand the epidemiology of viral-induced ALF to plan for clinical case management and case prevention. PARTICIPANTS This systematic review was conducted to synthesize data on the relative contribution of different viruses to the aetiology of viral-induced acute liver failure in an attempt to compile evidence that is currently missing in the field. EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science were searched for relevant literature published from 2009 to 2019. The initial search was run on 9 April 2019 and updated via PubMed on 30 September 2019 with no new eligible studies to include. Twenty-five eligible studies were included in the results of this review. RESULTS This systematic review estimated the burden of acute liver failure after infection with hepatitis B virus, hepatitis A virus, hepatitis C virus, hepatitis E virus, herpes simplex virus/human herpesvirus, cytomegalovirus, Epstein-Barr virus and parvovirus B19. Data were largely missing for acute liver failure after infection with varicella-zostervirus, human parainfluenza viruses, yellow fever virus, coxsackievirus and/or adenovirus. The prevalence of hepatitis A-induced acute liver failur was markedly lower in countries with routine hepatitis A immunisation versus no routine hepatitis A immunisation. Hepatitis E virus was the most common aetiological cause of viral-induced acute liver failure reported in this review. In addition, viral-induced acute liver failure had poor outcomes as indicated by high fatality rates, which appear to increase with poor economic status of the studied countries. CONCLUSIONS Immunisation against hepatitis A and hepatitis B should be prioritised in low-income and middle-income countries to prevent high viral-induced acute liver failure mortality rates, especially in settings where resources for managing acute liver failure are lacking. The expanded use of hepatitis E immunisation should be explored as hepatitis E virus was the most common cause of acute liver failure. REGISTRATION PROSPERO registration number: CRD42017079730.
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Affiliation(s)
- Jenna Patterson
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Hannah Sophia Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Sheetal Silal
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, Oxfordshire, UK
| | - Liz Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mashiko Setshedi
- Department of Medicine, Division of Gastroenterology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Wendy Spearman
- Department of Medicine, Division of Hepatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gregory D Hussey
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Benjamin M Kagina
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
| | - Rudzani Muloiwa
- Vaccines for Africa Initiative, School of Public Health and Family Medicine, University of Cape Town Faculty of Health Sciences, Cape Town, South Africa
- Department of Pediatrics & Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
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15
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Development of a Prognostic Score to Predict Mortality in Patients With Pediatric Acute Liver Failure. J Pediatr Gastroenterol Nutr 2020; 70:777-782. [PMID: 32443030 DOI: 10.1097/mpg.0000000000002625] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES This study aims to develop a new prognostic score based on changes in serial laboratory data from patients with pediatric acute liver failure (PALF). METHODS We retrospectively reviewed data on 146 patients with PALF at the Seoul National University Children Hospital (SNUCH) and the Asan Medical Center (AMC). Daily morning laboratory records were obtained for up to 7 days after diagnosis of PALF: total bilirubin (TB) (mg/dL), international normalized ratio for prothrombin time (INR) at enrolment; peak TB, peak INR, peak ammonia (μmol/L); the difference between the peak TB and TB at enrollment (ie, Δpeak TB), the difference between the peak INR and INR at enrollment (ie, Δpeak INR), the maximum change in serial TB (ie, Δdaily TB), the maximum change in serial INR level (ie, Δdaily INR). We assigned nontransplanted patients in SNUCH and AMC to derivation and validation cohorts, respectively. RESULTS Δpeak TB, Δdaily TB, Δpeak INR, and Δdaily INR were significantly higher in the nonsurvival group. We developed a new score that can predict mortality in nontransplanted patients (derivation cohort n = 42, validation cohort n = 33). PALF-Delta score (PALF-Ds) = [0.232 × Δpeak TB (mg/dL)] + [2.263 × Δdaily INR] + [0.013 × peak ammonia (μmol/L)] - 4.498. The score yielded AUC 0.918 in the derivation cohort (sensitivity 81%, specificity 91%) and AUC 0.947 in the validation cohort (sensitivity 100%, specificity 89%). CONCLUSION A prognostic scoring system using the change of TB/INR may be useful for predicting mortality in patients with PALF.
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16
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Dhawan A, Chaijitraruch N, Fitzpatrick E, Bansal S, Filippi C, Lehec SC, Heaton ND, Kane P, Verma A, Hughes RD, Mitry RR. Alginate microencapsulated human hepatocytes for the treatment of acute liver failure in children. J Hepatol 2020; 72:877-884. [PMID: 31843649 DOI: 10.1016/j.jhep.2019.12.002] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 12/03/2019] [Accepted: 12/05/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Liver transplantation (LT) is the most effective treatment for patients with acute liver failure (ALF), but is limited by surgical risks and the need for life-long immunosuppression. Transplantation of microencapsulated human hepatocytes in alginate is an attractive option over whole liver replacement. The safety and efficacy of hepatocyte microbead transplantation have been shown in animal models. We report our experience of this therapy in children with ALF treated on a named-patient basis. METHODS Clinical grade human hepatocyte microbeads (HMBs) and empty microbeads were tested in immunocompetent healthy rats. Subsequently, 8 children with ALF, who were awaiting a suitable allograft for LT, received intraperitoneal transplantation of HMBs. We monitored complications of the procedure, assessing the host immune response and residual function of the retrieved HMBs, either after spontaneous native liver regeneration or at the time of LT. RESULTS Intraperitoneal transplantation of HMBs in healthy rats was safe and preserved synthetic and detoxification functions, without the need for immunosuppression. Subsequently, 8 children with ALF received HMBs (4 neonatal haemochromatosis, 2 viral infections and 2 children with unknown cause at time of infusion) at a median age of 14.5 days, range 1 day to 6 years. The procedure was well tolerated without complications. Of the 8 children, 4 avoided LT while 3 were successfully bridged to LT following the intervention. HMBs retrieved after infusions (at the time of LT) were structurally intact, free of host cell adherence and contained viable hepatocytes with preserved functions. CONCLUSION The results demonstrate the feasibility and safety of an HMB infusion in children with ALF. LAY SUMMARY Acute liver failure in children is a rare but devastating condition. Liver transplantation is the most effective treatment, but it has several important limitations. Liver cell (hepatocyte) transplantation is an attractive option, as many patients only require short-term liver support while their own liver recovers. Human hepatocytes encapsulated in alginate beads can perform the functions of the liver while alginate coating protects the cells from immune attack. Herein, we demonstrated that transplantation of these beads was safe and feasible in children with acute liver failure.
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Affiliation(s)
- Anil Dhawan
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom; Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom.
| | - Nataruks Chaijitraruch
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom; Paediatric Gastroenterology and Hepatology, Department of Paediatrics, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Emer Fitzpatrick
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Sanjay Bansal
- Paediatric Liver GI and Nutrition Center, King's College Hospital, London, United Kingdom
| | - Celine Filippi
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Sharon C Lehec
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Nigel D Heaton
- Liver Transplant Surgery, Institute of Liver Studies, King's College Hospital, London, United Kingdom
| | - Pauline Kane
- Department of Radiology, King's College Hospital, London, United Kingdom
| | - Anita Verma
- Department of Infection Sciences and Microbiology, King's College Hospital, London, United Kingdom
| | - Robin D Hughes
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
| | - Ragai R Mitry
- Dhawan Lab at the Mowat Labs, Institute of Liver Studies, King's College London at King's College Hospital, London, United Kingdom
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17
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Prueksapraopong C, Piriyakitpaiboon V, Lumbiganon D. Twin-to-twin transfusion syndrome as a cause of neonatal acute liver failure. ASIAN BIOMED 2020. [DOI: 10.1515/abm-2019-0055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Abstract
Background
Acute liver failure (ALF) is a rare condition during neonatal period.
Objective
To report a case of recipient twin with fulminant ALF secondary to hydrops fetalis caused by twin-to-twin transfusion syndrome (TTTS).
Method
The patient was admitted to the neonatal intensive care unit (NICU) for respiratory failure requiring mechanical ventilation and fulminant ALF with prolonged international normalized ratio (INR) and elevated liver enzymes with highest aspartate aminotransferase of 4,580 U/L.
Results
Laboratory investigation for secondary causes of liver failure was not revealing. Her liver enzymes and coagulation levels were dramatically normalized as the clinical symptoms of hypervolemia improved within 1 week.
Conclusion
TTTS can be a possible cause of neonatal ALF. Early detection with proper management of TTTS is important to avoid adverse outcomes. However, pathogenesis of hepatic dysfunction in TTTS is rarely described, and further studies are needed to help understanding the correlation between liver diseases and TTTS.
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Affiliation(s)
| | | | - Dissajee Lumbiganon
- Department of Pediatrics, Faculty of Medicine, Vajira Hospital , Bangkok 10300 , Thailand
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18
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Di Giorgio A, Nicastro E, Dalla Rosa D, Nebbia G, Sonzogni A, D'Antiga L. Transplant-free Survival in Chronic Liver Disease Presenting as Acute Liver Failure in Childhood. Transplantation 2019; 103:544-551. [PMID: 30028785 DOI: 10.1097/tp.0000000000002367] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND In adults, the absence of a preexisting chronic liver disease (CLD) is required to diagnose acute liver failure (ALF). The pediatric classification does not consider this aspect, thus previous studies pooled together children with ALF and children with unknown CLD presenting with acute hepatic decompensation (ALF-CLD). We aimed to compare prevalence, features, and outcome of children with ALF-CLD to those with a proper ALF. METHODS Patients admitted between 1996 and 2017 because of ALF defined by Pediatric Acute Liver Failure criteria (raised transaminases, International Normal Ratio ≥2.0, no history of liver disease) were classified as ALF-CLD if diagnosed with autoimmune hepatitis, Wilson disease, Budd-Chiari syndrome, hepatitis B virus reactivation, inborn errors of metabolism. The others were classified as ALF. RESULTS Seventy-four children (median age, 4 years; 1.0-8.8; male/female, 36/38] with ALF were found; 18 of <1 year of age were excluded. Fifty-six (median age, 6.6 years; 2.7-11.7; male/female, 23/33], 22 with ALF-CLD (autoimmune hepatitis, n = 14; Wilson disease, n = 6; inborn errors of metabolism, n = 2) and 34 with ALF (paracetamol overdose, n = 6; viral infections, n = 3; mushroom poisoning, n = 5; indeterminate, n = 20) were compared. In ALF-CLD, the median age at onset was higher, alanine aminotransferase, albumin, and International Normal Ratio levels were lower, splenomegaly, ascites, and cirrhosis were more common (all P < 0.01). On multivariate analysis, the diagnosis of ALF-CLD was an independent predictor of transplant-free survival (P = 0.006). CONCLUSIONS In children, ALF-CLD is common, has peculiar features, and is associated with a favorable outcome. This study suggests the need to distinguish this entity from other forms of ALF in children.
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Affiliation(s)
- Angelo Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - Emanuele Nicastro
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - Davide Dalla Rosa
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - Gabriella Nebbia
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Aurelio Sonzogni
- Liver and Transplant Pathology, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - Lorenzo D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
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19
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Szymczak M, Kaliciński P, Kowalewski G, Broniszczak D, Markiewicz-Kijewska M, Ismail H, Stefanowicz M, Kowalski A, Teisseyre J, Jankowska I, Patkowski W. Acute liver failure in children-Is living donor liver transplantation justified? PLoS One 2018; 13:e0193327. [PMID: 29474400 PMCID: PMC5825073 DOI: 10.1371/journal.pone.0193327] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/08/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Living donor liver transplantation (LDLT) in patients with acute liver failure (ALF) has become an acceptable alternative to transplantation from deceased donors (DDLT). The aim of this study was to analyze outcomes of LDLT in pediatric patients with ALF based on our center's experience. MATERIAL AND METHODS We enrolled 63 children (at our institution) with ALF who underwent liver transplantation between 1997 and 2016. Among them 24 (38%) underwent a LDLT and 39 (62%) received a DDLT. Retrospectively analyzed patient clinical data included: time lapse between qualification for transplantation and transplant surgery, graft characteristics, postoperative complications, long-term results post-transplantation, and living donor morbidity. Overall, we have made a comparison of clinical results between LDLT and DDLT groups. RESULTS Follow-up periods ranged from 12 to 182 months (median 109 months) for LDLT patients and 12 to 183 months (median 72 months) for DDLT patients. The median waiting time for a transplant was shorter in LDLT group than in DDLT group. There was not a single case of primary non-function (PNF) in the LDLT group and 20 out of 24 patients (83.3%) had good early graft function; 3 patients (12.5%) in the LDLT group died within 2 months of transplantation but there was no late mortality. In comparison, 4 out of 39 patients (10.2%) had PNF in DDLT group while 20 patients (51.2%) had good early graft function; 8 patients (20.5%) died early within 2 months and 2 patients (5.1%) died late after transplantation. The LDLT group had a shorter cold ischemia time (CIT) of 4 hours in comparison to 9.2 hours in the DDLT group (p<0.0001). CONCLUSIONS LDLT is a lifesaving procedure for pediatric patients with ALF. Our experience showed that it may be performed with very good results, and with very low morbidity and no mortality among living donors when performed by experienced teams following strict procedures.
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Affiliation(s)
- Marek Szymczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Broniszczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Hor Ismail
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marek Stefanowicz
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Adam Kowalski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Joanna Teisseyre
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology and Immunology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Warsaw Medical University, Warsaw, Poland
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20
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Gilbert Pérez JJ, Jordano Moreno B, Rodríguez Salas M. Aetiology, outcomes and prognostic indicators of paediatric acute liver failure. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2018. [DOI: 10.1016/j.anpede.2017.02.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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21
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Uchida H, Sakamoto S, Fukuda A, Sasaki K, Shigeta T, Nosaka S, Kubota M, Nakazawa A, Nakagawa S, Kasahara M. Sequential analysis of variable markers for predicting outcomes in pediatric patients with acute liver failure. Hepatol Res 2017; 47:1241-1251. [PMID: 28032939 DOI: 10.1111/hepr.12859] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2016] [Revised: 12/01/2016] [Accepted: 12/26/2016] [Indexed: 02/08/2023]
Abstract
AIM Our aim was to analyze serial changes in the predictive variables and a scoring system retrospectively adapted to evaluate outcomes in pediatric patients with acute liver failure (ALF). METHODS We retrospectively collected data on 65 patients with ALF. The 65 patients were divided into two groups according to the need for liver transplantation (LT) as follows: LT group (n = 54) and non-LT group (n = 11). The early determination scoring system of the indications for LT proposed by the Intractable Hepato-Biliary Diseases Study Group of Japan (JIHBDSG) was used in our study. The area under the receiver operating characteristic curve (AUROC) was calculated for the JIHBDSG score between the LT group and non-LT group at the time of diagnosis (day 0) and day 3, and day 5 after the diagnosis. RESULTS A JIHBDSG score of >3 at day 5 was found to identify the patients requiring LT with 83.7% sensitivity, 81.8% specificity, and 83.3% diagnostic accuracy. Based on a comparison of AUROC values, the JIHBDSG score on day 5 (AUROC 0.91) was higher than that on day 0 (AUROC 0.75) and day 3 (AUROC 0.84). CONCLUSION We showed that a serial analysis of the JIHBDSG score might be useful for predicting outcomes of ALF in pediatric patients who fulfilled the criteria of LT indication in our center. However, further studies are needed to validate our results.
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Affiliation(s)
- Hajime Uchida
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Kengo Sasaki
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Takanobu Shigeta
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Shunsuke Nosaka
- Division of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Masaya Kubota
- Division of Neurology, National Center for Child Health and Development, Tokyo, Japan
| | - Atsuko Nakazawa
- Division of Pathology, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Division of Critical Care and Anesthesia, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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Di Giorgio A, Sonzogni A, Piccichè A, Alessio G, Bonanomi E, Colledan M, D'Antiga L. Successful management of acute liver failure in Italian children: A 16-year experience at a referral centre for paediatric liver transplantation. Dig Liver Dis 2017; 49:1139-1145. [PMID: 28663066 DOI: 10.1016/j.dld.2017.05.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 04/18/2017] [Accepted: 05/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Identifying the causes of acute liver failure (ALF) and predictors of death or liver transplantation (LTX) is crucial to decide its management. We aimed to describe features and outcome of ALF in Italian children. METHODS Retrospective review of cases presenting between 1996-2012. ALF was defined by high transaminases, INR ≥2.0 regardless of hepatic encephalopathy (HE), no evidence of underlying chronic liver disease. RESULTS 55 children (median age 2.6 years, range 0.1-15.1; M/F=31/24) had ALF due to autoimmune hepatitis (AIH) in 10 (18%), metabolic disorders in 9 (17%), paracetamol overdose in 6 (11%), mushroom poisoning in 3 (5%), viral infection in 1 (2%), indeterminate in 26 (47%); 25/55 recovered with supportive management (45%); 28/55 underwent LTX and 2 died on the waiting list (55%). On multivariate analysis severity of HE grade 3-4 and bilirubin ≥12mg/dl were independent predictors of death or LTX (p<0.05). After a median follow up of 4 years (range 2-15.0 years) the overall survival rate was 93%. CONCLUSION Children with ALF can be managed successfully with combined medical treatment and transplantation, warranting a survival rate similar to children transplanted because of chronic conditions. In our cohort of patients severe HE and high bilirubin on admission were independent predictors of the need of LTX.
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Affiliation(s)
- A Di Giorgio
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - A Sonzogni
- Liver and Transplant Pathology, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - A Piccichè
- Hospital Management, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - G Alessio
- Laboratory Medicine, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - E Bonanomi
- Paediatric Intensive Care Unit, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - M Colledan
- General Surgery and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy
| | - L D'Antiga
- Paediatric Hepatology, Gastroenterology and Transplantation, Hospital Papa Giovanni XXIII Bergamo, Italy.
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Gilbert Pérez JJ, Jordano Moreno B, Rodríguez Salas M. [Aetiology, outcomes and prognostic indicators of paediatric acute liver failure]. An Pediatr (Barc) 2017; 88:63-68. [PMID: 28395968 DOI: 10.1016/j.anpedi.2017.02.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 02/23/2017] [Accepted: 02/28/2017] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute liver failure (ALF) is a multisystem disease with severe impairment of liver function of acute onset. The Paediatric End-stage Liver Disease (PELD) score is used as a predictor of mortality in chronic liver disease, however experience is limited in ALF. OBJECTIVES To evaluate the aetiology and outcomes of children with ALF in a Children's Liver Transplant Centre, and to investigate the validity of PELD as a prognostic indicator. PATIENTS AND METHODS A retrospective study was conducted on patients diagnosed with ALF in our hospital from 2000 to 2013 using the criteria of the Paediatric ALF Study Group. RESULTS The study included 49 patients with an age range 0-14years. The most frequent aetiologies were: indeterminate (36.7%) and metabolic (26.5%). Liver transplant (LT) was required by 42.8%, and there were 16.3% deaths. Patients with higher levels of bilirubin, INR, or encephalopathy were more likely to require a liver transplant, yielding an OR for INR 1.93. A cut-off of 27 in the PELD score according to the ROC curve showed a sensitivity of 86% and a specificity of 85%, predicting a worse outcome (AUC: 0.90; P<.001). The survival of patients with ALF without transplantation seems more likely in those who have low values of PELD and absence of encephalopathy, with a RR of 0.326. CONCLUSIONS ALF patients with a high PELD score and the presence of encephalopathy had worse outcomes. The PELD score could be a useful tool to establish the optimum time for inclusion in the transplant list, however further studies are still needed.
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Affiliation(s)
- Juan José Gilbert Pérez
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España
| | - Belén Jordano Moreno
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España.
| | - Mónica Rodríguez Salas
- Unidad de Gastroenterología, Hepatología, Nutrición y Trasplante Hepático Pediátrico, Unidad de Gestión Clínica, Críticos y Urgencias Pediátricas, Hospital Universitario Reina Sofía, Córdoba, España
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Jain V, Dhawan A. Prognostic modeling in pediatric acute liver failure. Liver Transpl 2016; 22:1418-30. [PMID: 27343006 DOI: 10.1002/lt.24501] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 06/12/2016] [Accepted: 06/16/2016] [Indexed: 02/07/2023]
Abstract
Liver transplantation (LT) is the only proven treatment for pediatric acute liver failure (PALF). However, over a period of time, spontaneous native liver survival is increasingly reported, making us wonder if we are overtransplanting children with acute liver failure (ALF). An effective prognostic model for PALF would help direct appropriate organ allocation. Only patients who would die would undergo LT, and those who would spontaneously recover would avoid unnecessary LT. Deriving and validating such a model for PALF, however, encompasses numerous challenges. In particular, the heterogeneity of age and etiology in PALF, as well as a lack of understanding of the natural history of the disease, contributed by the availability of LT has led to difficulties in prognostic model development. Several prognostic laboratory variables have been identified, and the incorporation of these variables into scoring systems has been attempted. A reliable targeted prognostic model for ALF in Wilson's disease has been established and externally validated. The roles of physiological, immunological, and metabolomic parameters in prognosis are being investigated. This review discusses the challenges with prognostic modeling in PALF and describes predictive methods that are currently available and in development for the future. Liver Transplantation 22 1418-1430 2016 AASLD.
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Affiliation(s)
- Vandana Jain
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK
| | - Anil Dhawan
- Paediatric Liver, GI and Nutrition Centre, King's College Hospital, London, UK.
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Hegarty R, Hadzic N, Gissen P, Dhawan A. Inherited metabolic disorders presenting as acute liver failure in newborns and young children: King's College Hospital experience. Eur J Pediatr 2015; 174:1387-92. [PMID: 25902754 DOI: 10.1007/s00431-015-2540-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 04/04/2015] [Accepted: 04/08/2015] [Indexed: 11/27/2022]
Abstract
UNLABELLED Acute liver failure (ALF) in children is a rare condition that is often fatal without liver transplantation. The diagnostic work-up is complex, and the etiology is unidentified in up to half of patients, making decisions like therapeutic transplantation extremely difficult. We collected clinical, laboratory, and outcome data on all patients under 5 years of age who were admitted between January 2001 and December 2011 to King's College Hospital with ALF secondary to an inherited metabolic disease (IMD), a common cause of pediatric acute liver failure. Thirty-six of 127 children with ALF had a metabolic etiology: galactosemia (17); mitochondrial respiratory chain disorder (MRCD, 7); ornithine transcarbamylase (OTC) deficiency (4); tyrosinemia type 1 (4); Niemann-Pick disease type C (NPC, 3); and congenital disorder of glycosylation type 1b (1). Seven children died: MRCD (4) and NPC (3). Four children were transplanted: OTC deficiency (1) and MRCD (3). Fifteen of 25 children followed up showed evidence of developmental delay. CONCLUSION IMD is the most common group of disorders in this age group; indeterminate cases may yet include undiagnosed metabolic disorders; the overall survival rate is good but largely depends on diagnosis, while developmental outcome of the surviving patients is less favorable. WHAT IS KNOWN • Up to half of children with ALF may be undiagnosed. • IMD is a common cause of pediatric acute liver failure. What is New: • Initial diagnostic clues may be gathered from the child's age and laboratory parameters. • Survival of children with IMD-related ALF is good, but developmental outcome is less favorable. • In the future, novel sequencing methods will aid in the diagnosis of disorders in which therapeutic decisions depend upon.
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Affiliation(s)
- Robert Hegarty
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Nedim Hadzic
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
| | - Paul Gissen
- Metabolic Medicine Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Anil Dhawan
- Pediatric Liver Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, SE5 9RS, UK.
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Abstract
Liver biopsy (LB) is still the criterion standard procedure for obtaining liver tissue for histopathological examination and a valuable tool in the diagnosis, prognosis, and management of many parenchymal liver diseases. The aim of this position paper is to summarise the present practice of paediatric LB and make recommendations about its performance. Although histological evaluation of the liver is important in assessing prognosis and exploring treatment, noninvasive techniques (ie, imaging, laboratory markers) may replace use of liver histology. The indications for LB are changing as present knowledge of aetiologies, pathomechanism, and therapeutic options in paediatric liver disease is evolving. Adult and paediatric literature was reviewed to assess the existing clinical practice of LB with focus on the technique, indications, risk of complications, and contraindications in paediatrics. This position paper presents types of LB, indications, complications, contraindications, and an essential checklist for paediatric LB.
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Abstract
OBJECTIVE Autoimmune hepatitis (AIH) is considered an underdiagnosed cause of fulminant hepatic failure (FHF). Autoimmune FHF (AI-FHF) is believed to lead invariably to liver transplantation (LTX) or death. We aimed to describe the autoimmune features of children diagnosed as having AI-FHF and indeterminate FHF (ID-FHF), and describe the outcome of patients with AI-FHF treated with immunosuppressive drugs. METHODS In this case-control study, the files of patients with AI-FHF and ID-FHF were reviewed and compared. AIH was diagnosed based on positive autoantibodies, raised immunoglobulin G, and histology when available. FHF was defined by raised transaminases, international normalised ratio ≥ 2.0, presence of encephalopathy, and no previously recognised liver disease. RESULTS A total of 46 children with FHF were managed in the last 15 years: 10/46 (22%) had AI-FHF, 20/46 (43%) ID-FHF, and 16 had other diagnosis. The mean follow-up time was 4.6 years. AI-FHF and ID-FHF differed for the presence of autoantibodies (10/10, 6/10 liver/kidney microsome [LKM]-type, vs 3/20, none LKM, P < 0.0001), immunoglobulin G level (1845 vs 880 mg/dL, P < 0.001), median age at diagnosis (6.4 vs 1.8 years, P = 0.017), and alanine aminotransferase level (1020 vs 2386 IU/L, P = 0.029). Liver histology did not allow to differentiate the 2 conditions. Among the patients with AI-FHF, 4/9 who received steroids recovered; 5/9 required LTX and 1 died awaiting treatment. CONCLUSIONS AIH is a much more common cause of FHF than previously suggested, and a complete autoantibody testing including LKM-type is essential in this setting. Autoantibodies are uncommon in ID-FHF, and histology cannot distinguish it from AI-FHF. A cautious steroid trial may avoid LTX in some of the patients with AI-FHF.
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Pediatric acute liver failure: variations in referral timing are associated with disease subtypes. Eur J Pediatr 2015; 174:169-75. [PMID: 25005716 DOI: 10.1007/s00431-014-2363-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2014] [Revised: 06/13/2014] [Accepted: 06/16/2014] [Indexed: 10/25/2022]
Abstract
UNLABELLED In pediatric acute liver failure (PALF), rapid referral to a transplant center (TC) is advocated. Clinical variability of PALF may influence referral timing. We aimed to analyze early or late timing of referral in relation to clinical characteristics and outcome in PALF. We conducted a retrospective, single-center, comparative analysis of clinical and liver function parameters in two PALF cohorts (n = 23 per cohort): cohort 1 (early referral, duration of in-patient care before referral (DCR) <7 days) vs. cohort 2 (late referral, DCR ≥ 7 days). Compared to late referrals, patients referred early were more frequently non-icteric and encephalopathic at initial presentation (n = 14 vs. 5 and n = 13 vs. 4, each p < 0.05). Early referred PALF patients had lower hepatic encephalopathy (HE) grades and bilirubin (grade 1 vs. 2, p < 0.02; 215 vs. 439 μmol/l, p < 0.001, respectively) but higher alanine aminotransferase (ALAT) levels (4,340 vs. 963 U/l, p < 0.001). Cumulative poor prognostic indicators were lower in early referrals (2 vs. 4, p < 0.001). In multivariate analysis, subacute liver failure (SLF >7 days between disease onset and development of encephalopathy) was independently associated with late referral (relative risk 9.48; 95 % CI 1.37-64.85, p < 0.02). Differences in survival to discharge were not significant. CONCLUSION In PALF, referral timing variability is associated with distinct clinical and liver function patterns. Early recognition of prognostic indicators and of SLF may help to improve referral timing and thus PALF management.
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Quintero J, Miserachs M, Ortega J, Bueno J, Dopazo C, Bilbao I, Castells L, Charco R. Indocyanine green plasma disappearance rate: a new tool for the classification of paediatric patients with acute liver failure. Liver Int 2014; 34:689-94. [PMID: 24112412 DOI: 10.1111/liv.12298] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 06/15/2013] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Pediatric acute liver failure is a rare disorder which results in death or the need for liver transplantation in 25-50% of cases. The adults scores are unable to predict survival without liver transplantation of pediatric patients. The present study assessed the use the of indocyanine green plasma disappearance rate as a tool to predict the evolution of pediatric patients with acute liver failure. PATIENTS AND METHODS All patients met the criteria of acute liver failure according to the Pediatric Acute Liver Failure Study Group. King's College, Clichy's criteria and ICG-PDR were obtained on admission or when acute liver failure was diagnosed and repeated every 12-24 hours, respectively. RESULTS Thirteen out of 48 patients suffered an irreversible liver damage. Seven of them underwent a liver transplantation and 6 died on the waiting. A total of 154 ICG-PDR measurements were taken during the study (Median 12.4 %/min, r:6.2 - 26.3). The ICG-PDR was significantly lower in patients who suffered irreversible liver damage compared with those who survived without liver transplantation (median ICG-PDR 4.1 %/min; r:4.0 - 5.7 vs median ICG-PDR 20.3 %/min; r: 9.1 - 30.1; respectively. P < 0.001). Using a ROC curve the cutoff of ICG-PDR for assessing the need for liver transplantation was set at 5.9 %/min (sensitivity 92.3%, specificity 97.1%). Sensitivity, specificity, PPV, NPV and DA for ICG-PDR were higher than the King's College and Clichy's criteria. CONCLUSIONS ICG-PDR is a powerful tool that would improve the categorization of patients with pediatric acute liver failure.
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Affiliation(s)
- Jesús Quintero
- Pediatric Liver Transplant Unit, Hospital Universitari Vall d'Hebron, Universitat Autónoma de Barcelona, Barcelona, Catalunya, Spain
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Sato M, Tateishi R, Yasunaga H, Horiguchi H, Yoshida H, Matsuda S, Fushimi K, Koike K. Acute liver disease in Japan: a nationwide analysis of the Japanese Diagnosis Procedure Combination database. J Gastroenterol 2014; 49:547-54. [PMID: 23783841 DOI: 10.1007/s00535-013-0843-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 05/23/2013] [Indexed: 02/04/2023]
Abstract
BACKGROUND Accurate data on the incidence of acute liver disease (ALD) is lacking in most countries. We investigated the incidence of ALD-related admission in Japan using a large sample in a nationwide Japanese database. METHODS Data from the Diagnosis Procedure Combination database were analyzed for 1 July to 31 December 2007-2010. Patient characteristics, in-hospital mortality, and clinical practices, including drugs and procedures during hospitalization, were analyzed. RESULTS We identified 10509 patients with ALD from a total of 11.61 million inpatients in the database. The median age was 53 years and 54.7 % were male. The annual incidence of ALD-related hospital admission was estimated to be 131.1 cases/1 million people. The overall mortality rate was 5.9 % (622 cases). The infant (0-3 years), child (4-18 years), and adult in-hospital mortality rates were 2.7 % (7/261), 1.0 % (5/494), and 6.3 % (610/9754), respectively. The infant and child mortality rates were significantly lower than the adult mortality rate (Chi square test: P = 0.03 and P < 0.001, respectively). Hepatitis A virus- and hepatitis C virus-induced ALD had favorable outcomes, with in-hospital mortality rates of approximately 2 %. Plasma exchange and continuous hemodiafiltration were performed in 5.3 % (556 cases) and 3.4 % (360 cases) of all ALD cases, respectively. CONCLUSIONS In-hospital mortality of ALD in Japan was acceptably low, and was affected by the etiology and patient background characteristics. The present study adds important information on the incidence and prognosis of ALD in Japan. Improvement of public health surveillance systems is necessary for population-based patient monitoring.
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Affiliation(s)
- Masaya Sato
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
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Abstract
OBJECTIVE The aim of our study was to review the experiences of a living donor-dominant transplantation program for children with acute liver failure (ALF). METHODS Data were derived from the retrospective chart review of 50 children with ALF in a major liver center in the Republic of Korea. RESULTS A total of 50 children with ALF underwent 47 (94%) primary living donor liver transplantations and 3 (6%) cadaveric liver transplantations. The cumulative survival rates of the grafts at 1 and 5 years were 81.9% and 79.2%, respectively. The overall retransplantation rate was 12%. The cumulative survival rates of these patients at 1 and 5 years were all 87.9%. Most incidents of mortality followed the failure of the preceding graft. We observed no mortalities among donors. Based on multivariate analysis, children who had pretransplant thrombocytopenia or had to use the molecular adsorbent recycling system preoperatively were related to the graft loss. Age younger than 2 years and a hyperacute onset (within 7 days) of hepatic encephalopathy were associated with pretransplant thrombocytopenia. CONCLUSIONS Living donor-dominant transplantation program in the present study demonstrates tolerable achievements in terms of clinical outcomes of recipients and donors; however, putative factors, such as pretransplant thrombocytopenia, seem to play unclear roles in a poor prognosis following transplantation.
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Grabhorn E, Nielsen D, Hillebrand G, Brinkert F, Herden U, Fischer L, Ganschow R. Successful outcome of severe Amanita phalloides poisoning in children. Pediatr Transplant 2013; 17:550-5. [PMID: 23721499 DOI: 10.1111/petr.12108] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/05/2013] [Indexed: 12/01/2022]
Abstract
Amanita phalloides intoxication can lead to FHF with high mortality, especially in children. There is still ongoing discussion about the optimal treatment and decision criteria for emergency liver transplantation (LTx). Here, we summarize our experience with outcomes in five children. Five children with severe A. phalloides intoxication were treated at our tertiary center from 1995 to 2010 and studied retrospectively with respect to clinical and laboratory aspects that might help to decide between LTx or conservative therapy only. The findings are discussed with regard to recommended treatment and transplantation criteria for adults. All patients survived, of whom two of five received emergency LTx. Three patients survived with conservative treatment consisting of intravenous silibinin, NAC, detoxification measures, and intensive care. Indications for LTx in two children were progressive brain edema and cardiovascular failure. Children with FHF due to A. phalloides intoxication should be considered early for emergency LTx but should be monitored closely for the necessity of definite LTx. Early detoxification with active charcoal as well as silibinin and NAC seems to improve the outcome. Late recovery of liver function after day 4 post-ingestion is possible.
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Affiliation(s)
- Enke Grabhorn
- Department of Pediatric Hepatology and Liver Transplantation, University Hospital Hamburg-Eppendorf, Hamburg, Germany.
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Management of acute liver failure in infants and children: Consensus statement of the pediatric gastroenterology chapter, Indian academy of pediatrics. Indian Pediatr 2013; 50:477-82. [DOI: 10.1007/s13312-013-0147-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Rajanayagam J, Coman D, Cartwright D, Lewindon PJ. Pediatric acute liver failure: etiology, outcomes, and the role of serial pediatric end-stage liver disease scores. Pediatr Transplant 2013; 17:362-8. [PMID: 23586473 DOI: 10.1111/petr.12083] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/13/2013] [Indexed: 02/03/2023]
Abstract
To describe etiology, short-term outcomes and prognostic accuracy of serial PELD scores in PALF. Retrospective analysis of children aged ≤16 yr, admitted with PALF under the QLTS, Brisbane, Australia, between 1991 and 2011. PELD-MELD scores were ascertained at three time points (i) admission (ii), meeting PALF criteria, and (iii) peak value. Fifty-four children met criteria for PALF, median age 17 months (1 day-15.6 yr) and median weight 10.2 kg (1.9-57 kg). Etiology was known in 69%: 26% metabolic, 15% infective, 13% drug-induced, 6% autoimmune, and 9% hemophagocytic lymphohistiocytosis. Age <3 months and weight <4.7 kg predicted poor survival in non-transplanted children. Significant independent predictors of poor outcome (death or LT) were peak bilirubin > 220 μm/L and peak INR > 4. Serial PELD-MELD scores were higher in the 17 (32%) transplant recipients (mean: [i] 26.8, [ii] 31.8, [iii] 42.6); highest in the 12 (22%) non-transplanted non-survivors (mean: [i] 31.6, [ii] 37.2, [iii] 45.7) compared with the 25 (46%) transplant-free survivors (mean: [i] 25.3, [ii] 26.0, [iii] 30.3). PELD-MELD thresholds of ≥27 and ≥42 at (ii) meeting PALF criteria and (iii) peak predicted poor outcome (p < 0.001). High peak bilirubin and peak INR predict poor outcome and serial PELD-MELD is superior to single admission PELD-MELD score for predicting poor outcome.
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Affiliation(s)
- Jeremy Rajanayagam
- Department of Pediatric Gastroenterology, Royal Children's Hospital, Herston, Brisbane, QLD 4006, Australia
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35
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Lu BR, Zhang S, Narkewicz MR, Belle SH, Squires RH, Sokol RJ. Evaluation of the liver injury unit scoring system to predict survival in a multinational study of pediatric acute liver failure. J Pediatr 2013; 162:1010-6.e1-4. [PMID: 23260095 PMCID: PMC3786160 DOI: 10.1016/j.jpeds.2012.11.021] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 10/04/2012] [Accepted: 11/02/2012] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To examine the predictive value of the Liver Injury Units (LIU) and admission values (aLIU) of bilirubin and prothrombin time and international normalized ratio scores in a large cohort from the Pediatric Acute Liver Failure (PALF) Study Group, a multinational prospective study. STUDY DESIGN LIU and aLIU scores were calculated for 461 and 579 individuals, respectively, enrolled in the PALF study from 1999 to 2008. Receiver operator characteristic curves were used to evaluate the scores with respect to survival without liver transplantation (LT), death, or LT by 21 days after enrollment. RESULTS At 21 days, 50.3% of participants were alive without LT, 36.2% underwent LT, and 13.4% died. The c-indices for transplant-free survival were 0.81 based on the LIU score with the international normalized ratio (95% CI, 0.78-0.85) and 0.76 based on the aLIU score (95% CI, 0.72-0.79). The LIU score predicted LT better than it predicted death (c-index for LT 0.84, c-index for death 0.76). CONCLUSION Based on data from a large, multicenter cohort of patients with PALF, the LIU score was a better predictor of transplant-free survival than was the aLIU score. The LIU score might be a helpful, dynamic tool to predict clinical outcomes in patients with PALF.
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Affiliation(s)
- Brandy R. Lu
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO
| | - Song Zhang
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Michael R. Narkewicz
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Children's Hospital Colorado, Aurora, CO
| | - Steven H. Belle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Robert H. Squires
- Department of Pediatrics, University of Pittsburgh and the Children's Hospital of UPMC, Pittsburgh, PA
| | - Ronald J. Sokol
- Section of Pediatric Gastroenterology, Hepatology, and Nutrition, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO,Children's Hospital Colorado, Aurora, CO
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D'Agostino D, Diaz S, Sanchez MC, Boldrini G. Management and prognosis of acute liver failure in children. Curr Gastroenterol Rep 2012; 14:262-269. [PMID: 22528660 DOI: 10.1007/s11894-012-0260-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Although the etiologies of pediatric acute liver failure (ALF) are diverse, ultimate pathophysiologic pathways and management challenges for these disorders, usually lethal in the pre-transplant era, are similar. This review considers particularly the mechanisms of, and monitoring for, intracranial hypertension and coagulopathy; summarizes detailed advice for management of the ALF-associated failures of multiple body systems; and reviews the variety of prognostic scores available to guide management and assist in choosing the patients most apt to benefit from liver transplantation and the optimal timing for such transplantation.
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Affiliation(s)
- Daniel D'Agostino
- Gastroenterology-Hepatology Division, Liver-Intestinal Transplantation Center, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
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Srivastava A, Yachha SK, Poddar U. Predictors of outcome in children with acute viral hepatitis and coagulopathy. J Viral Hepat 2012; 19:e194-201. [PMID: 22239519 DOI: 10.1111/j.1365-2893.2011.01495.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
The presence of coagulopathy in acute viral hepatitis (AVH) in children raises issues about prognosis and need for liver transplantation. We evaluated factors predicting outcome in such patients and determined the applicability of the paediatric acute liver failure study group (PALFSG) definition of acute liver failure (ALF) of coagulopathy alone in comparison with coagulopathy and encephalopathy. Children with AVH (clinical features, raised transaminases and positive viral serology) with uncorrectable coagulopathy [prothrombin time (PT) > 15 s] with or without hepatic encephalopathy (HE) were enrolled. Comparative analysis was based on (i) outcome: survivors/nonsurvivors and (ii) ALF criteria: group A coagulopathy (PT > 15 s) and encephalopathy and group B coagulopathy (PT > 20 s). We studied 130 children (86 boys, mean age 7.5 ± 4.5 years): 86 recovered and 44 died. Single virus infection was present in 96 (74%), hepatitis A being the commonest (n-69). On multiple stepwise logistic regression analysis, age <3.5 years, serum bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and clinical signs of cerebral oedema were independent predictors of mortality. Mortality increased from 0% with single to 100% with four risk factors. Ninety-seven cases met the PALFSG criteria: group A-79 and group B-18. Group A subjects had higher mortality (55.6%vs 0%) and poorer liver functions (bilirubin 18.1 ± 8.9 vs 13.8 ± 6.9 mg/dL, PT 63.9 ± 35.1 vs 27.2 ± 5.2 s) than group B. PT deteriorated significantly with the appearance and progression of HE. One-third of children with AVH with coagulopathy die without transplantation. Age <3.5 years, bilirubin ≥ 16.7 mg/dL, PT ≥ 40.5 s and signs of cerebral oedema are predictors of poor outcome. Children with encephalopathy and coagulopathy have a poorer outcome than those with coagulopathy alone.
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Affiliation(s)
- A Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
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Teufel U, Weitz J, Flechtenmacher C, Prietsch V, Schmidt J, Hoffmann GF, Kölker S, Engelmann G. High urgency liver transplantation in ornithine transcarbamylase deficiency presenting with acute liver failure. Pediatr Transplant 2011; 15:E110-5. [PMID: 21884343 DOI: 10.1111/j.1399-3046.2009.01171.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OTCD can present with ALF at any age. Under adequate therapy symptoms resolve quickly. We report a three-yr-old girl with the manifestation of an OTCD as ALF. Despite adequate pharmacotherapy and protein restriction, the patient deteriorated and developed hepatic encephalopathy. A high urgency liver transplantation was performed and the patient recovered completely. We conclude that in patients with ALF urea cycle defects in general and OTCD in particular should be considered as differential diagnosis. Patients should be managed in a center that has the capacity for an emergency liver transplantation.
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Affiliation(s)
- Ulrike Teufel
- Department of General Pediatrics, University of Heidelberg, Heidelberg, Germany.
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Shanmugam NP, Bansal S, Greenough A, Verma A, Dhawan A. Neonatal liver failure: aetiologies and management--state of the art. Eur J Pediatr 2011; 170:573-81. [PMID: 20886352 DOI: 10.1007/s00431-010-1309-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/15/2010] [Indexed: 12/19/2022]
Abstract
Acute liver failure in neonates is rare, but carries a high mortality. Neonatal liver failure can be defined as "failure of the synthetic function of liver within 4 weeks of birth". Encephalopathy is not essential for the diagnosis. Acute liver failure in neonates differs from children with regard to aetiology and outcome. Common causes of neonatal liver failure are neonatal hemochromatosis, haematological malignancies, viral infections and liver-based metabolic defects. Early diagnosis and referral to a paediatric liver centre is recommended as liver transplantation is the only definitive treatment when supportive or a disease-specific treatment fails.
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Affiliation(s)
- Naresh P Shanmugam
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
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Shanmugam NP, Dhawan A. Selection criteria for liver transplantation in paediatric acute liver failure: the saga continues. Pediatr Transplant 2011; 15:5-6. [PMID: 21241436 DOI: 10.1111/j.1399-3046.2010.01457.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Abstract
Acute liver failure (ALF) is defined as a multisystem disorder of severe impairment of liver function, with or without encephalopathy, which is associated with hepatocellular necrosis (reflected as liver synthetic failure in patients with no recognized chronic liver disease), and can lead to death. ALF can be due to hepatotoxic drugs, natural toxins, autoimmune disease, severe bacterial infection and some neoplastic processes, or ALF can be idiopathic. In the pediatric group, the most frequent cause is viral agents; hepatitis A is the most common among these. The pathophysiologic changes in ALF consist of alterations in coagulation, elevated serum ammonia, hypoalbuminemia and hypoglycemia. In recent years, N-acetylcysteine has been utilized to treat this condition. Using this drug during the early stages of the disease has the potential to improve outcomes for the patient, including the avoidance liver transplantation. This article focuses on the criteria that help to identify ALF and emphasizes accessible alternative medical treatments.
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Affiliation(s)
- Norberto Sotelo
- Jefe del Servicio de Medicina Interna, Hospital Infantil del Estado de Sonora, Calle Reforma Numero 355 Norte, Colonia Ley 57, CP 83100, Hermosillo Sonora, Mexico
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Intensive care management of children with acute liver failure. Indian J Pediatr 2010; 77:1288-95. [PMID: 20799075 DOI: 10.1007/s12098-010-0167-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2010] [Accepted: 07/30/2010] [Indexed: 12/20/2022]
Abstract
Acute liver failure is an uncommon condition associated with multi organ involvement, high morbidity and mortality. Etiology of acute liver failure varies with age and geographical location. Most cases of acute liver failure in India are due to infectious causes predominantly viral hepatitis. A significant group with indeterminate causation remains, despite careful investigation. The etiology of acute liver failure in infants is largely metabolic. The mainstay of management is supportive care in an intensive care unit. Monitoring of clinical and biochemical parameters is done frequently until the patient becomes stable. Mortality is predominantly due to raised intracranial pressure, infections and multi-organ failure. Liver transplant is an important life saving procedure for children with acute liver failure.
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Acute toxicity profile of radiotherapy in 690 children and adolescents: RiSK data. Radiother Oncol 2010; 97:119-26. [DOI: 10.1016/j.radonc.2010.04.030] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2009] [Revised: 03/16/2010] [Accepted: 04/05/2010] [Indexed: 11/19/2022]
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Mahadeb P, Gras J, Sokal E, Otte JB, Lerut J, Detaille T, de Cléty SC, Reding R. Liver transplantation in children with fulminant hepatic failure: The UCL experience. Pediatr Transplant 2009; 13:414-20. [PMID: 19017285 DOI: 10.1111/j.1399-3046.2008.01008.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
The outcome of pediatric LT for FHF was shown to be poor in our center. To better understand such results, recipient and transplant parameters with a putative impact on post-transplant outcome were analyzed in LT for FHF. Between March 1984 and June 2002, 33 children with FHF received a primary liver allograft. The overall results in this series were studied with respect to pre-operative demographic and metabolic variables, peri-operative events, and outcome. Five-yr patient and graft survivals were 71% and 66%, respectively, with a retransplantation rate at 18%. Incidences of perioperative hemorrhage, of HAT and PVT were 14%, 8%, and 4%, respectively. Five-yr acute rejection-free survival rate was 55%. These data confirm the worse outcome following LT for FHF when compared with LT in elective, non-malignant indications such as BA; results in FHF could not be related to surgical or immunological complications in the post-transplant period and it is hypothesized that the MOF associated with FHF contributes to early post-transplant mortality which would justify special management, including aggressive renal and hepatic support.
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Affiliation(s)
- Parikshat Mahadeb
- Pediatric Liver Transplant Program, St Luc University Clinics, Université catholique de Louvain, Brussels, Belgium
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In vitro effects of sera from children with acute liver failure on metabolic and synthetic activity of cryopreserved human hepatocytes. J Pediatr Gastroenterol Nutr 2009; 48:604-7. [PMID: 19412010 DOI: 10.1097/mpg.0b013e31819114da] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
OBJECTIVE The aim of the study was to investigate the in vitro effects of sera from children with acute liver failure (ALF) who had received N-acetylcysteine (NAC) on the metabolic and synthetic activity of cryopreserved human hepatocytes. MATERIALS AND METHODS Cryopreserved human hepatocytes were plated on collagen-coated culture plates and incubated in cell culture medium containing pooled sera at 20% (v/v) obtained from children with ALF (ALF) who received treatment with NAC (ALF + NAC), no treatment with NAC and from normal controls (normal sera [NS]). The effects of the sera on cell metabolic functions were assessed using methylthiazolyldiphenyltetrazolium bromide, [14C]-leucine incorporation, and cytochrome P-450 (CYP1A1/2) activity assays. RESULTS The overall hepatocyte metabolic activity was lower with ALF sera than with NS and ALF + NAC sera. [14C]-leucine incorporation was higher with both ALF sera (ALF and ALF + NAC) than with NS sera. There was a slightly higher activity of cytochrome P450 (CYP1A1/2 activity) in cultures treated with ALF and ALF + NAC than with normal sera treated hepatocyte cultures. CONCLUSIONS Sera from children with ALF who received NAC did not impair the overall cell metabolic activity of cryopreserved human hepatocyte in vitro, which is encouraging for the use of hepatocytes transplantation in these patients.
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Rudnick DA, Dietzen DJ, Turmelle Y, Shepherd R, Zhang S, Belle SH, Squires R. Serum alpha-NH-butyric acid may predict spontaneous survival in pediatric acute liver failure. Pediatr Transplant 2009; 13:223-30. [PMID: 18643912 PMCID: PMC2659723 DOI: 10.1111/j.1399-3046.2008.00998.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
ALF is a serious, often fatal condition. Up to half of PALF patients do not survive without liver transplantation; however, early identification of those least likely to survive spontaneously remains difficult. Clinical experience suggests that recovery from ALF depends on the ability of the liver to regenerate. Based on this, we hypothesized that bio-markers of hepatic regeneration could have utility as predictors of recovery from PALF. In the studies reported here, we used comprehensive amino acid analysis to search for novel metabolomic markers of liver regeneration in mice subjected to partial hepatectomy. This analysis identified alpha-NH(2)-adipic acid and alpha-NH(2)-butyric acid as significantly increased in liver and plasma samples from mice subjected to partial hepatectomy compared to controls. Next, we tested whether serum levels of these markers were associated with clinical outcomes in PALF patients. This examination, performed on the initially collected serum samples from 40 randomly selected patients enrolled in the PALF Study Group, showed increased alpha-NH(2)-butyric-acid (Aab) and Aab:leucine (Aab:Leu) ratio in patients who survived without transplantation compared to those who were transplanted or died. These data indicate that Aab and the Aab:Leu ratio may predict clinical outcomes in PALF.
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Affiliation(s)
- David A. Rudnick
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO,Department of Developmental Biology, Washington University School of Medicine
| | - Dennis J. Dietzen
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Yumirle Turmelle
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Ross Shepherd
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO
| | - Song Zhang
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Steven H. Belle
- Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA
| | - Rob Squires
- Department of Pediatrics, University of Pittsburgh Medical Center
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Kirsch R, Yap J, Roberts EA, Cutz E. Clinicopathologic spectrum of massive and submassive hepatic necrosis in infants and children. Hum Pathol 2009; 40:516-26. [PMID: 19121848 DOI: 10.1016/j.humpath.2008.07.018] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2008] [Revised: 07/23/2008] [Accepted: 07/28/2008] [Indexed: 12/13/2022]
Abstract
Clinicopathologic features of 45 patients with fulminant hepatic failure due to massive or submassive hepatic necrosis were studied. Both percutaneous biopsies and liver explants were available in 23 patients, whole livers only in 11 cases, and biopsies only in 11 cases. An etiologic diagnosis was established in 16 cases (36%). A further 3 cases (7%) were associated with aplastic anemia. Established etiologies included drug reactions (n = 7); autoimmune hepatitis, type 2 (n = 3); halothane hepatitis (n = 1); ischemia/hypotension (n = 1); mushroom poisoning (n = 1); mitochondrial disorder (n = 1); hemophagocytic lymphohistiocytosis (n = 1); and adenoviral hepatitis (n = 1). The extent of necrosis on liver biopsy correlated poorly with that in liver explants (mean difference, 32% +/- 23.8%). Almost all cases could be classified into one of 2 broad patterns of necrosis, namely, (1) zonal coagulative necrosis or (2) panlobular (nonzonal) necrosis. These patterns differed significantly with respect to several clinical parameters including sex ratio, peripheral blood white cell count, serum aspartate transaminase and alanine transaminase, conjugated bilirubin, and alkaline phosphatase levels. Livers with panlobular necrosis showed a spectrum of histopathologic findings that included central venulitis (76%), lymphocytic infiltration of large duct/gallbladder epithelium (54%), and syncytial giant cell transformation (18%). These features were not seen in livers with zonal coagulative necrosis which frequently showed prominent steatosis (91%). Both patterns of necrosis frequently showed ductular proliferation (100%) and cholangiolitis (80%). The diagnostic yield of ancillary studies (histochemistry, immunohistochemistry, and electron microscopy) was very low (<1%). The small proportion of cases with etiologic diagnoses precluded correlation of clinical and histopathological parameters with specific etiologies. In summary, this study describes the spectrum of changes seen in massive and submassive necrosis in children and identifies clinical features that might differentiate between 2 broad patterns of necrosis.
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Affiliation(s)
- Richard Kirsch
- Division of Pathology, Department of Pediatric Laboratory Medicine, Mount Sinai Hospital, Toronto, Ontario, M5G 1X8 Canada.
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Shah UH, Wadhwa N, Sharma D, Jerath N, Wadhawan M, Vij V, Goyal N, Sibal A, Gupta S. Current Status of Pediatric Liver Transplantation in India. APOLLO MEDICINE 2008. [DOI: 10.1016/s0976-0016(11)60157-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
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