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Abstract
Patients with cirrhosis frequently require admission to the intensive care unit (ICU). Common indications for admission to ICU include one or more reasons of sepsis, shock due to any cause, acute gastrointestinal bleeding, and altered mentation either due to hepatic encephalopathy, alcohol withdrawal/intoxication, or metabolic encephalopathy. The appropriate critical care of an individual can determine the outcomes of these sick patients. The Airway, Breathing, Circulation, Disability (ABCD) approach to a patient admitted to ICU includes airway, breathing, circulation, and disability management. In this review, the authors discuss the common indications for ICU admission in a patient with cirrhosis and also their management.
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Affiliation(s)
- Mahathi Avadhanam
- Department of Emergency Medicine, Queen Elizabeth hospital, London, UK
| | - Anand V Kulkarni
- Department of Hepatology, AIG Hospitals, Gachibowli, Hyderabad, India-500032.
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2
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Krüger M, Ruppelt A, Kappler B, Van Soest E, Samsom RA, Grinwis GCM, Geijsen N, Helms JB, Stijnen M, Kock LM, Rasponi M, Kooistra HS, Spee B. Normothermic Ex Vivo Liver Platform Using Porcine Slaughterhouse Livers for Disease Modeling. Bioengineering (Basel) 2022; 9:bioengineering9090471. [PMID: 36135018 PMCID: PMC9495507 DOI: 10.3390/bioengineering9090471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/25/2022] [Accepted: 09/07/2022] [Indexed: 11/16/2022] Open
Abstract
Metabolic and toxic liver disorders, such as fatty liver disease (steatosis) and drug-induced liver injury, are highly prevalent and potentially life-threatening. To allow for the study of these disorders from the early stages onward, without using experimental animals, we collected porcine livers in a slaughterhouse and perfused these livers normothermically. With our simplified protocol, the perfused slaughterhouse livers remained viable and functional over five hours of perfusion, as shown by hemodynamics, bile production, indocyanine green clearance, ammonia metabolism, gene expression and histology. As a proof-of-concept to study liver disorders, we show that an infusion of free fatty acids and acetaminophen results in early biochemical signs of liver damage, including reduced functionality. In conclusion, the present platform offers an accessible system to perform research in a functional, relevant large animal model while avoiding using experimental animals. With further improvements to the model, prolonged exposure could make this model a versatile tool for studying liver diseases and potential treatments.
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Affiliation(s)
- Melanie Krüger
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Alicia Ruppelt
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
- Correspondence:
| | | | | | - Roos Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Guy C. M. Grinwis
- Veterinary Pathology Diagnostic Centre, Department of Biomedical Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3508 TD Utrecht, The Netherlands
| | - Niels Geijsen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - J. Bernd Helms
- Department of Biomolecular Health Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CL Utrecht, The Netherlands
| | - Marco Stijnen
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
| | - Linda M. Kock
- LifeTec Group BV, 5611 ZS Eindhoven, The Netherlands
- Department of Biomedical Engineering, Eindhoven University of Technology, 5600 MB Eindhoven, The Netherlands
| | - Marco Rasponi
- Dipartimento di Elettronica, Informazione e Bioingegneria, Politecnico di Milano, 20133 Milan, Italy
| | - Hans S. Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, 3584 CT Utrecht, The Netherlands
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Krüger M, Samsom RA, Oosterhoff LA, van Wolferen ME, Kooistra HS, Geijsen N, Penning LC, Kock LM, Sainz-Arnal P, Baptista PM, Spee B. High level of polarized engraftment of porcine intrahepatic cholangiocyte organoids in decellularized liver scaffolds. J Cell Mol Med 2022; 26:4949-4958. [PMID: 36017767 PMCID: PMC9549510 DOI: 10.1111/jcmm.17510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 05/30/2022] [Accepted: 07/23/2022] [Indexed: 12/01/2022] Open
Abstract
In Europe alone, each year 5500 people require a life-saving liver transplantation, but 18% die before receiving one due to the shortage of donor organs. Whole organ engineering, utilizing decellularized liver scaffolds repopulated with autologous cells, is an attractive alternative to increase the pool of available organs for transplantation. The development of this technology is hampered by a lack of a suitable large-animal model representative of the human physiology and a reliable and continuous cell source. We have generated porcine intrahepatic cholangiocyte organoids from adult stem cells and demonstrate that these cultures remained stable over multiple passages whilst retaining the ability to differentiate into hepatocyte- and cholangiocyte-like cells. Recellularization onto porcine scaffolds was efficient and the organoids homogeneously differentiated, even showing polarization. Our porcine intrahepatic cholangiocyte system, combined with porcine liver scaffold paves the way for developing whole liver engineering in a relevant large-animal model.
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Affiliation(s)
- Melanie Krüger
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Roos-Anne Samsom
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Loes A Oosterhoff
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Monique E van Wolferen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Hans S Kooistra
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Niels Geijsen
- Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands
| | - Louis C Penning
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
| | - Linda M Kock
- LifeTec Group BV, Eindhoven, The Netherlands.,Department of Biomedical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Pilar Sainz-Arnal
- Laboratory of Organ Bioengineering and Regenerative Medicine, Health Research Institute of Aragon (IIS Aragon), Zaragoza, Spain
| | - Pedro M Baptista
- Laboratory of Organ Bioengineering and Regenerative Medicine, Health Research Institute of Aragon (IIS Aragon), Zaragoza, Spain
| | - Bart Spee
- Department of Clinical Sciences, Faculty of Veterinary Medicine, Utrecht University, Utrecht, The Netherlands
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Plunkett A, Mortimore M, Good P. Palliative care in cirrhosis with decompensation. Intern Med J 2019; 49:904-908. [DOI: 10.1111/imj.14348] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2018] [Revised: 10/02/2018] [Accepted: 10/03/2018] [Indexed: 02/03/2023]
Affiliation(s)
- Angela Plunkett
- Department of Palliative and Supportive CareRoyal Brisbane and Women's Hospitals Brisbane Queensland Australia
- School of MedicineUniversity of Queensland Brisbane Queensland Australia
| | - Marianne Mortimore
- School of MedicineUniversity of Queensland Brisbane Queensland Australia
- Department of GastroenterologyMater Adult Hospital Brisbane Queensland Australia
| | - Phillip Good
- School of MedicineUniversity of Queensland Brisbane Queensland Australia
- Department of Palliative CareMater Adult Hospital Brisbane Queensland Australia
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Abstract
BACKGROUND Cirrhosis is a chronic disease with high morbidity and mortality. Few studies have evaluated healthcare resource use in patients with cirrhosis. OBJECTIVE We aimed to describe the point prevalence of cirrhosis on 31 December 2012 and the population-level distribution of healthcare resource use and expenditures in a non-selected population of patients with cirrhosis, stratified by whether their disease was compensated or decompensated, and by comorbidity burden. METHODS This population study included all known patients aged >18 years with cirrhosis (according to International Classification of Diseases, ninth revision) in Catalonia, Spain, on 31 December 2012. We evaluated healthcare resource use and expenditure during 2013, taking into account the presence of decompensation before or during 2012. RESULTS We documented 34 740 patients diagnosed with cirrhosis (58.7% men; mean age 61.8±14 years), yielding a point prevalence of 460 per 100 000 inhabitants on 31 December 2012. Annual mortality was 9.1%. During 2013, healthcare expenditures on patients with cirrhosis totalled €142.1 million (€4234 per patient), representing 1.8% of the total 2013 healthcare budget of Catalonia. Hospitalisation costs accounted for 35.1% of the total expenditure and outpatient care accounted for 22.4%. MultivariateMultivariate logistic regression identified morbidity burden, HIV infection, hospitalisation and emergency room visits during 2012 as independent predictors of expenditure above the 85th centile (area under the receiver operating curve, 0.88 (95% CI 0.883 to 0.893, P<0.001)). CONCLUSIONS Cirrhosis accounts for a high proportion of healthcare resource usage and expenditures; hospitalisation accounted for the highest expenditures.
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Affiliation(s)
- Mireia Miquel
- Hepatology Unit, Digestive Disease Department, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBERHED, Instituto de Salud Carlos III, Madrid, Spain
| | - Montserrat Clèries
- Unitat d'informació i Coneixement, Servei Català de la Salut, Generalitat de Catalunya, Barcelona, Spain
| | - Mercedes Vergara
- Hepatology Unit, Digestive Disease Department, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí I3PT, Universitat Autònoma de Barcelona, Sabadell, Spain
- CIBERHED, Instituto de Salud Carlos III, Madrid, Spain
| | - Emili Vela
- Unitat d'informació i Coneixement, Servei Català de la Salut, Generalitat de Catalunya, Barcelona, Spain
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Hudson BE, Ameneshoa K, Gopfert A, Goddard R, Forbes K, Verne J, Collins P, Gordon F, Portal AJ, Reid C, McCune CA. Integration of palliative and supportive care in the management of advanced liver disease: development and evaluation of a prognostic screening tool and supportive care intervention. Frontline Gastroenterol 2017; 8:45-52. [PMID: 28839884 PMCID: PMC5369436 DOI: 10.1136/flgastro-2016-100734] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 08/30/2016] [Accepted: 09/18/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with decompensated cirrhosis rarely receive palliative and supportive care interventions, which are routine in other life-limiting diseases. We aimed to design and evaluate a prognostic screening tool to routinely identify inpatients with decompensated cirrhosis at high risk of dying over the coming year, alongside the development of a supportive care intervention. DESIGN Clinical notes from consecutive patients admitted as an emergency to University Hospitals Bristol with a diagnosis of cirrhosis over two distinct 90-day periods were scrutinised retrospectively for the presence or absence of five evidence-based factors associated with poor prognosis. These were analysed against their ability to predict mortality at 1 year. 'Plan-Do-Study-Act' (PDSA) methodology was used to incorporate poor-prognosis screening into the routine assessment of patients admitted with cirrhosis, and develop a supportive care intervention. RESULTS 73 admissions were scrutinised (79.5% male, 63% alcohol-related liver disease, median age 54). The presence of three or more poor-prognosis criteria at admission predicted 1-year mortality with sensitivity, specificity and positive predictive value of 72.2%, 83.8% and 81.3%, respectively, and was used as a trigger for implementing the supportive care intervention. Following modification from six PDSA cycles, prognostic screening was integrated into the assessment of all patients admitted with decompensated cirrhosis, with the supportive care intervention (developed simultaneously) instigated for appropriate patients. CONCLUSIONS We describe a model of care which identifies inpatients with cirrhosis at significant risk of dying over the coming year, and describe development of a supportive care intervention, which can be offered to suitable patients in parallel to ongoing active management.
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Affiliation(s)
- Benjamin E Hudson
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK,School of Clinical Sciences, University of Bristol, Bristol, UK
| | - Kelly Ameneshoa
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Anya Gopfert
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rachael Goddard
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Karen Forbes
- School of Clinical Sciences, University of Bristol, Bristol, UK,Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Julia Verne
- Public Health England South Region, Bristol, UK
| | - Peter Collins
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Fiona Gordon
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew J Portal
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Colette Reid
- Department of Palliative Medicine, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - C Anne McCune
- Department of Hepatology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Younossi Z, Henry L. Overall health-related quality of life in patients with end-stage liver disease. Clin Liver Dis (Hoboken) 2015; 6:9-14. [PMID: 31040976 PMCID: PMC6490633 DOI: 10.1002/cld.480] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2015] [Accepted: 03/25/2015] [Indexed: 02/04/2023] Open
Affiliation(s)
- Zobair Younossi
- Center for Liver Diseases, Department of MedicineInova Fairfax HospitalFalls ChurchVA,Betty and Guy Beatty Center for Integrated ResearchInova Health SystemFalls ChurchVA
| | - Linda Henry
- Center for Liver Diseases, Department of MedicineInova Fairfax HospitalFalls ChurchVA,Betty and Guy Beatty Center for Integrated ResearchInova Health SystemFalls ChurchVA
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Palliative care in patients with liver cirrhosis: it is the time to deal with the burden. BMJ Support Palliat Care 2015; 5:466-7. [PMID: 26124513 DOI: 10.1136/bmjspcare-2015-000923] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Accepted: 06/13/2015] [Indexed: 11/03/2022]
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