1
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Alexander V, Benjamin SJ, Subramani K, Sathyendra S, Goel A. Acute liver failure in pregnancy. Indian J Gastroenterol 2024; 43:325-337. [PMID: 38691240 DOI: 10.1007/s12664-024-01571-9] [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: 11/25/2023] [Accepted: 03/09/2024] [Indexed: 05/03/2024]
Abstract
Liver function abnormalities are noted in a minority of pregnancies with multiple causes for the same. A small proportion of these develop severe liver injury and progress to acute liver failure (ALF). There is a discrete set of etiology for ALF in pregnancy and comprehensive understanding will help in urgent evaluation. Certain diseases such as acute fatty liver of pregnancy, hemolysis, elevated liver enzyme, low platelet (HELLP) syndrome and pre-eclampsia are secondary to pregnant state and can present as ALF. Quick and targeted evaluation with urgent institution of etiology-specific management, especially urgent delivery in patients with pregnancy-associated liver diseases, is the key to avoiding maternal deaths. Pregnancy, as also the fetal life, imparts a further layer of complication in assessment, prognosis and management of these sick patients with ALF. Optimal management often requires a multidisciplinary approach in a well-equipped centre. In this review, we discuss evaluation, assessment and management of pregnant patients with ALF, focussing on approach to pregnancy-associated liver diseases.
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Affiliation(s)
- Vijay Alexander
- Department of Hepatology, Christian Medical College, Vellore 632 004, India
| | - Santosh J Benjamin
- Department of Obstetrics and Gynaecology, Christian Medical College, Vellore 632 004, India
| | - Kandasamy Subramani
- Division of Critical Care, Christian Medical College, Vellore 632 004, India
| | - Sowmya Sathyendra
- Department of Obstetric Medicine, Christian Medical College, Vellore 632 004, India
| | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore 632 004, India.
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2
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Cabel T, Pascu CM, Ghenea CS, Dumbrava BF, Gunsahin D, Andrunache A, Negoita LM, Panaitescu A, Rinja EM, Pavel C, Plotogea OM, Stan-Ilie M, Sandru V, Mihaila M. Exceptional Liver Transplant Indications: Unveiling the Uncommon Landscape. Diagnostics (Basel) 2024; 14:226. [PMID: 38275473 PMCID: PMC10813978 DOI: 10.3390/diagnostics14020226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Revised: 01/14/2024] [Accepted: 01/18/2024] [Indexed: 01/27/2024] Open
Abstract
Liver transplantation represents the definitive intervention for various etiologies of liver failure and encompasses a spectrum of rare indications crucial to understanding the diverse landscape of end-stage liver disease, with significantly improved survival rates over the past three decades. Apart from commonly encountered liver transplant indications such as decompensated cirrhosis and liver cancer, several rare diseases can lead to transplantation. Recognition of these rare indications is essential, providing a lifeline to individuals facing complex liver disorders where conventional treatments fail. Collaborative efforts among healthcare experts lead not only to timely interventions but also to the continuous refinement of transplant protocols. This continued evolution in transplant medicine promises hope for those facing diverse and rare liver diseases, marking a paradigm shift in the landscape of liver disease management.
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Affiliation(s)
- Teodor Cabel
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Cristina Madalina Pascu
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
| | - Catalin Stefan Ghenea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Bogdan Florin Dumbrava
- Department of Gastroenterology, “Sf. Ioan” Emergency Hospital, 014461 Bucharest, Romania
| | - Deniz Gunsahin
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Andreea Andrunache
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
| | - Livia-Marieta Negoita
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Afrodita Panaitescu
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Ecaterina Mihaela Rinja
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
| | - Christopher Pavel
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Oana-Mihaela Plotogea
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Madalina Stan-Ilie
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Vasile Sandru
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 014461 Bucharest, Romania; (T.C.); (D.G.); (L.-M.N.); (E.M.R.)
- Department 5, “Carol Davila” University of Medicine and Pharmacy, 050447 Bucharest, Romania
| | - Mariana Mihaila
- Department of Internal Medicine, Fundeni Clinical Institute, 022328 Bucharest, Romania (M.M.)
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3
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Morrison MA, Chung Y, Heneghan MA. Managing hepatic complications of pregnancy: practical strategies for clinicians. BMJ Open Gastroenterol 2022; 9:bmjgast-2021-000624. [PMID: 35292523 PMCID: PMC8928321 DOI: 10.1136/bmjgast-2021-000624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/12/2022] [Indexed: 12/17/2022] Open
Abstract
Liver disorders specific to pregnancy are rare but can have potentially serious consequences for mother and fetus. Pregnancy-related liver disorders are the most common cause of liver disease in otherwise healthy pregnant women and pose a challenge to physicians because of the need to take into account both maternal and fetal health. A good knowledge of these disorders is necessary as prompt diagnosis and appropriate management results in improved maternal and fetal outcomes. This review will focus on pregnancy-specific disorders and will aim to serve as a guide for physicians in their diagnosis, management and subsequent monitoring.
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Affiliation(s)
| | - Yooyun Chung
- Institute of Liver Studies, King's College Hospital, London, UK
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4
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Messina V, Dondossola D, Paleari MC, Fornoni G, Tubiolo D, Vergani P, Rona R, Rossi G. Liver Bleeding Due to HELLP Syndrome Treated With Embolization and Liver Transplantation: A Case Report and Review of the Literature. Front Surg 2021; 8:774702. [PMID: 34881288 PMCID: PMC8646087 DOI: 10.3389/fsurg.2021.774702] [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: 09/12/2021] [Accepted: 10/14/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Liver bleeding secondary to haemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is uncommon, but a life-threatening peripartum condition that needs a prompt multidisciplinary approach. Case Presentation: In this study, we presented a case of 28-year-old pregnant woman, who was presented to the obstetrics department with signs of preeclampsia and foetal growth restriction. An emergency caesarean section was performed, and the patient developed a HELLP syndrome complicated by spontaneous liver rupture. After radiological and surgical procedures, liver failure became evident and liver transplantation was successfully performed. The patient and her daughter are now alive. Conclusions: Despite the rarity of this disease, liver complications due to HELLP syndrome must be properly diagnosed and treated given the gravity of the possible evolution in young women. After diagnosis, the patients must be treated in specialised centres with gynaecological, liver surgery, and transplant skills.
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Affiliation(s)
- Valentina Messina
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniele Dondossola
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
| | - Maria Chiara Paleari
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Gianluca Fornoni
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Daniela Tubiolo
- Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy
| | - Patrizia Vergani
- Department of Maternal Fetal Medicine, Fondazione MBBM, San Gerardo Hospital, Monza, Italy
| | - Roberto Rona
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giorgio Rossi
- Department of General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Milan, Italy.,Department of Pathophysiology and Transplantation, Università Degli Studi di Milano, Milan, Italy
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5
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Varlas VN, Bohîlțea R, Gheorghe G, Bostan G, Angelescu GA, Penes ON, Bors RG, Cloțea E, Bacalbasa N, Diaconu CC. State of the Art in Hepatic Dysfunction in Pregnancy. Healthcare (Basel) 2021; 9:1481. [PMID: 34828527 PMCID: PMC8618725 DOI: 10.3390/healthcare9111481] [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] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 10/25/2021] [Accepted: 10/28/2021] [Indexed: 12/21/2022] Open
Abstract
Hepatic dysfunction in pregnant women is always challenging for the obstetrician, as the spectrum of hepatic abnormalities can be very large and have various implications, both for mother and fetus. There is a diagnostic and therapeutic polymorphism of hepatic dysfunction in pregnancy and insufficient knowledge related to the etiopathogenesis and epidemiology of this disease. The clinical forms of hepatic dysfunction encountered in pregnancy can vary from liver diseases related to pregnancy (e.g., HELLP syndrome, intrahepatic cholestasis, hyperemesis gravidarum, or acute fatty liver of pregnancy) to de novo ones occurring in pregnancy, and pre-existing liver disease (cholelithiasis, Budd-Chiari syndrome, and cirrhosis). We performed a systematic literature search over 10 years. The review protocol assumed a search of two databases (PubMed®/MEDLINE and Web of Science Core Collection). The strategy regarding the management of these diseases involves multidisciplinary teams composed of different specialists (obstetricians, gastroenterologists and anesthetists) from specialized tertiary centers. Despite the improving prognosis of pregnant women with liver diseases, the risk of maternal-fetal complications remains very high. Therefore, it is necessary to ensure careful monitoring by a multidisciplinary team and to inform the patients of the potential risks.
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Affiliation(s)
- Valentin Nicolae Varlas
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Roxana Bohîlțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
| | - Gina Gheorghe
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Gastroenterology, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
| | - Georgiana Bostan
- Department of Obstetrics and Gynecology, County Emergency Hospital “St. John the New”, 720034 Suceava, Romania;
| | - Gabriela Anca Angelescu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Internal Medicine, County Emergency Hospital Ilfov, 022115 Bucharest, Romania
| | - Ovidiu Nicolae Penes
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Anesthesiology and Intensive Care, University Clinical Hospital, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Roxana Georgiana Bors
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Eliza Cloțea
- Department of Obstetrics and Gynecology, Filantropia Clinical Hospital, 011132 Bucharest, Romania; (V.N.V.); (R.G.B.); (E.C.)
| | - Nicolae Bacalbasa
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania; (G.A.A.); (O.N.P.); (N.B.)
- Department of Visceral Surgery, “Fundeni” Clinical Institute, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Camelia Cristina Diaconu
- Department of Internal Medicine, “Carol Davila” University of Medicine and Pharmacy, 050474 Bucharest, Romania;
- Department of Internal Medicine, Clinical Emergency Hospital of Bucharest, 105402 Bucharest, Romania
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6
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Mazzola A, Magro B, Perdigao F, Charlotte F, Atif M, Goumard C, Scatton O, Conti F. Acute liver failure and HELLP syndrome: A clinical case and literature review. Clin Res Hepatol Gastroenterol 2021; 45:101498. [PMID: 32828747 DOI: 10.1016/j.clinre.2020.07.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 07/06/2020] [Accepted: 07/07/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND HELLP syndrome is a pregnancy-related liver disease associated with increased maternal and foetal mortality. In rare cases, it can lead to the development of a subcapsular hepatic haematoma as well as its rupture. This rupture is life-threatening if not urgently treated. METHOD We describe a clinical case of HELLP syndrome involving a ruptured subcapsular liver haematoma and contextualise this with a literature overview. CLINICAL CASE A 39-year-old woman of 40 weeks' gestation presented to her local Emergency Department with symptoms and serology classically associated with HELLP syndrome. However, she clinically deteriorated and developed a ruptured subcapsular haematoma. She underwent an emergency Caesarean section at her initial hospital. Upon clinical stabilisation, she was transferred to our transplant unit for an urgent liver transplant. CONCLUSION LT is a life-saving procedure for patients with acute liver failure secondary to HELLP syndrome. These patients should be immediately referred to a high-volume transplant centre.
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Affiliation(s)
- Alessandra Mazzola
- APHP, Unité Médicale de Transplantation Hépatique Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France.
| | - Bianca Magro
- APHP, Unité Médicale de Transplantation Hépatique Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France; Di.BIMIS Gastroenterology, University of Palermo, Piazza delle Cliniche N2, 90100 Palermo, Italy
| | - Fabiano Perdigao
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France
| | - Fréderic Charlotte
- APHP, Service d'Anatomopathologie, Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France
| | - Muhammad Atif
- APHP, Centre d'immunologie et maladies infectieuses, Sorbonne Université, Paris, France
| | - Claire Goumard
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France; Sorbonne Université, INSERM, Institute of Cardiometabolisme and Nutrition (ICAN), Paris, France; Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Paris, France
| | - Olivier Scatton
- Liver Transplant Unit, APHP, Unité de Chirurgie Hépatobiliaire et Transplantation hépatique, Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France; Sorbonne Université, INSERM, Institute of Cardiometabolisme and Nutrition (ICAN), Paris, France; Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Paris, France
| | - Filomena Conti
- APHP, Unité Médicale de Transplantation Hépatique Hôpital Pitié Salpêtrière, Boulevard de l'Hôpital 47-83, 75013 Paris, France; Sorbonne Université, INSERM, Institute of Cardiometabolisme and Nutrition (ICAN), Paris, France; Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Paris, France
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7
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Anand AC, Nandi B, Acharya SK, Arora A, Babu S, Batra Y, Chawla YK, Chowdhury A, Chaoudhuri A, Eapen EC, Devarbhavi H, Dhiman RK, Datta Gupta S, Duseja A, Jothimani D, Kapoor D, Kar P, Khuroo MS, Kumar A, Madan K, Mallick B, Maiwall R, Mohan N, Nagral A, Nath P, Panigrahi SC, Pawar A, Philips CA, Prahraj D, Puri P, Rastogi A, Saraswat VA, Saigal S, Shalimar, Shukla A, Singh SP, Verghese T, Wadhawan M. Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure. J Clin Exp Hepatol 2020; 10:477-517. [PMID: 33029057 PMCID: PMC7527855 DOI: 10.1016/j.jceh.2020.04.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 04/12/2020] [Indexed: 12/12/2022] Open
Abstract
Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.
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Key Words
- ACLF, Acute on Chronic liver Failure
- AKI, Acute kidney injury
- ALF, Acute Liver Failure
- ALFED score
- ALT, alanine transaminase
- AST, aspartate transaminase
- CNS, central nervous system
- CT, Computerized tomography
- HELLP, Hemolysis, elevated liver enzymes, and low platelets
- ICH, Intracrainial hypertension
- ICP, Intracrainial Pressure
- ICU, Intensive care unit
- INR, International normalised ratio
- LAD, Liver assist device
- LDLT, Living donor liver transplantation
- LT, Liver transplantation
- MAP, Mean arterial pressure
- MELD, model for end-stage liver disease
- MLD, Metabolic liver disease
- NAC, N-acetyl cysteine
- PALF, Pediatric ALF
- WD, Wilson's Disease
- acute liver failure
- artificial liver support
- liver transplantation
- plasmapheresis
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Affiliation(s)
- Anil C. Anand
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Bhaskar Nandi
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
| | - Subrat K. Acharya
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
| | - Anil Arora
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Sethu Babu
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
| | - Yogesh Batra
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
| | - Yogesh K. Chawla
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
| | - Abhijit Chowdhury
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
| | - Ashok Chaoudhuri
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Eapen C. Eapen
- Department of Hepatology, Christian Medical College, Vellore, India
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
| | - Radha K. Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Siddhartha Datta Gupta
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
| | - Ajay Duseja
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
| | - Dinesh Jothimani
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
| | | | - Premashish Kar
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
| | - Mohamad S. Khuroo
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
| | - Ashish Kumar
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
| | - Kaushal Madan
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
| | - Bipadabhanjan Mallick
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Rakhi Maiwall
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
| | - Neelam Mohan
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Aabha Nagral
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
| | - Preetam Nath
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Sarat C. Panigrahi
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Ankush Pawar
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
| | - Cyriac A. Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
| | - Dibyalochan Prahraj
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
| | - Pankaj Puri
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
| | - Amit Rastogi
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
| | - Vivek A. Saraswat
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
| | - Sanjiv Saigal
- Department of Hepatology, Department of Liver Transplantation, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
| | - Akash Shukla
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
| | - Shivaram P. Singh
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
| | - Thomas Verghese
- Department of Gastroenterology, Government Medical College, Kozikhode, India
| | - Manav Wadhawan
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
| | - The INASL Task-Force on Acute Liver Failure
- Department of Gastroenterology, Kaliga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Department of Gastroenterology, Sarvodaya Hospital and Research Centre, Faridababd, Haryana, India
- Department of Gastroenterology and Hepatology, KIIT University, Patia, Bhubaneswar, Odisha, 751 024, India
- Institute of Liver Gastroenterology & Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, 110 060, India
- Department of Gastroenterology, Krishna Institute of Medical Sciences, Hyderabad, 500003, India
- Department of Gastroenterology, Indraprastha Apollo Hospital, SaritaVihar, New Delhi, 110 076, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences (KIMS), Kushabhadra Campus (KIIT Campus-5), Patia, Bhubaneswar, Odisha, 751 024, India
- Department of Hepatology, School of Digestive and Liver Diseases, Institute of Post Graduate Medical Education & Research, Kolkata, 700020, India
- Hepatology and Liver Transplant, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Hepatology, Christian Medical College, Vellore, India
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, 560034, India
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, 160 012, India
- Department of Pathology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110 029, India
- Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Chrompet, Chennai, 600044, India
- Gleneagles Global Hospitals, Hyderabad, Telangana, India
- Department of Gastroenterology and Hepatology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, 201 012, India
- Department of Gastroenterology, Dr Khuroo’ s Medical Clinic, Srinagar, Kashmir, India
- Gastroenterology and Hepatology, Max Smart Super Specialty Hospital, Saket, New Delhi, India
- Department of Gastroenterology, Kalinga Institute of Medical Sciences, Bhubaneswar, 751024, India
- Hepatology Incharge Liver Intensive Care, Institute of Liver & Biliary Sciences, D-1 Vasant Kunj, New Delhi, India
- Department of Pediatric Gastroenterology, Hepatology & Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Apollo and Jaslok Hospital & Research Centre, 15, Dr Deshmukh Marg, Pedder Road, Mumbai, Maharashtra, 400 026, India
- Liver & Digestive Diseases Institute, Fortis Escorts Hospital, Okhla Road, New Delhi, 110 025, India
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi 682028, Kerala, India
- Department of Hepatology and Gastroenterology, Fortis Escorts Liver & Digestive Diseases Institute (FELDI), Fortis Escorts Hospital, Delhi, India
- Department of Liver Transplantation, Medanta – the MedicityHospital, Sector – 38, Gurgaon, Haryana, India
- Department of Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Raibareli Road, Lucknow, Uttar Pradesh, 226 014, India
- Department of Hepatology, Department of Liver Transplantation, India
- Department of Gastroenterology and Human Nutrition Unit, All India Institute of Medical Sciences, New Delhi, 29, India
- Department of Gastroenterology, LTM Medical College & Sion Hospital, India
- Department of Gastroenterology, SCB Medical College, Dock Road, Manglabag, Cuttack, Odisha, 753 007, India
- Department of Gastroenterology, Government Medical College, Kozikhode, India
- Institute of Liver & Digestive Diseases and Head of Hepatology & Liver Transplant (Medicine), BLK Super Speciality Hospital, Delhi, India
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8
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Rovegno M, Vera M, Ruiz A, Benítez C. Current concepts in acute liver failure. Ann Hepatol 2020; 18:543-552. [PMID: 31126880 DOI: 10.1016/j.aohep.2019.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 03/29/2019] [Accepted: 04/02/2019] [Indexed: 02/04/2023]
Abstract
Acute liver failure (ALF) is a severe condition secondary to a myriad of causes associated with poor outcomes. The prompt diagnosis and identification of the aetiology allow the administration of specific treatments plus supportive strategies and to define the overall prognosis, the probability of developing complications and the need for liver transplantation. Pivotal issues are adequate monitoring and the institution of prophylactic strategies to reduce the risk of complications, such as progressive liver failure, cerebral oedema, renal failure, coagulopathies or infections. In this article, we review the main aspects of ALF, including the definition, diagnosis and complications. Also, we describe the standard-of-care strategies and recent advances in the treatment of ALF. Finally, we include our experience of care patients with ALF.
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Affiliation(s)
- Maximiliano Rovegno
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Magdalena Vera
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile
| | - Alex Ruiz
- Unidad de Gastroenterología, Instituto de Medicina, Escuela de Medicina, Universidad Austral de Chile, Chile
| | - Carlos Benítez
- Departamento de Gastroenterología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Chile.
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9
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Abstract
Liver disease in pregnancy may present as a disorder that is unique to pregnancy or as an acute or chronic liver disease occurring coincidentally in pregnancy. Hepatic diseases that are unique to pregnancy include hyperemesis gravidarum; preeclampsia/eclampsia; the syndrome of hemolysis, elevated liver enzymes, and low platelets; intrahepatic cholestasis of pregnancy; and acute fatty liver of pregnancy. Acute and chronic forms of primary hepatic disorders that are seen in pregnancy include viral hepatitis, autoimmune hepatitis, nonalcoholic fatty liver disease, and cirrhosis. Because of the need to consider both maternal and fetal health, there are special considerations for the implementation of diagnostic strategies and pharmacologic therapies for liver disease that occurs in pregnancy. An understanding of the pathogenesis and expression of liver diseases in pregnancy has been evolving, and various diagnostic and prognostic tools have been studied in order to determine noninvasive approaches to identifying and staging of such diseases. Investigations have also been underway to evaluate the safety and utility of existing and new therapeutic agents that previously were thought to not be compatible with pregnancy. This review will explore updates in the epidemiology, diagnosis, and management of various liver diseases seen in pregnancy.
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Affiliation(s)
- Carla W Brady
- Division of Gastroenterology Duke University Medical Center Durham NC
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10
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Abstract
Acute liver failure is a rare and severe consequence of abrupt hepatocyte injury, and can evolve over days or weeks to a lethal outcome. A variety of insults to liver cells result in a consistent pattern of rapid-onset elevation of aminotransferases, altered mentation, and disturbed coagulation. The absence of existing liver disease distinguishes acute liver failure from decompensated cirrhosis or acute-on-chronic liver failure. Causes of acute liver failure include paracetamol toxicity, hepatic ischaemia, viral and autoimmune hepatitis, and drug-induced liver injury from prescription drugs, and herbal and dietary supplements. Diagnosis requires careful review of medications taken, and serological testing for possible viral exposure. Because of its rarity, acute liver failure has not been studied in large, randomised trials, and most treatment recommendations represent expert opinion. Improvements in management have resulted in lower mortality, although liver transplantation, used in nearly 30% of patients with acute liver failure, still provides a life-saving alternative to medical management.
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Affiliation(s)
- R Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA, USA
| | - William M Lee
- Digestive and Liver Diseases Division, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA.
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11
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Liver Transplantation for Hemolysis, Elevated Liver Enzymes, and Low Platelet Count Syndrome: A Propensity-score Matched Long-term Survival of the Scientific Registry of Transplant Recipients Dataset. Transplant Proc 2019; 51:805-812. [PMID: 30979468 DOI: 10.1016/j.transproceed.2018.10.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 10/23/2018] [Indexed: 12/24/2022]
Abstract
BACKGROUND Hemolysis, elevated liver enzymes, and low platelet count (HELLP) syndrome is a life-threatening form of pre-eclampsia/eclampsia, with liver transplantation being the life-saving option for treatment for those who develop severe hepatic complications. METHODS We retrospectively analyzed data from the Scientific Registry of Transplant Recipients (SRTR) through October 1, 1987, to December 31, 2014. Forty patients were listed for liver transplantation, with 18 patients finally receiving their transplant. These 18 patients were matched with 1:10 patients using a propensity-score matched approach. RESULTS Baseline demographics were comparable between HELLP syndrome patients who received a transplant and those who did not. The 10-year intent-to-treat survival was 63.6% for non-transplanted HELLP patients, 64.2% for transplanted HELLP patients, and 61.8% for matched patients (P = .369). Overall survival was also similar between HELLP patients and matched patients, with 10-year survival at 64.2% and 61.8% respectively (P = .985). However, death-censored graft survival was inferior in HELLP patients, with 10-year survival at 63.4% compared with 75.4% in the matched patients (P = .044). CONCLUSIONS Patients with HELLP syndrome who did not receive a transplant achieved similar intent-to-treat survival with those transplanted patients, while the death-censored graft survival of transplanted patients was inferior to matched patients. This might guide improved liver donor allocation in clinical practice.
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12
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Abstract
Acute liver failure (ALF) is a rare but highly fatal condition. The most common causes include drug-induced and viral hepatitis, but other less common etiologies, especially autoimmune hepatitis, Budd-Chiari syndrome, and Wilson disease, need to be considered. Because diagnosis is frequently tied to potential for reversibility of ALF and prognosis, early identification in a timely manner is crucial. Other causes of ALF are more easily recognizable based on specific circumstances, such as ALF in pregnancy or ischemic hepatitis. Ultimately, maintaining a wide differential diagnosis in patients with ALF is essential to identifying the proper treatment and prognosis.
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Affiliation(s)
- Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA
| | - Robert S Brown
- Division of Gastroenterology and Hepatology, Weill Cornell Medical College, 1305 York Avenue, 4th Floor, New York, NY 10021, USA.
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13
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Varotti G, Andorno E, Valente U. Liver transplantation for spontaneous hepatic rupture associated with HELLP syndrome. Int J Gynaecol Obstet 2016; 111:84-5. [DOI: 10.1016/j.ijgo.2010.05.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Accepted: 06/07/2010] [Indexed: 11/16/2022]
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14
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Tran TT, Ahn J, Reau NS. ACG Clinical Guideline: Liver Disease and Pregnancy. Am J Gastroenterol 2016; 111:176-94; quiz 196. [PMID: 26832651 DOI: 10.1038/ajg.2015.430] [Citation(s) in RCA: 141] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Accepted: 12/01/2015] [Indexed: 12/11/2022]
Abstract
Consultation for liver disease in pregnant women is a common and oftentimes vexing clinical consultation for the gastroenterologist. The challenge lies in the need to consider the safety of both the expectant mother and the unborn fetus in the clinical management decisions. This practice guideline provides an evidence-based approach to common diagnostic and treatment challenges of liver disease in pregnant women.
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Affiliation(s)
- Tram T Tran
- Department of Medicine, Liver Transplant, Cedars Sinai Medical Center, Los Angeles, California, USA
| | - Joseph Ahn
- Department of Medicine, Oregon Health & Science University, Portland, Oregon, USA
| | - Nancy S Reau
- Department of Medicine, Rush University, Chicago, Illinois, USA
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15
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Shekhar S, Diddi G. Liver disease in pregnancy. Taiwan J Obstet Gynecol 2015; 54:475-82. [DOI: 10.1016/j.tjog.2015.01.004] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2015] [Indexed: 12/17/2022] Open
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16
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Pandey CK, Karna ST, Pandey VK, Tandon M. Acute liver failure in pregnancy: Challenges and management. Indian J Anaesth 2015; 59:144-9. [PMID: 25838585 PMCID: PMC4378074 DOI: 10.4103/0019-5049.153035] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Acute liver failure (ALF) in pregnancy negatively affects both maternal and foetal outcome. The spectrum of liver disease in pregnancy may range from mild asymptomatic transaminitis to fatal and irreversible deterioration in liver functions leading to significant morbidity and even mortality. In this comprehensive review, we searched articles published as review articles, clinical trials, and case series in the Medline from 1970 to 2012. The overall outcome of ALF in pregnancy depends on the aetiology, timely diagnosis, prompt management, and early referral to a centre equipped in managing medical or obstetric complication. The foetal outcome is affected by the stage of pregnancy in which the mother has a deterioration of the liver function, with a worst prognosis associated with first or second-trimester liver failure. When ALF complicates pregnancy, liver transplantation is the one of the viable options. Management protocols need to be individualised for each case keeping in mind the risk versus benefit to both the mother and the foetus.
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Affiliation(s)
- Chandra Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Sunaina Tejpal Karna
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Vijay Kant Pandey
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
| | - Manish Tandon
- Department of Anaesthesiology, Institute of Liver and Biliary Sciences, Vasant Kunj, New Delhi, India
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17
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Murali AR, Devarbhavi H, Venkatachala PR, Singh R, Sheth KA. Factors that predict 1-month mortality in patients with pregnancy-specific liver disease. Clin Gastroenterol Hepatol 2014; 12:109-13. [PMID: 23856360 DOI: 10.1016/j.cgh.2013.06.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 05/21/2013] [Accepted: 06/10/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Pregnancy-specific liver diseases such as acute fatty liver of pregnancy; hemolysis, elevated liver enzymes and low platelet syndrome; and preeclampsia-associated liver disease are associated with considerable morbidity and mortality. We investigated the ability of the model for end-stage liver disease (MELD) to predict 1-month mortality among patients with pregnancy-specific liver diseases. We also developed and tested a model to predict mortality based on features of pregnancy-specific liver diseases. METHODS We performed a retrospective study, analyzing hospital admission, clinical, hematologic, and biochemical data collected from 130 patients with pregnancy-specific liver diseases admitted to the St. John's Medical College Hospital (Bangalore, India) from January 2000 through April 2011. Patients were followed up until 3 months after delivery or death. Logistic regression models were fitted using the MELD score and other variables identified as clinically or statistically significant. The predictive accuracy and calibration of the models were assessed by receiver operating characteristic curves and the Hosmer-Lemeshow goodness-of-fit test. RESULTS Thirty-two patients (24.6%) died. Mortalities from pregnancy-specific liver diseases within 1 month of admission among patients with MELD scores of 20 to 29, 30 to 39, or 40 or greater were 24.2%, 45.45%, and 90.9%, respectively. Univariate analysis identified encephalopathy, ascites, serum total protein, bilirubin, platelet count, alkaline phosphatase, serum creatinine, and international normalized ratio (INR) as significant variables. Multivariate analysis identified total bilirubin (P < .001) and INR (P < .003) as significant predictors of mortality. MELD score and a model based on only 2 variables (bilirubin level and INR) accurately predicted mortality (C statistics, 0.83 and 0.86, respectively) and were well calibrated (Hosmer-Lemeshow χ(2) = 9.7 [P = .28] and 1.9 [P = .98], respectively). CONCLUSIONS A new logistic model based on only 2 variables (INR and total bilirubin) was comparable with the MELD model in predicting mortality among women with pregnancy-specific liver diseases.
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Affiliation(s)
- Arvind R Murali
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India; Department of Internal Medicine, John H Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Harshad Devarbhavi
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India.
| | - Preethi R Venkatachala
- Department of Obstetrics and Gynecology, St. John's Medical College Hospital, Bangalore, India
| | - Rajvir Singh
- Cardiology Research Center, St. John's Medical College Hospital, Bangalore, India
| | - Keyur A Sheth
- Department of Gastroenterology, St. John's Medical College Hospital, Bangalore, India
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18
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Than NN, Neuberger J. Liver abnormalities in pregnancy. Best Pract Res Clin Gastroenterol 2013; 27:565-75. [PMID: 24090943 DOI: 10.1016/j.bpg.2013.06.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 06/21/2013] [Indexed: 01/31/2023]
Abstract
Abnormalities of liver function (notably rise in alkaline phosphatase and fall in serum albumin) are common in normal pregnancy, whereas rise in serum bilirubin and aminotransferase suggest either exacerbation of underlying pre-existing liver disease, liver disease related to pregnancy or liver disease unrelated to pregnancy. Pregnant women appear to have a worse outcome when infected with Hepatitis E virus. Liver diseases associated with pregnancy include abnormalities associated hyperemesis gravidarum, acute fatty liver disease, pre-eclampsia, cholestasis of pregnancy and HELLP syndrome. Prompt investigation and diagnosis is important in ensuring a successful maternal and foetal outcome. In general, prompt delivery is the treatment of choice for acute fatty liver, pre-eclampsia and HELLP syndrome and ursodeoxycholic acid is used for cholestasis of pregnancy although it is not licenced for this indication.
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Affiliation(s)
- Nwe Ni Than
- Liver Unit, Queen Elizabeth Hospital, Birmingham B15 2TH, UK
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19
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Darby M, Martin JN, Mitchell SQ, Owens MY, Wallace K. Using case reports to determine when liver bleeding occurs during disease progression in HELLP syndrome. Int J Gynaecol Obstet 2013; 123:7-9. [DOI: 10.1016/j.ijgo.2013.06.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/26/2013] [Accepted: 06/21/2013] [Indexed: 11/28/2022]
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20
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Myers B. Diagnosis and management of maternal thrombocytopenia in pregnancy. Br J Haematol 2012; 158:3-15. [PMID: 22551110 DOI: 10.1111/j.1365-2141.2012.09135.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2012] [Accepted: 03/14/2012] [Indexed: 12/27/2022]
Abstract
Thrombocytopenia is a common finding in pregnancy, occurring in approximately 7-10% of pregnancies. It may be a diagnostic and management problem, and has many causes, some of which are specific to pregnancy. Although most cases of thrombocytopenia in pregnancy are mild, and have no adverse outcome for either mother or baby, occasionally a low platelet count may be part of a more complex disorder with significant morbidity and may be life-threatening. Overall, about 75% of cases are due to gestational thrombocytopenia, 15-20% secondary to hypertensive disorders; 3-4% due to an immune process, and the remaining 1-2% made up of rare constitutional thrombocytopenias, infections and malignancies. In this review, a diagnostic approach to investigating thrombocytopenia in pregnancy is presented, together with antenatal, anaesthetic and peri-natal management issues for mother and baby, followed by a detailed discussion on the specific causes of thrombocytopenia and the management options in each case.
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Affiliation(s)
- Bethan Myers
- Department of Haematology, Lincoln County Hospital, Lincoln, UK.
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21
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Abstract
Changes in the liver biochemical profile are normal in pregnancy. However, up to 3% to 5% of all pregnancies are complicated by liver dysfunction. It is important that liver disease during pregnancy is recognized because early diagnosis may improve maternal and fetal outcomes, with resultant decreased morbidity and mortality. Liver diseases that occur in pregnancy can be divided into 3 different groups: liver diseases that are unique to pregnancy, liver diseases that are not unique to pregnancy but can be revealed or exacerbated by pregnancy, and liver diseases that are unrelated to but occur coincidentally during pregnancy.
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Affiliation(s)
- Arjmand R Mufti
- Department of Medicine, Section of Gastroenterology, Hepatology and Nutrition, University of Chicago Medical Center, IL 60637, USA
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22
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Abstract
OBJECTIVE Rupture of hepatic hematoma associated with hemolysis, elevated liver enzymes, low platelets (HELLP) syndrome is a catastrophic complication of pregnancy. Maternal and fetal mortality rates are still high despite advances in diagnosis and treatment. We aimed to present our experience at two referral centers for hepatic disease and to compare it with cases from the literature. METHODS We reviewed nine cases that occurred over the past 6 years in our centers and made an extensive literature review covering the past 10 years. We reviewed and compared multiple outcomes for all these cases. RESULTS The median maternal age of our patients was 29 years (interquartile range 27-32). Embolization treatment was used with seven of nine (78%) of our patients compared with 5 of 88 (6%) in the literature (P<.001). Our maternal and fetal mortality rates were 0% (95% confidence interval [CI] 0-34%) and 30% (95% CI 7-65%), respectively, compared with 17% (95% CI 10-26%) and 38% (95% CI 31-52%]) from our review of the literature from 2000 to 2010. CONCLUSION The use of hepatic artery embolization to address hepatic rupture associated with HELLP syndrome may help minimize morbidity and maternal mortality.
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23
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Diagnostic challenges in the evaluation of hepatic grafts from donors with HELLP syndrome: case report and review of the literature. Transplant Proc 2011; 43:4010-2. [PMID: 22172890 DOI: 10.1016/j.transproceed.2011.08.073] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Accepted: 08/30/2011] [Indexed: 11/24/2022]
Abstract
HELLP syndrome (hemolysis, elevated liver function tests, low platelets) is a rare complication of pregnancy that can result in severe complications such as hepatic infarction, subcapsular liver hematomas, and maternal brain death from cerebral hemorrhage. Recently, several investigators have described cases of successful transplantation using livers procured from donors who suffered brain death as a result of HELLP syndrome. However, this new class of marginal liver donors must be approached with caution. We report the case of a 28-year-old pregnant woman who suffered brain death due to HELLP syndrome and was subsequently evaluated for potential liver donation. Although her transaminitis and other liver function tests were markedly improving during the final days of her hospital course, her liver demonstrated segments of necrosis during attempted procurement, and the histology revealed extensive centrilobular necrosis. This case suggests that peak values of serum transaminases, as well as partial resolution of transaminitis, appear to have limited predictive ability in determining the suitability of the hepatic graft for transplantation. Thus, donors with HELLP syndrome should be approached with caution, even in the setting of laboratory values suggesting minimal or resolving hepatic injury. Furthermore, there should be an additional emphasis on obtaining and reviewing histology of the potential graft to determine its suitability for transplantation.
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24
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Ichai P, Samuel D. Epidemiology of liver failure. Clin Res Hepatol Gastroenterol 2011; 35:610-7. [PMID: 21550329 DOI: 10.1016/j.clinre.2011.03.010] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 03/31/2011] [Indexed: 02/04/2023]
Abstract
The etiology of fulminant hepatitis varies in different countries and at different times. The main causes of fulminant hepatitis are viruses, paracetamol, drugs (other than paracetamol), poisons and 15-30% remained of undetermined origin. The prevalence of these etiologies varies according to the geographic region and has changed over the past 10 years. Paracetamol has now overtaken viruses (particularly hepatitis B virus) as the leading cause of fulminant hepatitis. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation be eliminated.
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Affiliation(s)
- Philippe Ichai
- Centre Hépato-Biliaire, hôpital Paul-Brousse, AP-HP, 94800 Villejuif, France
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25
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Bacq Y. Liver diseases unique to pregnancy: a 2010 update. Clin Res Hepatol Gastroenterol 2011; 35:182-93. [PMID: 21310683 DOI: 10.1016/j.clinre.2010.11.011] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2010] [Revised: 11/19/2010] [Accepted: 11/23/2010] [Indexed: 02/08/2023]
Abstract
Liver disorders occurring during pregnancy may be specifically pregnancy-related, or may be due to an intercurrent or chronic liver disease, which may present in anyone, pregnant or not. This review focuses on the liver diseases unique to pregnancy. Hyperemesis gravidarum, which occurs during early pregnancy, may be associated with liver dysfunction. Intrahepatic cholestasis of pregnancy typically occurs during the second or third trimester. Pruritus and the associated biological signs of cholestasis improve rapidly after delivery. Mutations in gene encoding biliary transporters, especially ABCB4 encoding the multidrug resistance 3 protein, have been found to be associated with this complex disease. Ursodeoxycholic acid is currently the most effective medical treatment in improving pruritus and liver tests. Pre-eclampsia, which presents in late pregnancy frequently involves the liver, and HELLP syndrome (Hemolysis-Elevated Liver enzymes-Low Platelets) is a life-threatening complication. Prognosis of acute fatty liver of pregnancy has been radically transformed by early delivery, and clinicians must have a high index of suspicion for this condition when a woman presents nausea or vomiting, epigastric pain, jaundice, or polyuria-polydipsia during the third trimester. Acute fatty liver of pregnancy has been found to be associated with a defect of long-chain 3-hydroxyacyl coenzyme A dehydrogenase in the fetus, and mothers and their offspring should undergo DNA testing at least for the main associated genetic mutation (c.1528G>C).
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Affiliation(s)
- Yannick Bacq
- Service d'hépatogastro-entérologie, hôpital Trousseau, Tours cedex, France.
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26
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Martin JN, Owens MY, Keiser SD, Parrish MR, Tam Tam KB, Brewer JM, Cushman JL, May WL. Standardized Mississippi Protocol Treatment of 190 Patients with HELLP Syndrome: Slowing Disease Progression and Preventing New Major Maternal Morbidity. Hypertens Pregnancy 2011; 31:79-90. [DOI: 10.3109/10641955.2010.525277] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Westbrook RH, Yeoman AD, Joshi D, Heaton ND, Quaglia A, O'Grady JG, Auzinger G, Bernal W, Heneghan MA, Wendon JA. Outcomes of severe pregnancy-related liver disease: refining the role of transplantation. Am J Transplant 2010; 10:2520-6. [PMID: 20977643 DOI: 10.1111/j.1600-6143.2010.03301.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Severe liver disease in pregnancy is generally considered to have a favorable prognosis. The limited data available have not yielded disease-specific prognostic criteria or guidance on who should undergo liver transplantation (LT). We retrospectively evaluated 54 admissions with pregnancy-related liver disease to (1) evaluate if any admission parameters were associated with death and/or transplantation and (2) identify maternal complications. Eighteen had acute fatty liver of pregnancy and 32 had hypertension/eclampsia related disease. Seven patients (13%) died and four (7%) underwent LT. Survival rates were 43/48 if not listed for LT and 4/6 if listed. Of the four transplanted, three survived. Patients who died and/or underwent LT were more likely to have encephalopathy (p = 0.04) and hyperlactaemia (p = 0.03). Serum lactate was the best discriminant (ROC AUC 0.84). An admission lactate greater than 2.8mg/dL had 73% sensitivity and 75% specificity for predicting death or LT. The addition of encephalopathy to this parameter increased sensitivity and specificity to 90% and 86%, respectively. The King's College criteria were not effective in predicting outcome. This study confirms the overall favorable prognosis in pregnancy-related liver failure but indicates that elevated lactate levels in the presence of encephalopathy best identify patients at greatest risk of death or LT.
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Affiliation(s)
- R H Westbrook
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, United Kingdom
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29
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Abstract
Severe liver disease in pregnancy is rare. Pregnancy-related liver disease is the most frequent cause of liver dysfunction in pregnancy and provides a real threat to fetal and maternal survival. A rapid diagnosis differentiating between liver disease related and unrelated to pregnancy is required in women who present with liver dysfunction during pregnancy. Research has improved our understanding of the pathogenesis of pregnancy-related liver disease, which has translated into improved maternal and fetal outcomes. Here, we provide an overview of liver diseases that occur in pregnancy, an update on the key mechanisms involved in their pathogenesis, and assessment of available treatment options.
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Affiliation(s)
- Deepak Joshi
- Institute of Liver Studies, King's College Hospital, London, UK
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Kulungowski AM, Kashuk JL, Moore EE, Hutting HG, Sadaria MR, Cothren CC, Johnson JL, Sauaia A. Hemolysis, elevated liver enzymes, and low platelets syndrome: when is surgical help needed? Am J Surg 2009; 198:916-20. [DOI: 10.1016/j.amjsurg.2009.05.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2009] [Revised: 05/18/2009] [Accepted: 05/18/2009] [Indexed: 12/20/2022]
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Transplantation hépatique pour hématome sous-capsulaire rompu lors d’un HELLP Syndrome. ACTA ACUST UNITED AC 2009; 28:1020-2. [DOI: 10.1016/j.annfar.2009.09.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2009] [Accepted: 09/22/2009] [Indexed: 11/20/2022]
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Abstract
Gastrointestinal complications of pre-eclampsia can occur and have the risk of being life-threatening for the mother and fetus. Hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome has been recognized as a complication of pre-eclampsia for decades. Pregnancies complicated by this syndrome require a well-formulated management plan, including assessing and stabilizing the maternal condition as well as evaluating fetal well-being. Patients with HELLP syndrome should receive anti-seizure prophylaxis with magnesium sulfate, treatment for severe hypertension, and correction of coagulopathy, if present. The potential benefits of expectant management of HELLP syndrome in those remote from term and the use of corticosteroids to improve maternal outcome remain experimental. Computed tomography or ultrasound of the abdomen should be performed if a subcapsular hematoma of the liver is suspected. If a ruptured hematoma is confirmed, massive transfusions and laparotomy are indicated. Ischemia associated with pre-eclampsia cannot only damage the liver but also the pancreas and gallbladder.
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Affiliation(s)
- John R Barton
- Division of Maternal-Fetal Medicine, Central Baptist Hospital, Lexington, KY, USA.
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Abstract
1. Establishing the cause of fulminant hepatitis is an important step in the management of acute liver failure, so that specific therapy can be initiated and any contraindications to liver transplantation can be eliminated. 2. The etiology of fulminant hepatitis varies in different countries and at different times. A viral etiology (in particular hepatitis B virus) is now less frequent, and paracetamol-induced fulminant hepatic failure is more common. 3. Many patients have miscellaneous causes of fulminant hepatitis. It is important to establish the main clinical and biological characteristics for specific management. 4. Assessment of the prognosis of fulminant hepatitis is important for distinguishing patients requiring liver transplantation from those whose will improve spontaneously. Prognosis depends on several factors, including the gold standard, the King's College Hospital criteria and Clichy's criteria.
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Affiliation(s)
- Philippe Ichai
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
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Heneghan MA, Selzner M, Yoshida EM, Mullhaupt B. Pregnancy and sexual function in liver transplantation. J Hepatol 2008; 49:507-19. [PMID: 18715668 DOI: 10.1016/j.jhep.2008.07.011] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Michael A Heneghan
- Institute of Liver Studies, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
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