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Bragança S, Ferraz M, Germano N. Sequential Use of High-Volume Plasma Exchange and Continuous Renal Replacement Therapy in Hepatitis B Virus-Related Acute Liver Failure: A Case Report. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2023; 30:32-38. [PMID: 38020821 PMCID: PMC10661706 DOI: 10.1159/000527584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Accepted: 10/03/2022] [Indexed: 12/01/2023]
Abstract
Background Acute liver failure (ALF) may represent an indication for liver transplantation (LT). However, in patients who do not meet the criteria or who have contraindications for LT, support measures remain indicated since they may improve survival. Continuous renal replacement therapy (CRRT) can be considered in the presence of hyperammonemia, 3 times above the upper normal limit, and hepatic encephalopathy (HE), even in the absence of the classic indications. High-volume plasma exchange (HVPE) is an artificial liver support system with proven benefits in ALF, allowing ammonia and inflammatory mediator clearance. Both techniques, HVPE and CRRT, are associated with an increase in transplant-free survival. Case Summary We share a case of a 51-year-old male, without relevant personal history, diagnosed with severe acute hepatitis B which progressed to ALF, with grade IV HE (West-Haven criteria) and hyperammonemia (423 μg/dL). Due to the simultaneously diagnosed malignant neoplasm, he was not a candidate for LT. After refractory to medical therapy, HVPE was started, followed by CRRT. There was a significant improvement in liver tests, allowing surgical treatment of malignancy. After recovery, the patient returned to his everyday life. Conclusion The authors present a successful case in which an early and invasive approach to ALF was revealed to be a game changer. The lack of response to the measures instituted, as well as the contraindication for LT, motivated the institution of HVPE and CRRT. Both techniques proved to be an asset, allowing complete clinical recovery, reaffirming their role in ALF.
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Affiliation(s)
- Sofia Bragança
- Serviço de Gastrenterologia, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - Mário Ferraz
- Unidade de Cuidados Intensivos Polivalente 7, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Nuno Germano
- Unidade de Cuidados Intensivos Polivalente 7, Hospital Curry Cabral, Centro Hospitalar Lisboa Central, Lisboa, Portugal
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Redant S, Warrillow S, Honoré PM. Ammonia and nutritional therapy in the critically ill: when to worry, when to test and how to treat? Curr Opin Clin Nutr Metab Care 2023; 26:160-166. [PMID: 36892962 DOI: 10.1097/mco.0000000000000899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/10/2023]
Abstract
PURPOSE OF REVIEW Hyperammonaemia is almost always develops in patients with severe liver failure and this remains the commonest cause of elevated ammonia concentrations in the ICU. Nonhepatic hyperammonaemia in ICU presents diagnostic and management challenges for treating clinicians. Nutritional and metabolic factors play an important role in the cause and management of these complex disorders. RECENT FINDINGS Nonhepatic hyperammonaemia causes such as drugs, infection and inborn errors of metabolism may be unfamiliar to clinicians and risk being overlooked. Although cirrhotic patients may tolerate marked elevations in ammonia, other causes of acute severe hyperammonaemia may result in fatal cerebral oedema. Any coma of unclear cause should prompt urgent measurement of ammonia and severe elevations warrant immediate protective measures as well as treatments such as renal replacement therapy to avoid life-threatening neurological injury. SUMMARY The current review explores important clinical considerations, the approach to testing and key treatment principles that may prevent progressive neurological damage and improve outcomes for patients with hyperammonaemia, especially from nonhepatic causes.
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Affiliation(s)
- Sebastien Redant
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Patrick M Honoré
- Department of Intensive Care, Brugmann University Hospital, Université Libre de Bruxelles (ULB), Brussels, Belgium
- Depatment of Intensive Care, CHU UCL Godinne Namur, UCL Louvain Medical School, Namur, Belgium
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3
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Matthewman MC, Warrillow S. What you need to know about: acute liver failure. Br J Hosp Med (Lond) 2022; 83:1-11. [DOI: 10.12968/hmed.2022.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Acute liver failure is a rare but important clinical syndrome, with a high mortality rate. Prompt recognition, appropriate management and early referral to a liver transplant centre can lead to good outcomes in these critically unwell patients. This article gives an overview of the key clinical challenges and optimal management of patients with acute liver failure. Acute liver failure is defined and a comprehensive list of aetiologies and suggested investigations is provided. The clinical challenges of sepsis, renal impairment, coagulopathy, hypoglycaemia, haemodynamic instability and cerebral oedema are discussed. Quadruple H therapy, a combination of therapies aimed to reduce cerebral oedema in acute liver failure, is described. A systemic guide to managing patients with acute liver failure is provided, as are indications for referral to a liver transplant centre.
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Affiliation(s)
| | - Stephen Warrillow
- Department of Intensive Care and Medicine, Austin Health, Melbourne, Australia
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4
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Fisher C, Baldwin I, Fealy N, Naorungroj T, Bellomo R. Ammonia Clearance with Different Continuous Renal Replacement Therapy Techniques in Patients with Liver Failure. Blood Purif 2022; 51:840-846. [PMID: 35042216 DOI: 10.1159/000521312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 12/02/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Continuous renal replacement therapy (CRRT) can be used to treat hyperammonaemia. However, no study has assessed the effect of different CRRT techniques on ammonia clearance. METHODS We compared 3 different CRRT techniques in adult patients with hyperammonaemia, liver failure, and acute kidney injury. We protocolized CRRT to progressively deliver continuous veno-venous haemofiltration (CVVH), haemodialysis (CVVHD) or haemodiafiltration (CVVHDF). Ammonia was simultaneously sampled from the patient's arterial blood and effluent fluid for each technique. We applied accepted equations to calculate clearance. RESULTS We studied 12 patients with a median age of 47 years (interquartile range [IQR] 25-79). Acute liver failure was present in 4 (25%) and acute-on-chronic liver failure in 8 (75%). There was no significant difference in median ammonia clearance between CRRT technique; CVVH: 27 (IQR 23-32) mL/min versus CVVHD: 21 (IQR 17-28) mL/min versus CVVHDF: 20 (IQR 14-28) mL/min, p = 0.32. Moreover, for all techniques, ammonia clearance was significantly less than urea and creatinine clearance; urea 50 (47-54) mL/min versus creatinine 42 (IQR 38-46) mL/min versus ammonia 25 (IQR 18-29) mL/min, p = 0.0001. CONCLUSION We found no significant difference in ammonia clearance according to CRRT technique and demonstrated that ammonia clearance is significantly less than urea or creatinine clearance.
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Affiliation(s)
- Caleb Fisher
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Nigel Fealy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | | | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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5
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Fayed M, Patel N, Al Turk Y, Bradley PB. Unexplained Fatal Hyperammonemia in a Patient With New Diagnosis of Acute Monoblastic Leukemia. Cureus 2021; 13:e20108. [PMID: 35003956 PMCID: PMC8723723 DOI: 10.7759/cureus.20108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/15/2022] Open
Abstract
Idiopathic hyperammonemia is a serious condition that can arise after induction of chemotherapy and is characterized by plasma ammonia levels greater than two times the normal upper limit but within the context of normal liver function. While this dangerous complication usually appears several weeks after the start of chemotherapy, we report a fatal case of idiopathic hyperammonemia that was detected only nine days after induction chemotherapy in a 22-year-old man with no liver pathology or other risks for hyperammonemia. The patient’s initial emergent presentation was altered mental status. Laboratory workup showed acute monoblastic leukemia and radiological investigation showed cerebral hemorrhagic foci secondary to leukostasis. He received leukoreduction apheresis and he was started on induction chemotherapy with daunorubicin and cytarabine. On the ninth day of induction chemotherapy, it was noted that he developed worsening neurological findings. Investigations showed significant elevation in ammonia level and associated cerebral edema. Although hyperammonemia was mitigated, the patient’s cerebral status worsened and he died 15 days after initial presentation. This case shows that critical hyperammonemia can occur quickly after chemotherapy induction and that strategies for preventing a rise in plasma ammonia are necessary.
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Chowdhury D, Mahmood F, Edwards C, Taylor-Robinson SD. Five-day outcome of hepatitis E-induced acute liver failure in the ICU. EGYPTIAN LIVER JOURNAL 2021; 11:39. [PMID: 34804613 PMCID: PMC8591700 DOI: 10.1186/s43066-021-00098-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 04/12/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Hepatitis E virus (HEV) is an important cause of acute liver failure (ALF) in Bangladesh with pregnant mothers being more vulnerable. As HEV occurs in epidemics, it limits medical capabilities in this resource-poor country. Cerebral oedema, resulting in raised intracranial pressure (ICP), is an important cause of morbidity and mortality. Practical treatments are currently few. To study the baseline characteristics and clinical outcome of HEV-induced ALF in a recent HEV epidemicTo detect raised ICP clinically and observe response to mannitol infusion.This was a prospective cohort study from June until August 2018 of 20 patients admitted to the intensive care unit (ICU) of a major Bangladeshi Referral Hospital with HEV-induced ALF. We diagnosed HEV infection by detecting serum anti-HEV IgM antibody. All were negative for hepatitis B surface antigen and hepatitis A IgM antibody. Data were collected on 5-day outcome after admission to ICU, monitoring all patients for signs of raised ICP. An intravenous bolus of 20% mannitol was administered at a single time point to patients with raised ICP. RESULTS Twenty patients were included in the study. Ten (50%) patients, seven (70%) females, received mannitol infusion. HE worsened in eight (40%): seven female and three pregnant. Glasgow Coma scores deteriorated in six (30%): all (100%) females and three pregnant. Consciousness status was not significantly different between pregnant and non-pregnant subjects, nor between those who received mannitol and those who did not. Six patients met King's College Criteria for liver transplantation. CONCLUSIONS Female patients had a worse outcome, but pregnancy status was not an additional risk factor in our cohort. Mannitol infusion was also not associated with a significant difference in outcome.
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Affiliation(s)
- Debashis Chowdhury
- Department of Gastroenterology and Hepatology, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Farhana Mahmood
- Department of Medicine, Chattogram Maa O Shishu Hospital (CMOSH) Medical College, Chattogram, Bangladesh
| | - Cathryn Edwards
- Office of the President, British Society of Gastroenterology, St Andrew’s Place, London, UK
| | - Simon D. Taylor-Robinson
- Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, UK
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Abstract
This article introduces the basic concepts of intracranial physiology and pressure dynamics. It also includes discussion of signs and symptoms and examination and radiographic findings of patients with acute cerebral herniation as a result of increased as well as decreased intracranial pressure. Current best practices regarding medical and surgical treatments and approaches to management of intracranial hypertension as well as future directions are reviewed. Lastly, there is discussion of some of the implications of critical medical illness (sepsis, liver failure, and renal failure) and treatments thereof on causation or worsening of cerebral edema, intracranial hypertension, and cerebral herniation.
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Affiliation(s)
- Aleksey Tadevosyan
- Department of Neurology, Tufts University School of Medicine, Beth Israel Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA.
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Tufts Medical Center, 800 Washington Street, Box#314, Boston, MA 02111, USA
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Naorungroj T, Yanase F, Eastwood GM, Baldwin I, Bellomo R. Extracorporeal Ammonia Clearance for Hyperammonemia in Critically Ill Patients: A Scoping Review. Blood Purif 2020; 50:453-461. [PMID: 33279903 DOI: 10.1159/000512100] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/02/2020] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Hyperammonemia is a life-threatening condition. However, clearance of ammonia via extracorporeal treatment has not been systematically evaluated. METHODS We searched EMBASE and MEDLINE databases. We included all publications reporting ammonia clearance by extracorporeal treatment in adult and pediatric patients with clearance estimated by direct dialysate ammonia measurement or calculated by formula. Two reviewers screened and extracted data independently. RESULTS We found 1,770 articles with 312 appropriate for assessment and 28 studies meeting eligibility criteria. Most of the studies were case reports. Hyperammonemia was typically secondary to inborn errors of metabolisms in children and to liver failure in adult patients. Ammonia clearance was most commonly reported during continuous renal replacement therapy (CRRT) and appeared to vary markedly from <5 mL/min/m2 to >250 mL/min/m2. When measured during intermittent hemodialysis (IHD), clearance was highest and correlated with blood flow rate (R2 = 0.853; p < 0.001). When measured during CRRT, ammonia clearance could be substantial and correlated with effluent flow rate (EFR; R2 = 0.584; p < 0.001). Neither correlated with ammonia reduction. Peritoneal dialysis (PD) achieved minimal clearance, and other extracorporeal techniques were rarely studied. CONCLUSIONS Extracorporeal ammonia clearance varies widely with sometimes implausible values. Treatment modality, blood flow, and EFR, however, appear to affect such clearance with IHD achieving the highest values, PD achieving minimal values, and CRRT achieving substantial values especially at high EFRs. The role of other techniques remains unclear. These findings can help inform practice and future studies.
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Affiliation(s)
- Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Monash University School and Public Health and Preventive Medicine, ANZICS-RC, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Ian Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia, .,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia, .,Data Analytics Research and Evaluation (DARE) Centre, The University of Melbourne and Austin Health, Melbourne, Victoria, Australia,
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9
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Ribaud J, McLernon S, Auzinger G. Targeted temperature management in acute liver failure: A systematic review. Nurs Crit Care 2020; 27:784-795. [PMID: 32602249 PMCID: PMC10078683 DOI: 10.1111/nicc.12524] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 06/03/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND Targeted temperature management is the modern term for therapeutic hypothermia, where cooling is induced by intensive care clinicians to achieve body temperatures below 36°C. Its use in acute liver failure to improve refractory intracranial hypertension and patient outcomes is not supported by strong quality evidence. AIM This systematic review aims to determine if targeted temperature management improves patient outcome as opposed to normothermia in acute liver failure. METHODS A computerized and systematic search of six academic and medical databases was conducted using the following keywords: "acute liver failure", "fulminant hepatic injury", "targeted temperature management", "therapeutic hypothermia", and "cooling". Broad criteria were applied to include all types of primary observational studies, from case reports to randomized controlled trials. Standardized tools were used throughout to critically appraise and extract data. FINDINGS Nine studies published between 1999 and 2016 were included. Early observational studies suggest a benefit of targeted temperature management in the treatment of refractory intracranial hypertension and in survival. More recent controlled studies do not show such a benefit in the prevention of intracranial hypertension. All studies revealed that the incidence of coagulopathy is not higher in patients treated with targeted temperature management. There remains some uncertainty regarding the increased risk of infection and dysrhythmias. Heterogeneity was found between study types, design, sample sizes, and quality. CONCLUSION Although it does not significantly improve survival, targeted temperature management is efficient in treating episodes of intracranial hypertension and stabilizing an unstable critical care patient without increasing the risk of bleeding. It does not, however, prevent intracranial hypertension. Data heterogeneity may explain the contradictory findings. RELEVANCE TO CLINICAL PRACTICE Controlled studies are needed to elucidate the true clinical benefit of targeted temperature management in improving patient outcome.
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Affiliation(s)
| | - Siobhan McLernon
- School of Health and Social Care, London South Bank University, London, UK
| | - Georg Auzinger
- Liver Intensive Treatment Unit, Institute of Liver Studies, King's College Hospital, London, UK
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10
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Warrillow S, Fisher C, Tibballs H, Bailey M, McArthur C, Lawson-Smith P, Prasad B, Anstey M, Venkatesh B, Dashwood G, Walsham J, Holt A, Wiersema U, Gattas D, Zoeller M, Garcia Alvarez M, Bellomo R. Coagulation abnormalities, bleeding, thrombosis, and management of patients with acute liver failure in Australia and New Zealand. J Gastroenterol Hepatol 2020; 35:846-854. [PMID: 31689724 DOI: 10.1111/jgh.14876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Revised: 09/19/2019] [Accepted: 09/21/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIM To study the management of coagulation and hematological derangements among severe acute liver failure (ALF) patients in Australia and New Zealand liver transplant intensive care units (ICUs). METHODS Analysis of key baseline characteristics, etiology, coagulation and hematological tests, use of blood products, thrombotic complications, and clinical outcomes during the first ICU week. RESULTS We studied 62 ALF patients. The first day median peak international normalized ratio was 5.5 (inter-quartile range [IQR] 3.8-8.7), median longest activated partial thromboplastin time was 62 s (IQR 44-87), and median lowest fibrinogen was 1.1 (IQR 0.8-1.6) g/L. Fibrinogen was only measured in 85% of patients, which was less than other tests (P < 0.0001). Median initial lowest platelet count was 83 (IQR 41-122) × 109 /L. Overall, 58% of patients received fresh frozen plasma, 40% cryoprecipitate, 35% platelets, and 15% prothrombin complex concentrate. Patients with bleeding complications (19%) had more severe overall hypofibrinogenemia and thrombocytopenia. Thrombotic complications were less common (10% of patients), were not associated with consistent patterns of abnormal hemostasis, and were not immediately preceded by clotting factor administration and half occurred only after liver transplantation surgery. CONCLUSION In ALF patients admitted to dedicated Australia and New Zealand ICUs, fibrinogen was measured less frequently than other coagulation parameters but, together with platelets, appeared more relevant to bleeding risk. Blood products and procoagulant factors were administered to most patients at variable levels of hemostatic derangement, and bleeding complications were more common than thrombotic complications. This epidemiologic information and practice variability provide baseline data for the design and powering of interventional studies.
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Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - Caleb Fisher
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Heath Tibballs
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Monash University School of Public Health and Preventive Medicine, Victoria, Melbourne, Australia
| | - Colin McArthur
- Medical Research Institute of New Zealand, Auckland, New Zealand.,Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Pia Lawson-Smith
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - Matthew Anstey
- Department of Intensive Care, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
| | - Bala Venkatesh
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - Gemma Dashwood
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - James Walsham
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, Australia
| | - Andrew Holt
- Department of Intensive Care, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Ubbo Wiersema
- Department of Intensive Care, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - David Gattas
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Matthew Zoeller
- Department of Intensive Care, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mercedes Garcia Alvarez
- Department of Anesthesiology and Pain Medicine, Hospital Santa Creu i Sant Pau, University of Barcelona, Barcelona, Spain
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia.,Department of Medicine and Surgery, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, Australia.,Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Australia
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11
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Warrillow S, Fisher C, Bellomo R. Correction and Control of Hyperammonemia in Acute Liver Failure: The Impact of Continuous Renal Replacement Timing, Intensity, and Duration. Crit Care Med 2020; 48:218-224. [PMID: 31939790 DOI: 10.1097/ccm.0000000000004153] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVES Hyperammonemia is a key contributing factor for cerebral edema in acute liver failure. Continuous renal replacement therapy may help reduce ammonia levels. However, the optimal timing, mode, intensity, and duration of continuous renal replacement therapy in this setting are unknown. We aimed to study continuous renal replacement therapy use in acute liver failure patients and to assess its impact on hyperammonemia. DESIGN Retrospective observational study. SETTING ICU within a specialized liver transplant hospital. PATIENTS Fifty-four patients with acute liver failure. INTERVENTIONS Data were obtained from medical records and analyzed for patient characteristics, continuous renal replacement therapy use, ammonia dynamics, and outcomes. MAIN RESULTS Forty-five patients (83%) had high grade encephalopathy. Median time to continuous renal replacement therapy commencement was 4 hours (interquartile range, 2-4.5) with 35 (78%) treated with continuous venovenous hemodiafiltration and 10 (22%) with continuous venovenous hemofiltration. Median hourly effluent flow rate was 43 mL/kg (interquartile range, 37-62). The median ammonia concentration decreased every day during treatment from 151 µmol/L (interquartile range, 110-204) to 107 µmol/L (interquartile range, 84-133) on day 2, 75 µmol/L (interquartile range, 63-95) on day 3, and 52 µmol/L (interquartile range, 42-70) (p < 0.0001) on day 5. The number of patients with an ammonia level greater than 150 µmol/L decreased on the same days from 26, to nine, then two, and finally none. Reductions in ammonia levels correlated best with the cumulative duration of therapy hours (p = 0.03), rather than hourly treatment intensity. CONCLUSIONS Continuous renal replacement therapy is associated with reduced ammonia concentrations in acute liver failure patients. This effect is related to greater cumulative dose. These findings suggest that continuous renal replacement therapy initiated early and continued or longer may represent a useful approach to hyperammonemia control in acute liver failure patients.
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Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Critical Care Institute, Epworth HealthCare, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Caleb Fisher
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
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12
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Hey P, Hanrahan TP, Sinclair M, Testro AG, Angus PW, Peterson A, Warrillow S, Bellomo R, Perini MV, Starkey G, Jones RM, Fink M, McClure T, Gow P. Epidemiology and outcomes of acute liver failure in Australia. World J Hepatol 2019; 11:586-595. [PMID: 31388400 PMCID: PMC6669190 DOI: 10.4254/wjh.v11.i7.586] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Revised: 06/19/2019] [Accepted: 07/05/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) is a life-threatening syndrome with varying aetiologies requiring complex care and multidisciplinary management. Its changing incidence, aetiology and outcomes over the last 16 years in the Australian context remain uncertain.
AIM To describe the changing incidence, aetiology and outcomes of ALF in South Eastern Australia.
METHODS The database of the Victorian Liver Transplant Unit was interrogated to identify all cases of ALF in adults (> 16 years) in adults hospitalised between January 2002 and December 2017. Overall, 169 patients meeting criteria for ALF were identified. Demographics, aetiology of ALF, rates of transplantation and outcomes were collected for all patients. Transplant free survival and overall survival (OS) were assessed based on survival to discharge from hospital. Results were compared to data from a historical cohort from the same unit from 1988-2001.
RESULTS Paracetamol was the most common aetiology of acute liver failure, accounting for 50% of cases, with an increased incidence compared with the historical cohort (P = 0.046). Viral hepatitis and non-paracetamol drug or toxin induced liver injury accounted for 15% and 10% of cases respectively. Transplant free survival (TFS) improved significantly compared to the historical cohort (52% vs 38%, P = 0.032). TFS was highest in paracetamol toxicity with spontaneous recovery in 72% of cases compared to 31% of non-paracetamol ALF (P < 0.001). Fifty-nine patients were waitlisted for emergency liver transplantation. Nine of these died while waiting for an organ to become available. Forty-two patients (25%) underwent emergency liver transplantation with a 1, 3 and 5 year survival of 81%, 78% and 72% respectively.
CONCLUSION Paracetamol toxicity is the most common aetiology of ALF in South-Eastern Australia with a rising incidence over 30 years. TFS has improved, however it remains low in non-paracetamol ALF.
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Affiliation(s)
- Penelope Hey
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | | | - Marie Sinclair
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Adam G Testro
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Peter W Angus
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Adam Peterson
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Heath, Melbourne 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Heath, Melbourne 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Marcos V Perini
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Graham Starkey
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Robert M Jones
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Michael Fink
- Department of Surgery, Austin Health, Melbourne 3084, Australia
| | - Tess McClure
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Health, Heidelberg 3084, Australia
- The University of Melbourne, Melbourne 3052, Australia
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13
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Porteous J, Cioccari L, Ancona P, Osawa E, Jones K, Gow P, Angus P, Warrillow S, Bellomo R. Outcome of Acetaminophen-Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation. Liver Transpl 2019; 25:35-44. [PMID: 30379388 DOI: 10.1002/lt.25377] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 10/28/2018] [Indexed: 02/07/2023]
Abstract
Acetaminophen-induced acute liver failure (ALF) may require emergency liver transplantation (LT) in the presence of specific criteria, and its management may also include intracranial pressure (ICP) monitoring in selected patients at high risk of cerebral edema. We aimed to test the hypothesis that management of such patients without ICP monitoring or LT would yield outcomes similar to those reported with conventional management. We interrogated a database of all patients treated in an intensive care unit for acetaminophen-induced ALF between November 2010 and October 2016 and obtained relevant information from electronic medical records. We studied 64 patients (58 females) with a median age of 38 years. Such patients had a high prevalence of depression, substance abuse, or other psychiatric disorders and had ingested a median acetaminophen dose of 25 g. No patient received ICP monitoring or LT. Overall, 51 (79.7%) patients survived. Of the 42 patients who met King's College Hospital (KCH) criteria, 29 (69.0%) survived without transplantation. There were 45 patients who developed severe hepatic encephalopathy, and 32 (71.1%) of these survived. Finally, compared with the KCH criteria, the current UK Registration Criteria for Super-Urgent Liver Transplantation (UKRC) for super-urgent LT had better sensitivity (92.3%) and specificity (80.4%) for hospital mortality. In conclusion, in a center applying a no ICP monitoring and no LT approach to the management of acetaminophen-induced ALF, during a 6-year period, overall survival was 79.7%, and for patients fulfilling KCH criteria, it was 69.0%, which were both higher than for equivalent patients treated with conventional management as reported in the literature. Finally, the current UKRC may be a better predictor of hospital mortality in this patient population.
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Affiliation(s)
- Jennifer Porteous
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Luca Cioccari
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, University Hospital, University of Bern, Bern, Switzerland.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia
| | - Paolo Ancona
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Eduardo Osawa
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Kelly Jones
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul Gow
- Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Peter Angus
- Liver Transplant Unit, Austin Hospital, Melbourne, Victoria, Australia
| | - Stephen Warrillow
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Victoria, Australia
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14
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Abstract
Drug-induced acute liver failure (ALF) disproportionately affects women and nonwhites. It is most frequently caused by antimicrobials and to a lesser extent by complementary and alternative medications, antiepileptics, antimetabolites, nonsteroidals, and statins. Most drug-induced liver injury ALF patients have hepatocellular injury pattern. Cerebral edema and intracranial hypertension are the most serious complications of ALF. Other complications include coagulopathy, sepsis, metabolic derangements, and renal, circulatory, and respiratory dysfunction. Although advances in intensive care have improved outcome, ALF has significant mortality without liver transplantation. Liver-assist devices may provide a bridge to transplant or to spontaneous recovery.
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Affiliation(s)
- Shahid Habib
- Department of Medicine, Southern Arizona Veterans Affairs Healthcare System 3601 S 6th Avenue, Tucson, AZ 85723 USA
| | - Obaid S Shaikh
- Section of Gastroenterology, Department of Medicine, Veterans Affairs Pittsburgh Healthcare System, University Drive C, FU #112, Pittsburgh, PA 15240, USA; Division of Gastroenterology, Hepatology, and Nutrition, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15213, USA.
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15
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Abstract
Hyperammonemia is an important cause of cerebral edema in both adults with liver failure and children with inborn errors of metabolism. There are few studies that have analyzed the role of extracorporeal dialysis in reducing blood ammonia levels in the adult population. Furthermore, there are no firm guidelines about when to implement RRT, because many of the conditions that are characterized by hyperammonemia are extremely rare. In this review of existing literature on RRT, we present the body's own mechanisms for clearing ammonia as well as the dialytic properties of ammonia. We review the available literature on the use of continuous venovenous hemofiltration, peritoneal dialysis, and hemodialysis in neonates and adults with conditions characterized by hyperammonemia and discuss some of the controversies that exist over selecting one modality over another.
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Affiliation(s)
| | - Andrew Z. Fenves
- Renal Division, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
| | - Robert Hootkins
- ESRD Consulting, PLLC, Austin, Texas; and
- Department of Medicine, University of Texas Southwestern, Dallas, Texas
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16
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Yonai R, Sato R, Nasu M. Cerebral edema induced by hyperammonemia: a case report. Am J Emerg Med 2016; 34:2461.e3-2461.e5. [PMID: 27269953 DOI: 10.1016/j.ajem.2016.05.065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 05/21/2016] [Accepted: 05/24/2016] [Indexed: 10/21/2022] Open
Affiliation(s)
- Ryo Yonai
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Urasoe City, Okinawa, Japan
| | - Ryota Sato
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Urasoe City, Okinawa, Japan.
| | - Michitaka Nasu
- Department of Emergency and Critical Care Medicine, Urasoe General Hospital, Urasoe City, Okinawa, Japan
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17
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Dalal A. Anesthesia for liver transplantation. Transplant Rev (Orlando) 2016; 30:51-60. [DOI: 10.1016/j.trre.2015.05.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Revised: 09/28/2014] [Accepted: 05/11/2015] [Indexed: 02/08/2023]
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18
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Warrillow S, Herrera-Gutiérrez ME. Is LiFe worth living? It all depends on the liver. Intensive Care Med 2015; 42:448-450. [PMID: 26630878 DOI: 10.1007/s00134-015-4149-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Affiliation(s)
- Stephen Warrillow
- Department of Intensive Care, Austin Health and The University of Melbourne, Heidelberg, Melbourne, VIC, Australia.
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