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Tsai CY, Lee CL, Wu JCC. Astrocyte-secreted lipocalin-2 elicits bioenergetic failure-induced neuronal death that is causally related to high fatality in a mouse model of hepatic encephalopathy. Neurochem Int 2024; 178:105800. [PMID: 38964718 DOI: 10.1016/j.neuint.2024.105800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 06/24/2024] [Accepted: 07/01/2024] [Indexed: 07/06/2024]
Abstract
Hepatic encephalopathy (HE) is a neurological complication arising from acute liver failure with poor prognosis and high mortality; the underlying cellular mechanisms are still wanting. We previously found that neuronal death caused by mitochondrial dysfunction in rostral ventrolateral medulla (RVLM), which leads to baroreflex dysregulation, is related to high fatality in an animal model of HE. Lipocalin-2 (Lcn2) is a secreted glycoprotein mainly released by astrocytes in the brain. We noted the presence of Lcn2 receptor (Lcn2R) in RVLM neurons and a parallel increase of Lcn2 gene in astrocytes purified from RVLM during experimental HE. Therefore, our guiding hypothesis is that Lcn2 secreted by reactive astrocytes in RVLM may underpin high fatality during HE by eliciting bioenergetic failure-induced neuronal death in this neural substrate. In this study, we first established the role of astrocyte-secreted Lcn2 in a liver toxin model of HE induced by azoxymethane (100 μg/g, ip) in C57BL/6 mice, followed by mechanistic studies in primary astrocyte and neuron cultures prepared from postnatal day 1 mouse pups. In animal study, immunoneutralization of Lcn2 reduced apoptotic cell death in RVLM, reversed defunct baroreflex-mediated vasomotor tone and prolonged survival during experimental HE. In our primary cell culture experiments, Lcn2 produced by cultured astrocytes and released into the astrocyte-conditioned medium significantly reduced cell viability of cultured neurons. Recombinant Lcn2 protein reduced cell viability, mitochondrial ATP (mitoATP) production, and pyruvate dehydrogenase (PDH) activity but enhanced the expression of pyruvate dehydrogenase kinase (PDK) 1, PDK3 and phospho-PDHA1 (inactive PDH) through MAPK/ERK pathway in cultured neurons, with all cellular actions reversed by Lcn2R knockdown. Our results suggest that astrocyte-secreted Lcn2 upregulates PDKs through MAPK/ERK pathway, which leads to reduced PDH activity and mitoATP production; the reinforced neuronal death in RVLM is causally related to baroreflex dysregulation that underlies high fatality associated with HE.
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Affiliation(s)
- Ching-Yi Tsai
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Chin-Lai Lee
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Jacqueline C C Wu
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Shi H, Chen R, Li M, Ge J. Acute hepatotoxicity of intravenous amiodarone in a Becker muscular dystrophy patient with decompensated heart failing and ABCB4 gene mutation: as assessed for causality using the updated RUCAM. J Cardiothorac Surg 2024; 19:464. [PMID: 39044225 PMCID: PMC11265456 DOI: 10.1186/s13019-024-02869-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/14/2024] [Indexed: 07/25/2024] Open
Abstract
BACKGROUND Cardiac dysfunction, including arrhythmias, may be one of the main clinical manifestations of Becker muscular dystrophy (BMD). Amiodarone is widely used to treat arrhythmia. However, multi-systemic toxicity caused by amiodarone, especially hepatotoxicity, should not be neglected. Here, we introduce a novel case of multi-systemic amiodarone toxicity involving the liver, renal and coagulation in BDM patient with ABCB4 gene mutation. CASE PRESENTATION We present a case of a 16-year-old boy admitted with heart failure and atrial fibrillation (AF). He was diagnosed with Becker muscular dystrophy (BMD) and gene testing showed comorbid mutations in gene DMD, ABCB4 and DSC2. Amiodarone was prescribed to control the paroxysmal atrial fibrillation intravenously. However, his liver enzyme levels were sharply elevated, along with cardiac shock, renal failure and coagulation disorders. After bedside continuous renal replacement therapy, the patient's liver function and clinical status rehabilitated. CONCLUSIONS ABCB4 gene mutation might be involved in amiodarone-induced hepatotoxicity. Studies in a cohort might help to prove this hypothesis in the future.
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Affiliation(s)
- Hui Shi
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, 1069 Xietu Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
| | - Ruizhen Chen
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, 1069 Xietu Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Minghui Li
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China.
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, 1069 Xietu Road, Shanghai, 200032, China.
- National Clinical Research Center for Interventional Medicine, Shanghai, China.
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Cardiology, Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Shanghai Medical College of Fudan University, 1069 Xietu Road, Shanghai, 200032, China
- National Clinical Research Center for Interventional Medicine, Shanghai, China
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Agumava LU, Gulyaev VA, Lutsyk KN, Olisov OD, Akhmetshin RB, Magomedov KM, Kazymov BI, Akhmedov AR, Alekberov KF, Yaremin BI, Novruzbekov MS. Issues of intensive care and liver transplantation tactics in fulminant liver failure. BULLETIN OF THE MEDICAL INSTITUTE "REAVIZ" (REHABILITATION, DOCTOR AND HEALTH) 2023. [DOI: 10.20340/vmi-rvz.2023.1.tx.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Fulminant liver failure is usually characterized as severe acute liver injury with encephalopathy and synthetic dysfunction (international normalized ratio [INR] ≥1.5) in a patient without cirrhosis or previous liver disease. Management of patients with acute liver failure includes ensuring that the patient is cared for appropriately, monitoring for worsening liver failure, managing complications, and providing nutritional support. Patients with acute liver failure should be treated at a liver transplant center whenever possible. Serial laboratory tests are used to monitor the course of a patient's liver failure and to monitor for complications. It is necessary to monitor the level of aminotransferases and bilirubin in serum daily. More frequent monitoring (three to four times a day) of blood coagulation parameters, complete blood count, metabolic panels, and arterial blood gases should be performed. For some causes of acute liver failure, such as acetaminophen intoxication, treatment directed at the underlying cause may prevent the need for liver transplantation and reduce mortality. Lactulose has not been shown to improve overall outcomes, and it can lead to intestinal distention, which can lead to technical difficulties during liver transplantation. Early in acute liver failure, signs and symptoms of cerebral edema may be absent or difficult to detect. Complications of cerebral edema include increased intracranial pressure and herniation of the brain stem. General measures to prevent increased intracranial pressure include minimizing stimulation, maintaining an appropriate fluid balance, and elevating the head of the patient's bed. For patients at high risk of developing cerebral edema, we also offer hypertonic saline prophylaxis (3%) with a target serum sodium level of 145 to 155 mEq/L (level 2C). High-risk patients include patients with grade IV encephalopathy, high ammonia levels (>150 µmol/L), or acute renal failure, and patients requiring vasopressor support. Approximately 40 % of patients with acute liver failure recover spontaneously with supportive care. Predictive models have been developed to help identify patients who are unlikely to recover spontaneously, as the decision to undergo liver transplant depends in part on the likelihood of spontaneous recovery of the liver. However, among those who receive a transplant, the one-year survival rate exceeds 80 %, making this treatment the treatment of choice in this difficult patient population.
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Affiliation(s)
- L. U. Agumava
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - V. A. Gulyaev
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - K. N. Lutsyk
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - O. D. Olisov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center; Pirogov Russian National Research Medical University, Department of Transplantology and Artificial Organs
| | - R. B. Akhmetshin
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - K. M. Magomedov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - B. I. Kazymov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - A. R. Akhmedov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - K. F. Alekberov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center
| | - B. I. Yaremin
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center; Pirogov Russian National Research Medical University, Department of Transplantology and Artificial Organs
| | - M. S. Novruzbekov
- Research Institute of Ambulance them. N.V. Sklifosovsky, liver transplant center; Pirogov Russian National Research Medical University, Department of Transplantology and Artificial Organs
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Tsai CY, Wu JCC, Wu CJ, Chan SHH. Protective role of VEGF/VEGFR2 signaling against high fatality associated with hepatic encephalopathy via sustaining mitochondrial bioenergetics functions. J Biomed Sci 2022; 29:47. [PMID: 35786324 PMCID: PMC9251935 DOI: 10.1186/s12929-022-00831-0] [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: 04/07/2022] [Accepted: 06/27/2022] [Indexed: 11/30/2022] Open
Abstract
Background The lack of better understanding of the pathophysiology and cellular mechanisms associated with high mortality seen in hepatic encephalopathy (HE), a neurological complication arising from acute hepatic failure, remains a challenging medical issue. Clinical reports showed that the degree of baroreflex dysregulation is related to the severity of HE. Furthermore, mitochondrial dysfunction in the rostral ventrolateral medulla (RVLM), a key component of the baroreflex loop that maintains blood pressure and sympathetic vasomotor tone, is known to underpin impairment of baroreflex. Realizing that in addition to angiogenic and vasculogenic effects, by acting on its key receptor (VEGFR2), vascular endothelial growth factor (VEGF) elicits neuroprotection via maintenance of mitochondrial function, the guiding hypothesis of the present study is that the VEGF/VEGFR2 signaling plays a protective role against mitochondrial dysfunction in the RVLM to ameliorate baroreflex dysregulation that underpins the high fatality associated with HE. Methods Physiological, pharmacological and biochemical investigations were carried out in proof-of-concept experiments using an in vitro model of HE that involved incubation of cultured mouse hippocampal neurons with ammonium chloride. This was followed by corroboratory experiments employing a mouse model of HE, in which adult male C57BL/6 mice and VEGFR2 wild-type and heterozygous mice received an intraperitoneal injection of azoxymethane, a toxin used to induce acute hepatic failure. Results We demonstrated that VEGFR2 is present in cultured neurons, and observed that whereas recombinant VEGF protein maintained cell viability, gene-knockdown of vegfr2 enhanced the reduction of cell viability in our in vitro model of HE. In our in vivo model of HE, we found that VEGFR2 heterozygous mice exhibited shorter survival rate and time when compared to wild-type mice. In C57BL/6 mice, there was a progressive reduction in VEGFR2 mRNA and protein expression, mitochondrial membrane potential and ATP levels, alongside augmentation of apoptotic cell death in the RVLM, accompanied by a decrease in baroreflex-mediated sympathetic vasomotor tone and hypotension. Immunoneutralization of VEGF exacerbated all those biochemical and physiological events. Conclusions Our results suggest that, acting via VEGFR2, the endogenous VEGF plays a protective role against high fatality associated with HE by amelioration of the dysregulated baroreflex-mediated sympathetic vasomotor tone through sustaining mitochondrial bioenergetics functions and eliciting antiapoptotic action in the RVLM. Supplementary Information The online version contains supplementary material available at 10.1186/s12929-022-00831-0.
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Affiliation(s)
- Ching-Yi Tsai
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Jacqueline C C Wu
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Chiung-Ju Wu
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Samuel H H Chan
- Institute for Translational Research in Biomedicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
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Kanjo A, Ocskay K, Gede N, Kiss S, Szakács Z, Párniczky A, Mitzner S, Stange J, Hegyi P, Molnár Z. Efficacy and safety of liver support devices in acute and hyperacute liver failure: a systematic review and network meta-analysis. Sci Rep 2021; 11:4189. [PMID: 33602961 PMCID: PMC7893063 DOI: 10.1038/s41598-021-83292-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 01/28/2021] [Indexed: 12/19/2022] Open
Abstract
Acute liver failure (ALF) is a potentially life-threatening condition. Liver support therapies can be applied as a bridging-to-transplantation or bridging-to-recovery; however, results of clinical trials are controversial. Our aim was to compare liver support systems in acute and hyperacute liver failure with network meta-analysis. After systematic search, randomized controlled trials (RCT) comparing liver support therapies in adults with acute or hyperacute liver failure were included. In-hospital mortality was the primary outcome, the secondary outcomes were hepatic encephalopathy and mortality-by-aetiology. A Bayesian-method was used to perform network meta-analysis and calculate surface under the cumulative ranking curve (SUCRA) values to rank interventions. Eleven RCTs were included. BioLogic-DT and molecular adsorbent recirculating system (MARS) resulted in the lowest mortality (SUCRAs: 76% and 73%, respectively). In non-paracetamol-poisoned patients, BioLogic-DT, charcoal hemoperfusion and MARS may be equally efficient regarding mortality (SUCRAs: 53%, 52% and 52%, respectively). Considering hepatic encephalopathy, extracorporeal liver assist device (ELAD) may be the most effective option (SUCRA: 78%). However, in pairwise meta-analysis, there were no statistically significant differences between the interventions in the outcomes. In conclusion, MARS therapy seems to be the best available option in reducing mortality. Further research is needed on currently available and new therapeutic modalities. (CRD42020160133).
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Affiliation(s)
- Anna Kanjo
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Klementina Ocskay
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Noémi Gede
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Szabolcs Kiss
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Zsolt Szakács
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Andrea Párniczky
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Heim Pál National Paediatric Institute, Budapest, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary
| | - Steffen Mitzner
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Jan Stange
- Division of Nephrology, Department of Medicine, University of Rostock, Rostock, Germany
| | - Péter Hegyi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary.,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary.,János Szentágothai Research Centre, University of Pécs, Pécs, Hungary
| | - Zsolt Molnár
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary. .,Doctoral School of Clinical Medicine, University of Szeged, Szeged, Hungary. .,Department of Anesthesiology and Intensive Therapy, Poznan University for Medical Sciences, Medical Faculty, Poznan, Poland.
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de Ávila RE, José Fernandes H, Barbosa GM, Araújo AL, Gomes TCC, Barros TG, Moreira RLF, Silva GLC, de Oliveira NR. Clinical profiles and factors associated with mortality in adults with yellow fever admitted to an intensive care unit in Minas Gerais, Brazil. Int J Infect Dis 2020; 93:90-97. [PMID: 32004691 DOI: 10.1016/j.ijid.2020.01.039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Yellow fever (YF) is a viral hemorrhagic disease caused by an arbovirus from the Flaviviridae family. Data on the clinical profile of severe YF in intensive care units (ICUs) are scarce. This study aimed to evaluate factors associated with YF mortality in patients admitted to a Brazilian ICU during the YF outbreaks of 2017 and 2018. METHODS This was a longitudinal cohort case series study that included YF patients admitted to the ICU. Demographics, clinical and laboratory data were analyzed. Cox regression identified independent predictors of death risk. RESULTS A total of 114 patients were studied. The median age was 48 years, and 92.1% were males. In univariate analysis, jaundice, leukopenia, bradycardia, prothrombin time, expressed as a ratio to the international normalized ratio-(PT-INR), alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin, lactate, arterial pH and bicarbonate, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score 3 (SAPS 3) severity scores, transfusion of fresh frozen plasma, acute renal failure (Acute Kidney Injury Network stage III (AKIN III)), hemodialysis, cumulative fluid balance at 72 h of ICU, vasopressor use, seizures and grade IV encephalopathy were significantly associated with mortality. In multivariate analysis, factors independently associated with YF mortality were PT-INR, APACHE II, and grade IV hepatic encephalopathy. CONCLUSIONS In the large outbreak in Brazil, factors independently associated with death risk in YF were: PT-INR, APACHE II, and grade IV hepatic encephalopathy. Early identification of patients with YF mortality risk factors may be very useful. Once these patients with a poor prognosis have been identified, proper management should be promptly implemented.
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Affiliation(s)
- Renata Eliane de Ávila
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil.
| | - Herbert José Fernandes
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil.
| | - Gerdson Magno Barbosa
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
| | - Argus Leão Araújo
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
| | | | - Teresa Gamarano Barros
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
| | - Ricardo Luiz Fontes Moreira
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
| | - Guilherme Lima Castro Silva
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
| | - Neimy Ramos de Oliveira
- Hospital Eduardo de Menezes (HEM), Fundação Hospitalar do Estado de Minas Gerais (FHEMIG), Belo Horizonte, Brazil
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Wang YM, Li K, Dou XG, Bai H, Zhao XP, Ma X, Li LJ, Chen ZS, Huang YC. Treatment of AECHB and Severe Hepatitis (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498915 DOI: 10.1007/978-94-024-1603-9_4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This chapter describes the general treatment and immune principles and internal management for AECHB and HBV ACLF, including ICU monitoring, general supportive medications/nutrition/nursing, immune therapy, artificial liver supportive systems, hepatocyte/stem cell, and liver transplant, management for special populations, frequently clinical complications and the utilization of Chinese traditional medicines.Early clinical indicators of severe hepatitis B include acratia, gastrointestinal symptoms, a daily increase in serum bilirubin >1 mg/dL, toxic intestinal paralysis, bleeding tendency and mild mind anomaly or character change, and the presence of other diseases inducing severe hepatitis. Laboratory indicators include T-Bil, PTA, cholinesterase, pre-albumin and albumin. The roles of immune indicators (such as IL-6, TNF-α, and fgl2), gene polymorphisms, HBV genotypes, and gene mutations as early clinical indicators. Intensive Care Unit monitor patients with severe hepatitis include intracranial pressure, infection, blood dynamics, respiratory function, renal function, blood coagulation function, nutritional status and blood purification process. Nursing care should not only include routine care, but psychological and special care (complications). Nutrition support and nursing care should be maintained throughout treatment for severe hepatitis. Common methods of evaluating nutritional status include direct human body measurement, creatinine height index (CHI) and subject global assessment of nutrition (SGA). Malnourished patients should receive enteral or parenteral nutrition support. Immune therapies for severe hepatitis include promoting hepatocyte regeneration (e.g. with glucagon, hepatocyte growth factor and prostaglandin E1), glucocorticoid suppressive therapy, and targeting molecular blocking. Corticosteroid treatment should be early and sufficient, and adverse drug reactions monitored. Treatments currently being investigated are those targeting Toll-like receptors, NK cell/NK cell receptors, macrophage/immune coagulation system, CTLA-4/PD-1 and stem cell transplantation. In addition to conventional drugs and radioiodine, corticosteroids and artificial liver treatment can also be considered for severe hepatitis patients with hyperthyreosis. Patients with gestational severe hepatitis require preventive therapy for fetal growth restriction, and it is necessary to choose the timing and method of fetal delivery. For patients with both diabetes and severe hepatitis, insulin is preferred to oral antidiabetic agents to control blood glucose concentration. Liver toxicity of corticosteroids and immune suppressors should be monitored during treatment for severe hepatitis in patients with connective tissue diseases including SLE, RA and sicca syndrome. Patient with connective tissue diseases should preferably be started after the antiviral treatment with nucleos(t)ide analogues. An artificial liver can improve patients’ liver function; remove endotoxins, blood ammonia and other toxins; correct amino acid metabolism and coagulation disorders; and reverse internal environment imbalances. Non-bioartificial livers are suitable for patients with early and middle stage severe hepatitis; for late-stage patients waiting for liver transplantation; and for transplanted patients with rejection reaction or transplant failure. The type of artificial liver should be determined by each patient’s condition and previous treatment purpose, and patients should be closely monitored for adverse reactions and complications. Bio- and hybrid artificial livers are still under development. MELD score is the international standard for choosing liver transplantation. Surgical methods mainly include the in situ classic type and the piggyback type; transplantation includes no liver prophase, no liver phase or new liver phase. Preoperative preparation, management of intraoperative and postoperative complications and postoperative long-term treatment are keys to success. Severe hepatitis belongs to the categories of “acute jaundice”, “scourge jaundice”, and “hot liver” in traditional Chinese medicine. Treatment methods include Chinese traditional medicines, acupuncture and acupoint injection, external application of drugs, umbilical compress therapy, drip, blow nose therapy, earpins, and clysis. Dietary care is also an important part of traditional Chinese medicine treatment.
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Montrief T, Koyfman A, Long B. Acute liver failure: A review for emergency physicians. Am J Emerg Med 2018; 37:329-337. [PMID: 30414744 DOI: 10.1016/j.ajem.2018.10.032] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 10/15/2018] [Accepted: 10/17/2018] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Acute liver failure (ALF) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization. OBJECTIVE This narrative review provides an evidence-based summary of the current data for the emergency medicine evaluation and management of ALF. DISCUSSION While ALF remains a rare clinical presentation, surveillance data suggest an overall incidence between 1 and 6 cases per million people every year, accounting for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the U.S. The definition of ALF includes neurologic dysfunction, an international normalized ratio ≥ 1.5, no prior evidence of liver disease, and a disease course of ≤26 weeks, and can be further divided into hyperacute, acute, and subacute presentations. There are many underlying etiologies, including acetaminophen toxicity, drug induced liver injury, and hepatitis. Emergency physicians will be faced with several complications, including encephalopathy, coagulopathy, infectious processes, renal injury, and hemodynamic instability. Critical patients should be evaluated in the resuscitation bay, and consultation with the transplant team for appropriate patients improves patient outcomes. This review provides several guiding principles for management of acute complications. Using a pathophysiological-guided approach to the management of ALF associated complications is essential to optimizing patient care. CONCLUSIONS ALF remains a rare clinical presentation, but has significant morbidity and mortality. Physicians must rapidly diagnose these patients while evaluating for other diseases and complications. Early consultation with a transplantation center is imperative, as is identifying the underlying etiology and initiating symptomatic care.
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Affiliation(s)
- Tim Montrief
- University of Miami, Jackson Memorial Hospital/Miller School of Medicine, Department of Emergency Medicine, 1611 N.W. 12th Avenue, Miami, FL 33136, United States
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, 5323 Harry Hines Boulevard, Dallas, TX 75390, United States
| | - Brit Long
- Brooke Army Medical Center, Department of Emergency Medicine, 3841 Roger Brooke Dr, Fort Sam Houston, TX 78234, United States.
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Zabron A, Quaglia A, Fatourou E, Peddu P, Lewis D, Heneghan M, Willars C, Auzinger G, Heaton N, Wendon J, Kane P, Karani J, Bernal W. Clinical and prognostic associations of liver volume determined by computed tomography in acute liver failure. Liver Int 2018; 38:1592-1601. [PMID: 29461676 DOI: 10.1111/liv.13725] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 02/11/2018] [Indexed: 02/13/2023]
Abstract
BACKGROUND Liver volume (LV) can be non-invasively determined from the analysis of computed tomography (CT) images, and in patients with acute liver injury (ALI) or failure (ALF), it can reflect the balance of structural collapse with hepatic regeneration. We examined its relation to cause of liver injury, measures of liver function and histopathological findings, and utility in prediction of complications and mortality. METHODS Two hundred and seventy-three patients with ALF/ALI admitted to a specialist intensive care unit were studied. One hundred and ninety-nine patients (73%) had non-acetaminophen (NA) aetiologies and 74 (27%) had acetaminophen-induced disease. LV and proportion of predicted LV (PLV%) were determined from admission CT imaging. RESULTS LV and PLV% showed marked variation when aetiologic groups were compared (P < .0001), including loss in cases with indeterminate cause (LV 939 cm3 [IQR 680-1259], PLV% 56% [42-84]) and increase in Budd-Chiari syndrome (1891 cm3 [1601-2094], 121% [111-131]). Progression to high-grade encephalopathy was more common with smaller LV and PLV. A < 1000 cm3 threshold identified NA patients who later developed it with 93% (95%CI 83-98) specificity and odds ratio 10.6 (3.3-34.5) at median 5 days prior to onset, and risk of death in those with NA-drug-induced (DILI) or indeterminate disease with 91% (71-99) specificity and 63% (50-75) sensitivity. CONCLUSION In patients with ALF/ALI, LV shows marked variation by the cause of disease, and in prognostic importance. In indeterminate and DILI cases, loss of volume to <1000 cm3 may indicate irreversible liver injury and regenerative failure and serve as an early clinical predictor for the development of high-grade encephalopathy and death.
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Affiliation(s)
- Abigail Zabron
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Alberto Quaglia
- Histopathology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Evangelia Fatourou
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Praveen Peddu
- Radiology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Dylan Lewis
- Radiology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Michael Heneghan
- Hepatology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Christopher Willars
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Georg Auzinger
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Nigel Heaton
- Liver Transplant Surgery, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Julia Wendon
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Pauline Kane
- Radiology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - John Karani
- Radiology, Institute of Liver Studies, Kings College Hospital, London, UK
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
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11
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Prognostic factors and treatment effect of standard-volume plasma exchange for acute and acute-on-chronic liver failure: A single-center retrospective study. Transfus Apher Sci 2018; 57:537-543. [PMID: 29880246 DOI: 10.1016/j.transci.2018.05.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 05/29/2018] [Accepted: 05/31/2018] [Indexed: 12/15/2022]
Abstract
Patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) have a high risk of mortality. Few studies have reported prognostic factors for patients receiving plasma exchange (PE) for liver support. We conducted a retrospective analysis using data of 55 patients with severe ACLF (n = 45) and ALF (n = 10) who received standard-volume PE (1-1.5 plasma volume) in the ICU. Hepatitis B virus infection accounts for the majority of ACLF (87%) and ALF (50%) patients. PE significantly improved the levels of total bilirubin, prothrombin time and liver enzymes (P<0.05). Thirteen ACLF patients (29%) and one ALF patient (10%) underwent liver transplantation. Two ALF patients (20%) recovered spontaneously without transplantation. The overall in-hospital survival rates for ACLF and ALF patients were 24% and 30%, and the transplant-free survival rates were 0% and 20%, respectively. For the 14 transplanted patients, the one-year survival rate was 86%. Multivariate analysis showed that pre-PE hemoglobin (P = 0.008), post-PE hemoglobin (P = 0.039), and post-PE CLIF-C ACLF scores (P = 0.061) were independent predictors of survival in ACLF. The post-PE CLIF-C ACLF scores ≥59 were a discriminator predicting the in-hospital mortality (area under the curve = 0.719, P = 0.030). Cumulative survival rates differed significantly between patients with CLIF-C ACLF scores ≤ 58 and those with CLIF-C ACLF scores ≥ 59 after PE (P< 0.05). The findings suggest that PE is mainly a bridge for liver transplantation and spontaneous recovery is exceptional even in patients treated with PE. A higher improvement in the post-PE CLIF-C ACLF score is associated with a superior in-hospital survival rate.
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12
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Dominik A, Stange J, Baumann AK, Pfensig C, Suraj M, Ibrahim B, Eggert M. Targeting Albumin Binding Function as a Therapy Goal in Liver Failure: Development of a Novel Adsorbent for Albumin Dialysis. Ther Apher Dial 2017; 22:196-204. [PMID: 29266788 DOI: 10.1111/1744-9987.12645] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 09/28/2017] [Accepted: 09/28/2017] [Indexed: 01/15/2023]
Abstract
Liver failure results in impaired hepatic detoxification combined with diminished albumin synthesis and is associated with secondary organ failure. The accumulation of liver toxins has shown to saturate albumin binding sites. This was previously demonstrated by an in vitro test for albumin binding capacity (ABiC) that has shown to inversely correlate with the established MELD (Model for End-Stage Liver Disease) score. In this study, we introduced a new adsorbent material for albumin dialysis treatments that improves albumin binding capacity. The new charcoal adsorbent was developed by an evolutionary test schedule. Batch testing of charcoals was performed as steady-state experiments. The charcoal reflecting the highest increase in albumin binding capacity was then introduced to kinetic models: Perfusion tests were designed to evaluate adsorption capacity and kinetics for liver failure marker toxins. A dynamic recirculation model for liver failure was used for upscaling and comparison against conventional MARS adsorbents as the gold standard in an albumin dialysis setting. Batch tests revealed that powdered activated Hepalbin charcoal displayed the highest ABiC score. Hepalbin charcoal also demonstrated higher adsorptive capacity and kinetics for liver failure marker toxins as determined by perfusion tests. These findings translated to tests of upscaled adsorbents in a dynamic model for liver failure: upscaled Hepalbin adsorbent removes bile acids, direct bilirubin and indirect bilirubin significantly better than MARS adsorbents and significantly increases ABiC. The novel adsorbent Hepalbin offers a significant improvement over both MARS adsorbents concerning liver failure marker toxin removal and ABiC improvement.
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Affiliation(s)
- Adrian Dominik
- Center for Extracorporeal Organ Support, Department of Internal Medicine, University of Rostock, Rostock, Germany
| | - Jan Stange
- Department of Internal Medicine, University of Rostock, Rostock, Germany.,Albutec GmbH, Rostock, Germany
| | - Anja K Baumann
- Department of Internal Medicine, University of Rostock, Rostock, Germany
| | - Claudia Pfensig
- Center for Extracorporeal Organ Support, Department of Internal Medicine, University of Rostock, Rostock, Germany
| | | | - Badr Ibrahim
- Department of Internal Medicine, University of Rostock, Rostock, Germany.,Albutec GmbH, Rostock, Germany
| | - Martin Eggert
- Center for Extracorporeal Organ Support, Department of Internal Medicine, University of Rostock, Rostock, Germany
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Hamdi T, Yessayan L, Yee J, Szamosfalvi B. High sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation in patients with acute liver failure and cerebral edema. Hemodial Int 2017; 22:184-191. [DOI: 10.1111/hdi.12572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tamim Hamdi
- Department of Internal Medicine, Division of Nephrology; UT Southwestern; Dallas TX USA
| | - Lenar Yessayan
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
| | - Jerry Yee
- Department of Internal Medicine, Division of Nephrology; Henry Ford Hospital; Detroit MI USA
| | - Balazs Szamosfalvi
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
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14
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Liver transplantation for acute liver failure. Cir Esp 2017; 95:181-189. [PMID: 28433231 DOI: 10.1016/j.ciresp.2017.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 12/16/2022]
Abstract
Before liver transplantation became widely applicable as a treatment option, the mortality rate for acute liver failure was as high as 85%. Today, acute liver failure is a relatively common transplant indication in some settings, but the results of liver transplantation in this context appear to be worse than those for chronic forms of liver disease. In this review, we discuss the indications and contraindications for urgent liver transplantation. In particular, we consider the roles of auxiliary, ABO-incompatible, and urgent living donor liver transplantation and address the management of a «status 1» patient with total hepatectomy and portocaval shunt for toxic liver syndrome.
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15
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Abstract
Amiodarone is a class III antiarrhythmic drug widely used for the treatment of both supraventricular and ventricular arrhythmias in intensive care unit. Hepatotoxicity of amiodarone is usually mild and delayed onset. Acute hepatotoxicity is a rare side effect and usually correlated to intravenous form use. In this case, acute hepatocellular injury occurred within 24 hours after the administration of intravenous amiodarone. Liver enzyme significantly improved after holding intravenous amiodarone use. Because ventricular arrhythmia persisted and side effects occurred to alternative therapy, low dose of oral amiodarone was resumed and hepatotoxicity did not occur afterward. Acute hepatotoxicity of intravenous amiodarone is possibly related to polysorbate 80, the solubilizer of amiodarone infusion or higher dose. As a result, when intravenous amiodarone is prescribed, closely monitoring liver enzyme is highly suggested. If acute hepatitis takes place secondary to intravenous amiodarone, oral therapy should not be resumed afterward. If there is no alternative treatment, lower dose of oral amiodarone (≤200 mg/d) could be tried and should monitor liver function regularly.
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16
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La transplantation hépatique en urgence. MEDECINE INTENSIVE REANIMATION 2016. [DOI: 10.1007/s13546-016-1207-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Demethyleneberberine Protects against Hepatic Fibrosis in Mice by Modulating NF-κB Signaling. Int J Mol Sci 2016; 17:ijms17071036. [PMID: 27376272 PMCID: PMC4964412 DOI: 10.3390/ijms17071036] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 06/17/2016] [Accepted: 06/23/2016] [Indexed: 12/16/2022] Open
Abstract
Demethyleneberberine (DMB) is an essential metabolite of Berberine (BBR) in vivo. Recent reports have revealed multiple novel therapeutic applications of BBR. However, the pharmacological activities of DMB remain to be elucidated. This study aimed to demonstrate the hepatoprotective and anti-fibrotic effects of DMB both in vitro and in vivo. Here we showed that DMB protects against thioacetamide (TAA)-induced hepatic fibrosis in mice and exhibits a higher safety profile as compared to BBR. Flow cytometry and Western blotting analysis showed that DMB is able to suppress the activation of hepatic stellate cells (HSCs) and induce cell apoptosis through the nuclear factor-κB (NF-κB) cascade. Immunohistochemical (IHC) and quantitative polymerase chain reaction (qPCR) analysis indicated that DMB also has inhibitory effects on collagen synthesis and is able to increase collagen degradation by blocking the transforming growth factor β 1 (TGF-β1)-Smad signaling and reducing the expression of matrix metalloproteinases (MMPs) and tissue inhibitors of MMP (TIMPs). These findings indicate that DMB has the potential to attenuate hepatic fibrosis via suppressing HSC activation.
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18
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Laoprasopwattana K, Jundee P, Pruekprasert P, Geater A. Outcome of Severe Dengue Viral Infection-caused Acute Liver Failure in Thai Children. J Trop Pediatr 2016; 62:200-5. [PMID: 26851434 DOI: 10.1093/tropej/fmv099] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
To determine clinical course and outcomes of liver functions in children with dengue viral infection-caused acute liver failure (ALF), the records of patients aged <15 years attending our institution during 1989-2011 were reviewed. Of the 41 ALF patients, 2, 6 and 33 patients had dengue hemorrhagic fever grade II, III and IV, respectively. Multiorgan failure including respiratory failure, massive bleeding and acute kidney injury occurred in 80.0%, 96.0% and 84.0% of the ALF cases, respectively, with an overall fatality rate of 68.3%. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels were highest on the day that the patient developed ALF. Lactate dehydrogenase levels had positive correlations with AST (r = 0.95) and ALT (r = 0.87) (all p < 0.01). The median (interquartile range) days before the AST and ALT levels returned to lower than 200 U/L after the ALF were 10.5 (8.8, 12.8) and 10.5 (7.8, 14.0) days, respectively.
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Affiliation(s)
- Kamolwish Laoprasopwattana
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Puthachat Jundee
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Pornpimol Pruekprasert
- Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
| | - Alan Geater
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla 90110, Thailand
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19
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Intracranial Pressure Monitoring in Acute Liver Failure: Institutional Case Series. Neurocrit Care 2016; 25:86-93. [DOI: 10.1007/s12028-016-0261-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Rule JA, Hynan LS, Attar N, Sanders C, Korzun WJ, Lee WM. Procalcitonin Identifies Cell Injury, Not Bacterial Infection, in Acute Liver Failure. PLoS One 2015; 10:e0138566. [PMID: 26393924 PMCID: PMC4579124 DOI: 10.1371/journal.pone.0138566] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 09/01/2015] [Indexed: 12/22/2022] Open
Abstract
Background Because acute liver failure (ALF) patients share many clinical features with severe sepsis and septic shock, identifying bacterial infection clinically in ALF patients is challenging. Procalcitonin (PCT) has proven to be a useful marker in detecting bacterial infection. We sought to determine whether PCT discriminated between presence and absence of infection in patients with ALF. Method Retrospective analysis of data and samples of 115 ALF patients from the United States Acute Liver Failure Study Group randomly selected from 1863 patients were classified for disease severity and ALF etiology. Twenty uninfected chronic liver disease (CLD) subjects served as controls. Results Procalcitonin concentrations in most samples were elevated, with median values for all ALF groups near or above a 2.0 ng/mL cut-off that generally indicates severe sepsis. While PCT concentrations increased somewhat with apparent liver injury severity, there were no differences in PCT levels between the pre-defined severity groups–non-SIRS and SIRS groups with no documented infections and Severe Sepsis and Septic Shock groups with documented infections, (p = 0.169). PCT values from CLD patients differed from all ALF groups (median CLD PCT value 0.104 ng/mL, (p ≤0.001)). Subjects with acetaminophen (APAP) toxicity, many without evidence of infection, demonstrated median PCT >2.0 ng/mL, regardless of SIRS features, while some culture positive subjects had PCT values <2.0 ng/mL. Summary/Conclusions While PCT appears to be a robust assay for detecting bacterial infection in the general population, there was poor discrimination between ALF patients with or without bacterial infection presumably because of the massive inflammation observed. Severe hepatocyte necrosis with inflammation results in elevated PCT levels, rendering this biomarker unreliable in the ALF setting.
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Affiliation(s)
- Jody A Rule
- Department of Internal Medicine, Division of Digestive Diseases, UT Southwestern Medical Center, Dallas, Texas, United States of America; Department of Clinical Laboratory Sciences, School of Allied Health, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - Linda S Hynan
- Department of Clinical Sciences and Department of Psychiatry, Division of Biostatistics, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Nahid Attar
- Department of Internal Medicine, Division of Digestive Diseases, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - Corron Sanders
- Department of Internal Medicine, Division of Digestive Diseases, UT Southwestern Medical Center, Dallas, Texas, United States of America
| | - William J Korzun
- Department of Clinical Laboratory Sciences, School of Allied Health, Virginia Commonwealth University, Richmond, Virginia, United States of America
| | - William M Lee
- Department of Internal Medicine, Division of Digestive Diseases, UT Southwestern Medical Center, Dallas, Texas, United States of America
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Fulminant presentation of autoimmune hepatitis: clinical features and early predictors of corticosteroid treatment failure. Eur J Gastroenterol Hepatol 2015; 27:644-8. [PMID: 25923939 DOI: 10.1097/meg.0000000000000353] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND AIMS Classical features of autoimmune hepatitis (AIH) may be altered during the abrupt onset of the disease. Corticosteroid therapy can be life-saving, but its use in the fulminant presentation of AIH (F-AIH) remains controversial. We aimed to assess the clinical features of patients with F-AIH and to describe the role of corticosteroids in this population. PATIENTS AND METHODS We retrospectively analyzed 154 adult patients with fulminant hepatic failure who were admitted to six liver transplantation (LT) programs. The AIH simplified criteria were used to identify patients with F-AIH. RESULTS We identified 40 (26%) patients with F-AIH. Compared with other etiologies, patients with F-AIH presented a longer interval from jaundice to encephalopathy (26 vs. 16 days, P=0.02) and a lower Model for End-Stage Liver Disease (MELD) score on admission (29 vs. 33, P=0.002). Overall, 25 (62%) patients with F-AIH underwent LT, eight (20%) patients survived, and seven (18%) died without LT. Seventeen patients received corticosteroids therapy, of whom seven (41%) survived without LT. Among the treated patients, higher MELD score and encephalopathy grade of 3 or more were associated significantly with corticosteroid failure. CONCLUSION Patients with F-AIH have a more indolent presentation compared with the non-F-AIH population. Altogether, only eight (20%) patients presenting with F-AIH survived without LT. A subset of patients with F-AIH and an initial MELD score less than 27 and low-grade hepatic encephalopathy might benefit from administration of corticosteroids.
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22
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Weingarten MA, Sande AA. Acute liver failure in dogs and cats. J Vet Emerg Crit Care (San Antonio) 2015; 25:455-73. [PMID: 25882813 DOI: 10.1111/vec.12304] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 01/26/2015] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To define acute liver failure (ALF), review the human and veterinary literature, and discuss the etiologies and current concepts in diagnostic and treatment options for ALF in veterinary and human medicine. ETIOLOGY In veterinary medicine ALF is most commonly caused by hepatotoxin exposure, infectious agents, inflammatory diseases, trauma, and hypoxic injury. DIAGNOSIS A patient may be deemed to be in ALF when there is a progression of acute liver injury with no known previous hepatic disease, the development of hepatic encephalopathy of any grade that occurs within 8 weeks after the onset of hyperbilirubinemia (defined as plasma bilirubin >50 μM/L [>2.9 mg/dL]), and the presence of a coagulopathy. Diagnostic testing to more specifically characterize liver dysfunction or pathology is usually required. THERAPY Supportive care to aid the failing liver and compensate for the lost functions of the liver remains the cornerstone of care of patients with ALF. Advanced therapeutic options such as extracorporeal liver assist devices and transplantation are currently available in human medicine. PROGNOSIS The prognosis for ALF depends upon the etiology, the degree of liver damage, and the response to therapy. In veterinary medicine, the prognosis is generally poor.
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23
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Karvellas CJ, Cavazos J, Battenhouse H, Durkalski V, Balko J, Sanders C, Lee WM. Effects of antimicrobial prophylaxis and blood stream infections in patients with acute liver failure: a retrospective cohort study. Clin Gastroenterol Hepatol 2014. [PMID: 24674942 DOI: 10.106/j.cgh.2014.03.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND & AIMS We investigated whether antimicrobial prophylaxis alters the incidence of bloodstream infection in patients with acute liver failure (ALF), and whether bloodstream infections affect overall mortality within 21 days after development of ALF. METHODS We performed a retrospective cohort analysis of 1551 patients with ALF enrolled by the US Acute Liver Failure Study Group from January 1998 through November 2009. We analyzed data on infections in the first 7 days after admission and the effects of prophylaxis with antimicrobial drugs on the development of bloodstream infections and 21-day mortality. RESULTS In our study population, 600 patients (39%) received antimicrobial prophylaxis and 226 patients (14.6%) developed at least 1 bloodstream infection. Exposure to antimicrobial drugs did not affect the proportion of patients who developed bloodstream infections (12.8% in patients with prophylaxis vs 15.7% in nonprophylaxed patients; P = .12), but a greater percentage of patients who received prophylaxis received liver transplants (28% vs 22%; P = .01). After adjusting for confounding factors, overall mortality within 21 days was associated independently with age (odds ratio [OR], 1.014), Model for End-stage Liver Disease score at admission (OR, 1.078), and vasopressor administration at admission (OR, 2.499). Low grade of coma (OR, 0.47) and liver transplantation (OR, 0.101) reduced mortality. Although bloodstream infection was associated significantly with 21-day mortality (P = .004), an interaction between bloodstream infection and etiology was detected: blood stream infection affected mortality to a greater extent in nonacetaminophen ALF patients (OR, 2.03) than in acetaminophen ALF patients (OR, 1.14). CONCLUSIONS Based on a large, observational study, antimicrobial prophylaxis does not reduce the incidence of bloodstream infection or mortality within 21 days of ALF. However, bloodstream infections were associated with increased 21-day mortality in patients with ALF-to a greater extent in patients without than with acetaminophen-associated ALF. Our findings do not support the routine use of antimicrobial prophylaxis in patients with ALF.
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Affiliation(s)
| | - Jorge Cavazos
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Holly Battenhouse
- Faculty of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Valerie Durkalski
- Faculty of Medicine, Medical University of South Carolina, Charleston, South Carolina
| | - Jody Balko
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Corron Sanders
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas
| | - William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas.
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Effects of antimicrobial prophylaxis and blood stream infections in patients with acute liver failure: a retrospective cohort study. Clin Gastroenterol Hepatol 2014; 12:1942-9.e1. [PMID: 24674942 PMCID: PMC4205208 DOI: 10.1016/j.cgh.2014.03.011] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Revised: 03/11/2014] [Accepted: 03/12/2014] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We investigated whether antimicrobial prophylaxis alters the incidence of bloodstream infection in patients with acute liver failure (ALF), and whether bloodstream infections affect overall mortality within 21 days after development of ALF. METHODS We performed a retrospective cohort analysis of 1551 patients with ALF enrolled by the US Acute Liver Failure Study Group from January 1998 through November 2009. We analyzed data on infections in the first 7 days after admission and the effects of prophylaxis with antimicrobial drugs on the development of bloodstream infections and 21-day mortality. RESULTS In our study population, 600 patients (39%) received antimicrobial prophylaxis and 226 patients (14.6%) developed at least 1 bloodstream infection. Exposure to antimicrobial drugs did not affect the proportion of patients who developed bloodstream infections (12.8% in patients with prophylaxis vs 15.7% in nonprophylaxed patients; P = .12), but a greater percentage of patients who received prophylaxis received liver transplants (28% vs 22%; P = .01). After adjusting for confounding factors, overall mortality within 21 days was associated independently with age (odds ratio [OR], 1.014), Model for End-stage Liver Disease score at admission (OR, 1.078), and vasopressor administration at admission (OR, 2.499). Low grade of coma (OR, 0.47) and liver transplantation (OR, 0.101) reduced mortality. Although bloodstream infection was associated significantly with 21-day mortality (P = .004), an interaction between bloodstream infection and etiology was detected: blood stream infection affected mortality to a greater extent in nonacetaminophen ALF patients (OR, 2.03) than in acetaminophen ALF patients (OR, 1.14). CONCLUSIONS Based on a large, observational study, antimicrobial prophylaxis does not reduce the incidence of bloodstream infection or mortality within 21 days of ALF. However, bloodstream infections were associated with increased 21-day mortality in patients with ALF-to a greater extent in patients without than with acetaminophen-associated ALF. Our findings do not support the routine use of antimicrobial prophylaxis in patients with ALF.
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25
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Quintanilha LF, Takami T, Hirose Y, Fujisawa K, Murata Y, Yamamoto N, Goldenberg RCDS, Terai S, Sakaida I. Canine mesenchymal stem cells show antioxidant properties against thioacetamide-induced liver injury in vitro and in vivo. Hepatol Res 2014; 44:E206-17. [PMID: 23889977 DOI: 10.1111/hepr.12204] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2013] [Revised: 06/19/2013] [Accepted: 07/08/2013] [Indexed: 02/06/2023]
Abstract
AIM To overcome current limitations of therapy for liver diseases, cell-based therapies using mesenchymal stem cells (MSC) have been attempted through basic and clinical approaches. Oxidative stress is a crucial factor in hepatology, and reactive oxygen species (ROS) are well-established molecules responsible for its deleterious effects. The antioxidant properties of MSC were recently demonstrated, and therefore we examined the antioxidant activity of canine MSC (cMSC), their effects on isolated hepatocytes in vitro and their curative potential against thioacetamide (TAA)-induced liver injury in vivo. METHODS To evaluate the ability of cMSC to challenge oxidative stress, cell viability, cytotoxicity and ROS were measured in cultured cMSC treated with TAA. Also, cMSC were co-cultured with hepatocytes in the same injury condition, and the ROS level was measured exclusively in hepatocytes. Finally, to verify the curative potential of cMSC, 2.0 × 10(6) cells or phosphate-buffered saline were injected systemically in non-obese diabetic/severe combined immunodeficiency mice that received TAA injections twice a week for 13 weeks. We then evaluated histological parameters, serum injury markers and redox homeostasis. RESULTS cMSC overcame TAA-induced oxidative stress in vitro, as shown by increased viability and lower cytotoxicity and ROS levels. Moreover, hepatocytes co-cultured with cMSC also showed decreased cellular ROS. The in vivo study showed that mice treated with cMSC presented with an ameliorated histological pattern, suppressed fibrosis, lower serum injury marker levels and better oxidative parameters. CONCLUSION We concluded that cMSC injection reduce TAA-induced liver injury through antioxidant activities and hepatoprotective effects, showing a curative potential in liver diseases.
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Affiliation(s)
- Luiz Fernando Quintanilha
- Department of Gastroenterology and Hepatology, Yamaguchi University Graduate School of Medicine, Ube, Japan; Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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Chen KJ, Chen TH, Sue YM, Chen TJ, Cheng CY. High-volume plasma exchange in a patient with acute liver failure due to non-exertional heat stroke in a sauna. J Clin Apher 2014; 29:281-3. [PMID: 24497379 DOI: 10.1002/jca.21315] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2013] [Revised: 08/24/2013] [Accepted: 12/26/2013] [Indexed: 12/23/2022]
Abstract
Heat stroke is a life-threatening condition characterized by an increased core body temperature (over 40°C) and a systemic inflammatory response, which may lead to a syndrome of multiple organ dysfunction. Heat stroke may be due to either strenuous exercise or non-exercise-induced exposure to a high environmental temperature. Current management of heat stroke is mostly supportive, with an emphasis on cooling the core body temperature and preventing the development of multiple organ dysfunction. Prognosis of heat stroke depends on the severity of organ involvement. Here, we report a rare case of non-exercise-induced heat stroke in a 73-year-old male patient who was suffering from acute liver failure after prolonged exposure in a hot sauna room. We successfully managed this patient by administering high-volume plasma exchange, and the patient recovered completely after treatment.
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Affiliation(s)
- Kuan-Jung Chen
- Division of Nephrology, Department of Internal Medicine, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
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27
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Current topics in therapeutic plasmapheresis. Clin Exp Nephrol 2013; 18:41-9. [PMID: 23887747 DOI: 10.1007/s10157-013-0838-0] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2013] [Accepted: 06/27/2013] [Indexed: 12/14/2022]
Abstract
Therapeutic plasmapheresis has been used for intractable diseases that cannot be cured by conventional drug therapy. Currently, the use of therapeutic plasmapheresis has been approved for 27 diseases by Japan's National Health Insurance system and is mainly categorized into three modalities: plasma exchange (PE), double-filtration plasmapheresis (DFPP), and plasma adsorption (PA). Plasma separators and/or fractionators are essential for the therapy. PE is performed for two purposes: removal of pathogenic antigens or substances in the plasma fraction and supplementation of essential factors, such as albumin and coagulation factors. PE can be used for thrombotic microangiopathy and acute hepatic failure. DFPP can be performed for selective removal of macromolecules while avoiding the use of substitution fluid (i.e., albumin or fresh frozen plasma). DFPP has now been used for conditions involving relatively larger plasma molecules, including hyperviscosity syndrome and ABO-incompatible kidney transplantation. PA can specifically remove pathogenic agents, such as low-density lipoprotein or autoantibodies, in the IgG fractions by the adsorption column and does not require substitution fluids. PA has now been used for a wide variety of neurological diseases, including chronic inflammatory demyelinating polyneuropathy. This review describes the characteristics of each modality, seeking to improve the efficacy and specificity of removal of the target substance.
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Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJW, Auzinger G, Rela M, Heaton N, O'Grady JG, Wendon J, Williams R. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol 2013; 59:74-80. [PMID: 23439263 DOI: 10.1016/j.jhep.2013.02.010] [Citation(s) in RCA: 277] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 02/11/2013] [Accepted: 02/12/2013] [Indexed: 12/04/2022]
Abstract
BACKGROUND & AIMS Acute liver failure (ALF) is a rapidly progressive critical illness with high mortality. Complex intensive care unit (ICU) protocols and emergency liver transplantation (ELT) are now often available, but rarity and severity of illness have limited its study and evidence-base for care. We reviewed patients treated over a 35-year period at a specialist high-volume ICU, quantifying changes in disease aetiology, severity and evolution of ICU support and ELT use and outcome. METHODS Review of adult patients admitted during the period 1973-2008, with acute liver dysfunction and coagulopathy with overt hepatic encephalopathy (ALF) and those without (acute liver injury; ALI). RESULTS 3305 patients fulfilled inclusion criteria, 2095 with ALF. Overall hospital survival increased from 30% in 1973-78 to 76% in 2004-08; in ALF from 17% to 62% (both p<0.0001). In ALF patients treated without ELT, survival rose from 17% to 48% (p<0.0001); in those undergoing ELT (n=387) from 56% in 1984-88 to 86% in 2004-08 (p<0.01). Coincident with drug sales-restriction, paracetamol-related admissions fell significantly. Viral admissions fell from 56% to 17% of non-paracetamol cases (p<0.0001). Admission markers of liver injury severity fell significantly and the proportion of patients with intracranial hypertension (ICH) fell from 76% in 1984-88 to 20% in 2004-08 (p<0.0001). In those with ICH, mortality fell from 95% to 55% (p<0.0001). CONCLUSIONS The nature and outcome of ALF have transformed over 35 years, with major improvements in survival and a fall in prevalence of cerebral oedema and ICH, likely consequent upon earlier illness recognition, improved ICU care, and use of ELT.
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Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, United Kingdom.
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Poddar B, Saigal S, Kumar A, Singh RK, Azim A, Gurjar M, Baronia A. Factors associated with outcome in acute liver failure in an intensive care unit. Indian J Gastroenterol 2013; 32:172-8. [PMID: 23054946 DOI: 10.1007/s12664-012-0252-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2012] [Accepted: 08/30/2012] [Indexed: 02/04/2023]
Abstract
AIM To study the factors associated with outcome in acute liver failure (ALF) in an intensive care unit (ICU). METHODS Consecutive patients with ALF admitted to the ICU from August 2003 to April 2010 were included. Factors associated with the primary outcome, death or survival, were compared. RESULTS Of 52 patients of median age 19 years (range 3-65), 35 (67 %) died. The etiology was viral hepatitis in 66 %, drug induced (anti-tubercular therapy) in 15 % and idiopathic in 15 %. Grades III+IV encephalopathy were found in 12 (70.6 %) survivors as against 33 (94.3 %) nonsurvivors (p = 0.019). The median admission sequential organ failure assessment (SOFA) score was eight in survivors vs. 12 in nonsurvivors (p < 0.001). Median admission prothrombin time (PT) was 42 s in survivors vs. 51 in nonsurvivors (p = 0.384); 16/17 (94.1 %) survivors had normal PT on day 4 as compared to 7/35 (20 %) nonsurvivors (p < 0.001). Median PT on day 4 was 18 s in survivors against 37 in nonsurvivors (p < 0.001). Serum bilirubin, alanine aminotransferase; and serum creatinine, sodium and phosphorus were similar in survivors and nonsurvivors. Mechanical ventilation, vasopressors and dialysis were used in 65 %, 30 %, and 12 % survivors as against 100 % (p < 0.001), 51 % and 26 % nonsurvivors. Sixteen patients had upper gastrointestinal (GI) bleed. Blood cultures were positive more often in nonsurvivors (p = 0.058). On multiple regression analysis, factors independently associated with outcome included admission SOFA score >9.5 and absolute value of PT on day 4. CONCLUSIONS Grades III and IV encephalopathy, higher SOFA score at admission and a prolonged PT which did not normalize by 4 days were associated with mortality in ALF.
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Affiliation(s)
- Banani Poddar
- Department of Critical Care Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India.
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Schick MA, Isbary JT, Stueber T, Brugger J, Stumpner J, Schlegel N, Roewer N, Eichelbroenner O, Wunder C. Effects of crystalloids and colloids on liver and intestine microcirculation and function in cecal ligation and puncture induced septic rodents. BMC Gastroenterol 2012; 12:179. [PMID: 23245375 PMCID: PMC3547783 DOI: 10.1186/1471-230x-12-179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 12/11/2012] [Indexed: 01/10/2023] Open
Abstract
Background Septic acute liver and intestinal failure is associated with a high mortality. We therefore investigated the influence of volume resuscitation with different crystalloid or colloid solutions on liver and intestine injury and microcirculation in septic rodents. Methods Sepsis was induced by cecal ligation and puncture (CLP) in 77 male rats. Animals were treated with different crystalloids (NaCl 0.9% (NaCl), Ringer’s acetate (RA)) or colloids (Gelafundin 4% (Gel), 6% HES 130/0.4 (HES)). After 24 h animals were re-anesthetized and intestinal (n = 6/group) and liver microcirculation (n = 6/group) were obtained using intravital microscopy, as well as macrohemodynamic parameters were measured. Blood assays and organs were harvested to determine organ function and injury. Results HES improved liver microcirculation, cardiac index and DO2-I, but significantly increased IL-1β, IL-6 and TNF-α levels and resulted in a mortality rate of 33%. Gel infused animals revealed significant reduction of liver and intestine microcirculation with severe side effects on coagulation (significantly increased PTT and INR, decreased haemoglobin and platelet count). Furthermore Gel showed severe hypoglycemia, acidosis and significantly increased ALT and IL-6 with a lethality of 29%. RA exhibited no derangements in liver microcirculation when compared to sham and HES. RA showed no intestinal microcirculation disturbance compared to sham, but significantly improved the number of intestinal capillaries with flow compared to HES. All RA treated animals survided and showed no severe side effects on coagulation, liver, macrohemodynamic or metabolic state. Conclusions Gelatine 4% revealed devastated hepatic and intestinal microcirculation and severe side effects in CLP induced septic rats, whereas the balanced crystalloid solution showed stabilization of macro- and microhemodynamics with improved survival. HES improved liver microcirculation, but exhibited significantly increased pro-inflammatory cytokine levels. Crystalloid infusion revealed best results in mortality and microcirculation, when compared with colloid infusion.
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Zhou P, Xia J, Guo G, Huang ZX, Lu Q, Li L, Li HX, Shi YJ, Bu H. A Macaca mulatta model of fulminant hepatic failure. World J Gastroenterol 2012; 18:435-44. [PMID: 22346249 PMCID: PMC3270505 DOI: 10.3748/wjg.v18.i5.435] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Revised: 06/23/2011] [Accepted: 06/30/2011] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish an appropriate primate model of fulminant hepatic failure (FHF).
METHODS: We have, for the first time, established a large animal model of FHF in Macaca mulatta by intraperitoneal infusion of amatoxin and endotoxin. Clinical features, biochemical indexes, histopathology and iconography were examined to dynamically investigate the progress and outcome of the animal model.
RESULTS: Our results showed that the enzymes and serum bilirubin were markedly increased and the enzyme-bilirubin segregation emerged 36 h after toxin administration. Coagulation activity was significantly decreased. Gradually deteriorated parenchymal abnormality was detected by magnetic resonance imaging (MRI) and ultrasonography at 48 h. The liver biopsy showed marked hepatocyte steatosis and massive parenchymal necrosis at 36 h and 49 h, respectively. The autopsy showed typical yellow atrophy of the liver. Hepatic encephalopathy of the models was also confirmed by hepatic coma, MRI and pathological changes of cerebral edema. The lethal effects of the extrahepatic organ dysfunction were ruled out by their biochemical indices, imaging and histopathology.
CONCLUSION: We have established an appropriate large primate model of FHF, which is closely similar to clinic cases, and can be used for investigation of the mechanism of FHF and for evaluation of potential medical therapies.
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Proceedings of the Anaesthetic Research Society. Br J Anaesth 2011. [DOI: 10.1093/bja/aer234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Chadipiralla K, Reddanna P, Chinta RM, Reddy PVB. Thioacetamide-induced fulminant hepatic failure induces cerebral mitochondrial dysfunction by altering the electron transport chain complexes. Neurochem Res 2011; 37:59-68. [PMID: 21879353 DOI: 10.1007/s11064-011-0583-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2011] [Revised: 08/12/2011] [Accepted: 08/18/2011] [Indexed: 12/13/2022]
Abstract
Fulminant hepatic failure (FHF) is an acute form of hepatic encephalopathy resulting from severe inflammatory or necrotic liver damage without any previously established liver damage. This develops as a complication due to viral infections, and drug abuse. FHF also occurs in acute disorders like Reye's syndrome. Although the exact mechanisms in the etiology of FHF are not understood, elevated levels of brain ammonia have been consistently reported. Such increased ammonia levels are suggested to alter neurotransmission signals and impair cerebral energy metabolism due to mitochondrial dysfunctions. In the present study we have examined the role of cerebral electron transport chain complexes, including complex I, II, III IV, and pyruvate dehydrogenase in the non-synaptic mitochondria isolated from the cortex of the thioacetamide-induced FHF rats. Further, we have examined if the structure of mitochondria is altered. The results of the current study demonstrated a decrease in the activity of the complex I by 31 and 48% at 18 and 24 h respectively after the thioacetamide injection. Similarly, the activity of electron transport chain complex III was inhibited by 35 and 52% respectively, at 18 and 24 h, respectively. The complex II and complex IV, on the other hand, revealed unaltered activity. Further the activity of pyruvate dehydrogenase at 18 and 24 h after the induction of FHF was inhibited by 29 and 43%, respectively. Our results also suggest mitochondrial swelling in FHF induced rats. The inhibition of the respiratory complexes III and I and pyruvate dehydrogenase might lead to the increased production of free radical resulting in oxidative stress and cerebral energy disturbances thereby leading to mitochondrial swelling and further contributing to the pathogenesis of FHF.
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Affiliation(s)
- Kiranmai Chadipiralla
- Nephrology and Hypertension Division, Veteran Affairs Medical Center, Miami, FL, USA
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Wicklund BM. Bleeding and clotting disorders in pediatric liver disease. HEMATOLOGY. AMERICAN SOCIETY OF HEMATOLOGY. EDUCATION PROGRAM 2011; 2011:170-177. [PMID: 22160030 DOI: 10.1182/asheducation-2011.1.170] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The coagulopathy of liver disease in pediatric patients presents an unusual set of challenges. Little pediatric data have been published, so this review is based largely on adult studies. There is a precarious balance between deficiencies of clotting factors and anticoagulation factors in liver disease that result in abnormal prothrombin time (PT) and activated partial thromboplastin time (aPTT) tests that would suggest a bleeding tendency, yet the patients can form a clot and are at risk of thromboembolic disease. Attention has centered on thromboelastography and thrombin-generation assays to clarify the patient's ability to control bleeding, but these tests are not routinely available to many treating physicians.
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Affiliation(s)
- Brian M Wicklund
- Department of Hematology/Oncology, Children's Mercy Hospital, Kansas City, MO 64108, USA.
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Abstract
Acute liver failure (ALF) is defined as a multisystem disorder of severe impairment of liver function, with or without encephalopathy, which is associated with hepatocellular necrosis (reflected as liver synthetic failure in patients with no recognized chronic liver disease), and can lead to death. ALF can be due to hepatotoxic drugs, natural toxins, autoimmune disease, severe bacterial infection and some neoplastic processes, or ALF can be idiopathic. In the pediatric group, the most frequent cause is viral agents; hepatitis A is the most common among these. The pathophysiologic changes in ALF consist of alterations in coagulation, elevated serum ammonia, hypoalbuminemia and hypoglycemia. In recent years, N-acetylcysteine has been utilized to treat this condition. Using this drug during the early stages of the disease has the potential to improve outcomes for the patient, including the avoidance liver transplantation. This article focuses on the criteria that help to identify ALF and emphasizes accessible alternative medical treatments.
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Affiliation(s)
- Norberto Sotelo
- Jefe del Servicio de Medicina Interna, Hospital Infantil del Estado de Sonora, Calle Reforma Numero 355 Norte, Colonia Ley 57, CP 83100, Hermosillo Sonora, Mexico
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Effects of intestinal intervention on bacterial translocation in a rat model of acute liver failure in vivo. Eur J Gastroenterol Hepatol 2010; 22:1316-22. [PMID: 20595903 DOI: 10.1097/meg.0b013e32833ccaae] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND/AIMS The study aimed to confirm bacterial translocation (BT) in rats with acute liver failure (ALF), to explore the correlation between the concentration of lipopolysaccharides and Toll-like receptor 4 (TLR4) expression, and further, to evaluate the curative effects of lactulose and montmorillonite (smecta) in this setting. METHODS D-Galactosamine was injected into the abdominal cavity of rats to induce ALF. Escherichia coli JM109 labeled with enhanced green fluorescent protein was administered to track BT. Simultaneously, the rats were given lactulose or smecta. Blood samples were collected for measuring liver function, cytokines, endotoxins, and TLR4 expression. Representative tissue specimens from the liver, spleen, and mesenteric lymph nodes were aseptically harvested for bacterial identification by agarose gel electrophoresis, laser scanning confocal microscopy, and flow cytometry. RESULTS BT occurred in ALF, accompanied by impaired liver function with increased cytokines, endotoxins, and TLR4 expression. After the treatment with lactulose or smecta, all these parameters decreased, including the relative quantity of translocated bacteria while albumin increased. Furthermore, compared with the lactulose treatment group, the parameters in the smecta treatment group improved. Moreover, in the group in which smecta was given for prophylaxis, there was greater improvement than with treatment. CONCLUSION Intestinal intervention with lactulose or smecta can ameliorate BT; moreover, smecta has a better effect than lactulose, and its preventive effect was also better than its therapeutic effect.
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Kwon HJ, Lim JH, Han JT, Lee SB, Yoon WK, Nam KH, Choi IP, Kim DY, Won YS, Kim HC. The role of vitamin D3 upregulated protein 1 in thioacetamide-induced mouse hepatotoxicity. Toxicol Appl Pharmacol 2010; 248:277-84. [DOI: 10.1016/j.taap.2010.08.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 07/27/2010] [Accepted: 08/07/2010] [Indexed: 11/16/2022]
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Reygaert WC. Antibiotic optimization in the difficult-to-treat patient with complicated intra-abdominal or complicated skin and skin structure infections: focus on tigecycline. Ther Clin Risk Manag 2010; 6:419-30. [PMID: 20856688 PMCID: PMC2940750 DOI: 10.2147/tcrm.s9117] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2010] [Indexed: 01/22/2023] Open
Abstract
Complicated intra-abdominal and skin and skin structure infections are widely varied in presentation. These infections very often lead to an increase in length of hospital stay, with a resulting increase in costs and mortality. In addition, these infections may be caused by a wide variety of bacteria and are often polymicrobial with the possibility of the presence of antimicrobial-resistant strains, such as methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, extended-spectrum β-lactamase strains (Escherichia coli, Klebsiella pneumoniae), and K. pneumoniae carbapenemase-producing strains. In combination with patients’ immunosuppression or comorbidities, the treatment and management options for initial therapy success are few. Tigecycline, a new glycylcyline antimicrobial from the tetracycline drug class, represents a viable option for the successful treatment of these infections. It has been shown to have activity against a wide variety of bacteria, including the antimicrobial-resistant strains. As with all tetracycline drugs, it is not recommended for pregnant or nursing women. The potential side effects are those typical of tetracycline drugs: nausea, vomiting, and headaches. Drug–drug interactions are not expected, and renal function monitoring is not necessary.
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Affiliation(s)
- Wanda C Reygaert
- Department of Biomedical Sciences, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
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Crespo I, Miguel BS, Laliena A, Alvarez M, Culebras JM, González-Gallego J, Tuñón MJ. Melatonin prevents the decreased activity of antioxidant enzymes and activates nuclear erythroid 2-related factor 2 signaling in an animal model of fulminant hepatic failure of viral origin. J Pineal Res 2010; 49:193-200. [PMID: 20609075 DOI: 10.1111/j.1600-079x.2010.00787.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
This work was undertaken to investigate whether treatment with melatonin prevents oxidative stress and changes in the expression and activity of factor erythroid 2-related factor 2 (Nrf2)-mediated antioxidant enzymes in an animal model of fulminant hepatic failure of viral origin. Rabbits were experimentally infected with 2 x 10(4) hemagglutination units of a rabbit hemorrhagic disease virus (RHDV) isolate and received melatonin at two concentrations of 10 mg/kg and 20 mg/kg at 0, 12 and 24 hr postinfection. Blood transaminases, blood lactate dehydrogenase, liver concentration of thiobarbituric reactive acid substances and the liver oxidized to reduced glutathione ratio significantly increased at 36 hr postinfection in infected animals. Significant decreases were found in the mRNA levels and in the liver activities of Mn-superoxide dismutase, glutathione peroxidase and glutathione-S-transferase in infected rabbits. These effects were prevented by melatonin administration in a concentration-dependent manner. Melatonin treatment was not accompanied by changes in protein levels of Kelch-like ECH-associating protein 1 (Keap1) but resulted in an increased protein expression of Nrf2 in the cytoplasm and the nucleus, which was confirmed by the results of Nrf2 immunostaining. Nuclear extracts from livers of melatonin-treated rats displayed an enhanced antioxidant responsive element (ARE)-binding activity of Nrf2. Our results suggest a potential hepatoprotective role of melatonin in fulminant hepatic failure, partially mediated through the abrogation of oxidative stress and the prevention of the decreased activity of antioxidant enzymes via the Nrf2 pathways.
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Affiliation(s)
- Irene Crespo
- Institute of Biomedicine (IBIOMED), University of León, León, Spain
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Abstract
The objective of this article is to describe adverse drug events related to the liver and gastrointestinal tract in critically ill patients. PubMed and other resources were used to identify information related to drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis in critically ill patients. This information was reviewed, and data regarding pathophysiology, common drug causes, and guidelines for prevention and management were collected and summarized. In cases in which data in critically ill patients were unavailable, data were extrapolated from other patient populations. Drug-induced acute liver failure can be caused by many drugs routinely used in the intensive care unit and may be associated with significant morbidity and mortality. Drug-related hypomotility and constipation and drug-related diarrhea are reported with many drugs, and these are common adverse drug events in critically ill patients that can substantially complicate the care of these patients. Drug-induced gastrointestinal bleeding and drug-induced pancreatitis occur less frequently, can range in disease severity, and can be associated with morbidity and mortality. Many drugs used in critically ill patients are associated with adverse drug events related to the liver and gastrointestinal tract. Critical care clinicians should be aware of common drug causes of drug-induced acute liver failure, gastrointestinal hypomotility, constipation, diarrhea, gastrointestinal bleeding, and pancreatitis, and should be familiar with the prevention and management of these diverse conditions.
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Abstract
The acutely septic patient is a multifaceted challenge for the anesthetist. Unlike most elective surgery patients, acutely septic patients have severe systemic disease before the physiologic insults of anesthesia and surgery. The decision to operate is usually informed by the urgent or emergent need to correct a severe surgical problem and weighed against the higher risks of morbidity and mortality from the procedure itself. The care of the septic patient in the intensive care unit can help guide operating room management. However, the acuity and time course of intraoperative events, including hemorrhage and drug-induced shock states, compel the anesthetist to respond aggressively with therapies that may or may not be strongly substantiated with long-term data in the intensive care unit setting. The anesthesiologist must place considerations concerning short-term survival from the acute insult of surgery ahead of longer-term considerations.
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Affiliation(s)
- Jennifer E Hofer
- Department of Anesthesia and Critical Care, The University of Chicago Hospitals, 5841 South Maryland Avenue, MC 4028, Chicago, IL 60637, USA.
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Bernal W. Lactate is important in determining prognosis in acute liver failure. J Hepatol 2010; 53:209-10. [PMID: 20471710 DOI: 10.1016/j.jhep.2010.02.017] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2010] [Revised: 02/23/2010] [Accepted: 02/23/2010] [Indexed: 01/05/2023]
Affiliation(s)
- William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, Denmark Hill, London SE5 9RS, UK.
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Nguyen HM, Cutie AJ, Pham DQ. How to manage medications in the setting of liver disease with the application of six questions. Int J Clin Pract 2010; 64:858-67. [PMID: 20584219 DOI: 10.1111/j.1742-1241.2010.02364.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE Reviewing the current literature to guide clinicians managing medications in the setting of liver disease. LITERATURE SOURCES Using the terms liver disease, medication management, and therapeutic monitoring, a literature review was conducted to identify peer-reviewed articles in MEDLINE (1966-April 2009). Reference citations were reviewed as an additional resource. Published English-language literatures, articles and trials were reviewed. Emphasis was placed on prospective, randomised, double-blind, placebo-controlled clinical trials. QUESTION SYNTHESIS An informed decision on how to manage medications in the setting of liver disease should account for changes that transpire in a medication's first-pass metabolism, protein binding, volume of distribution, clearance and pharmacodynamic interactions. To incorporate these issues within one's thought process, clinicians can utilise the following six questions to evaluate a medication use: (i) Is the patient experiencing acute or chronic liver failure? (ii) Does the drug have high hepatic first-pass metabolism? (iii) Is the medication highly protein-bound? (iv) Is there a change in the volume of distribution for the medication? (v) Is the clearance of the medication significantly altered? and (vi) Is there a pharmacodynamic interaction with the medication? CONCLUSIONS The introduction and use of six clinically relevant questions in the setting of liver disease can serve as a guide to clinicians who manage patients with liver disease.
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Affiliation(s)
- H M Nguyen
- Pharmacy Practice, Western University of Health Sciences, College of Pharmacy, Pomona, CA 91766-1854, USA.
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Atienza Merino G. [Evaluation of extracorporeal liver support systems in the treatment of liver failure. A systematic review]. GASTROENTEROLOGIA Y HEPATOLOGIA 2010; 33:352-62. [PMID: 20363534 DOI: 10.1016/j.gastrohep.2010.01.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 11/11/2009] [Revised: 01/11/2010] [Accepted: 01/21/2010] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the MARS and Prometheus extracorporeal liver support systems in the treatment of liver failure. DESIGN We performed a systematic review of the literature from January 1999 to June 2009 in the Medline, Embase, HTA, DARE, NHSEED, Cochrane Library Plus, Clinical Trials Registry and HSRPROJ databases. Study selection was based on a series of previously established inclusion criteria related to the study design, population, type of intervention, language, and outcome measures. PATIENTS AND INTERVENTIONS Patients with acute liver failure or acute exacerbations of chronic liver failure treated with the MARS or Prometheus systems. OUTCOME MEASURES Data on safety, long-term survival, clinical effects and biochemical and hemodynamic variables. RESULTS We selected 22 studies evaluating the safety and efficacy of the MARS and Prometheus systems. Adequate evaluation of these techniques was hampered by the heterogeneity of the studies and their methodological limitations. CONCLUSIONS Extracorporeal liver support systems are able to purify both hydrosoluble and protein-bound substances. However, current data show that only the MARS system reduces mortality in acute liver failure and in acute exacerbations of chronic liver failure, although this reduction is non-significant. These techniques can be considered safe, with adverse effects similar to those of the control group. Their main indication is severe liver failure, for short periods while the liver recovers or a liver transplant becomes available.
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Affiliation(s)
- Gerardo Atienza Merino
- Agencia de Evaluación de Tecnologías Sanitarias de Galicia, Consellería de Sanidade, Xunta de Galicia, Galicia, España.
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Heme oxygenase (HO)-1 protects from lipopolysaccharide (LPS)-mediated liver injury by inhibition of hepatic leukocyte accumulation and improvement of microvascular perfusion. Langenbecks Arch Surg 2010; 395:387-94. [PMID: 20237939 DOI: 10.1007/s00423-010-0603-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2009] [Accepted: 01/26/2010] [Indexed: 02/06/2023]
Abstract
PURPOSE Lipopolysaccharide (LPS) represents a highly toxic substance which may aggravate morbidity and mortality in septic diseases. A recent study has reported that the induction of heme oxygenase (HO)-1 protects from LPS-induced liver injury. The mechanisms of action however, have not been clarified yet. Therefore, we analyzed in vivo the effects of HO-1 on the liver microcirculation under conditions of LPS exposure. METHODS In C57BL/6 mice, endotoxemia was induced by intraperitoneal (i.p.) administration of LPS (500 microg/kg) and D-galactosamine (Gal, 800 mg/kg). HO-1 was induced in vivo by pretreatment with hemin dissolved in DMSO (50 micromol/kg i.p.). Animals treated with DMSO only served as controls. Six hours after LPS exposure the hepatic microcirculation and leukocyte-endothelial cell interaction were analyzed by intravital fluorescence microscopy. HO-1 expression was determined by Western blot analysis. Hepatocellular damage was assessed by measuring the serum levels of aspartate aminotransferase and alanine aminotransferase. In addition, leukocyte transmigration and hepatocellular apoptosis were analyzed by histology and immunohistochemistry. RESULTS In controls, LPS/Gal caused severe liver injury, as indicated by increased liver enzyme levels and apoptotic cell death. This was associated with distinct sinusoidal perfusion failure and microvascular intrahepatic leukocyte accumulation. Of interest, induction of HO-1 significantly reduced numbers of adherent and extravascular leukocytes when compared to controls. Moreover, microvascular perfusion was significantly improved, resulting in a decrease of AST and ALT and a reduction of hepatocellular apoptosis. CONCLUSIONS Our novel data indicate that induction of HO-1 protects the liver from LPS-mediated injury by reducing leukocytic inflammation and improving intrahepatic microcirculation.
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Respuesta. Med Clin (Barc) 2010. [DOI: 10.1016/j.medcli.2009.04.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Craig DGN, Lee A, Hayes PC, Simpson KJ. Review article: the current management of acute liver failure. Aliment Pharmacol Ther 2010; 31:345-58. [PMID: 19845566 DOI: 10.1111/j.1365-2036.2009.04175.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Acute liver failure is a devastating clinical syndrome with a persistently high mortality rate despite critical care advances. Orthotopic liver transplantation (OLT) is a life-saving treatment in selected cases, but effective use of this limited resource requires accurate prognostication because of surgical risks and the requirement for subsequent life-long immunosuppression. AIM To review the aetiology of acute liver failure, discuss the evidence behind critical care management strategies and examine potential treatment alternatives to OLT. METHODS Literature review using Ovid, PubMed and recent conference abstracts. RESULTS Paracetamol remains the most common aetiology of acute liver failure in developed countries, whereas acute viral aetiologies predominate elsewhere. Cerebral oedema is a major cause of death, and its prevention and prompt recognition are vital components of critical care support, which strives to provide multiorgan support and 'buy time' to permit either organ regeneration or psychological and physical assessment prior to acquisition of a donor organ. Artificial liver support systems do not improve mortality in acute liver failure, whilst most other interventions have limited evidence bases to support their use. CONCLUSION Acute liver failure remains a truly challenging condition to manage, and requires early recognition and transfer of patients to specialist centres providing intensive, multidisciplinary input and, in some cases, OLT.
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Affiliation(s)
- D G N Craig
- Scottish Liver Transplantation Unit, Royal Infirmary of Edinburgh, Little France, Edinburgh EH16 4SA, UK
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