1
|
Henderson D, Gupta A, Menon S, Deep A. Intraoperative kidney replacement therapy in acute liver failure. Pediatr Nephrol 2024:10.1007/s00467-023-06272-7. [PMID: 38526761 DOI: 10.1007/s00467-023-06272-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/16/2023] [Accepted: 12/18/2023] [Indexed: 03/27/2024]
Abstract
Paediatric acute liver failure (PALF) is often characterised by its rapidity of onset and potential for significant morbidity and even mortality. Patients often develop multiorgan dysfunction/failure, including severe acute kidney injury (AKI). Whilst the management of PALF focuses on complications of hepatic dysfunction, the associated kidney impairment can significantly affect patient outcomes. Severe AKI requiring continuous kidney replacement therapy (CKRT) is a common complication of both PALF and liver transplantation. In both scenarios, the need for CKRT is a poor prognostic indicator. In adults, AKI has been shown to complicate ALF in 25-50% of cases. In PALF, the incidence of AKI is often higher compared to other critically ill paediatric ICU populations, with reports of up to 40% in some observational studies. Furthermore, those presenting with AKI regularly have a more severe grade of PALF at presentation. Observational studies in the paediatric population corroborate this, though data are not as robust-mainly reflecting single-centre cohorts. Perioperative benefits of CKRT include helping to clear water-soluble toxins such as ammonia, balancing electrolytes, preventing fluid overload, and managing raised intracranial pressure. As liver transplantation often takes 6-10 h, it is proposed that these benefits could be extended to the intraoperative period, avoiding any hiatus. Intraoperative CKRT (IoCKRT) has been shown to be practicable, safe and may help sicker recipients tolerate the operation with outcomes analogous with less ill patients not requiring IoCKRT. Here, we provide a comprehensive guide describing the rationale, practicalities, and current evidence base surrounding IoCKRT during transplantation in the paediatric population.
Collapse
Affiliation(s)
- Daniel Henderson
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Anish Gupta
- Division of Liver Transplant, Anaesthetic Department, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Shina Menon
- Division of Nephrology, Department of Paediatrics, University of Washington and Seattle Children's Hospital, Seattle, WA, USA
| | - Akash Deep
- Paediatric Intensive Care Unit, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Women and Children's Health, School of Life Course Sciences, King's College London, London, UK.
| |
Collapse
|
2
|
Paschoal-Jr FM, Nogueira RC, Ronconi KDAL, de Lima Oliveira M, Almeida KJ, Rocha IS, Paschoal EHA, Paschoal JKSF, D'Albuquerque LAC, Teixeira MJ, Panerai RB, Bor-Seng-Shu E. TCD assessment in fulminant hepatic failure: Improvements in cerebral autoregulation after liver transplantation. Ann Hepatol 2024; 29:101167. [PMID: 37802415 DOI: 10.1016/j.aohep.2023.101167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 08/25/2023] [Accepted: 09/25/2023] [Indexed: 10/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES Acute liver failure, also known as fulminant hepatic failure (FHF), includes a spectrum of clinical entities characterized by acute liver injury, severe hepatocellular dysfunction and hepatic encephalopathy. The objective of this study was to assess cerebral autoregulation (CA) in 25 patients (19 female) with FHF and to follow up with seventeen of these patients before and after liver transplantation. PATIENTS AND METHODS The mean age was 33.8 years (range 14-56, SD 13.1 years). Cerebral hemodynamics was assessed by transcranial Doppler (TCD) bilateral recordings of cerebral blood velocity (CBv) in the middle cerebral arteries (MCA). RESULTS CA was assessed based on the static CA index (SCAI), reflecting the effects of a 20-30 mmHg increase in mean arterial blood pressure on CBv induced with norepinephrine infusion. SCAI was estimated at four time points: pretransplant and on the 1st, 2nd and 3rd posttransplant days, showing a significant difference between pre- and posttransplant SCAI (p = 0.005). SCAI peaked on the third posttransplant day (p = 0.006). Categorical analysis of SCAI showed that for most patients, CA was reestablished on the second day posttransplant (SCAI > 0.6). CONCLUSIONS These results suggest that CA impairment pretransplant and on the 1st day posttransplant was re-established at 48-72 h after transplantation. These findings can help to improve the management of this patient group during these specific phases, thereby avoiding neurological complications, such as brain swelling and intracranial hypertension.
Collapse
Affiliation(s)
- Fernando M Paschoal-Jr
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil; Department of Neurology, Federal University of Pará Medical School, Brazil.
| | - Ricardo C Nogueira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| | - Karla de Almeida Lins Ronconi
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| | - Marcelo de Lima Oliveira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| | - Kelson James Almeida
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| | | | | | | | | | - Manoel Jacobsen Teixeira
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Edson Bor-Seng-Shu
- Laboratory for Neurosonology and Cerebral Hemodynamics, Division of Neurological Surgery, Hospital das Clinicas, Sao Paulo University Medical School, Brazil
| |
Collapse
|
3
|
Amer K, Flikshteyn B, Lingiah V, Tafesh Z, Pyrsopoulos NT. Mechanisms of Disease and Multisystemic Involvement. Clin Liver Dis 2023; 27:563-579. [PMID: 37380283 DOI: 10.1016/j.cld.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Affiliation(s)
- Kamal Amer
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Ben Flikshteyn
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Vivek Lingiah
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 538, Newark, NJ 07101-1709, USA
| | - Zaid Tafesh
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 53, Newark, NJ 07101-1709, USA
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Department of Medicine, Rutgers University, 185 South Orange Avenue, MSB H Room - 536, Newark, NJ 07101-1709, USA.
| |
Collapse
|
4
|
Colak N, Bayrak Basakci O, Bayram B, Aksay E, Simsek MK, Karabay N. Optic nerve sheath diameter in patients with hepatic encephalopathy. PLoS One 2022; 17:e0277643. [PMID: 36383620 PMCID: PMC9668157 DOI: 10.1371/journal.pone.0277643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 11/01/2022] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND This study aims to reveal whether the optic nerve sheath diameter (ONSD) increases in hepatic encephalopathy (HE) patients, and to determine ONSD is associated with the poor prognosis of patients with HE. METHODS AND MATERIAL In this retrospective case-control study, HE patients who underwent cranial computerized tomography (CT) were included in the case group; and the patients who underwent CT for other reasons for the same age and gender and were normally interpreted were included in the control group. ONSD measurements in the case and control groups and clinical grades of HE with in-hospital mortality and ONSD measurements were compared in the case group. RESULTS This study was done with 74 acute HE patients and 74 control patients. The mean age was 62.9 ± 11.0 years and 67.6% of patients were male in both groups. The ONSD in the case group was higher than the control group (5.27-mm ± 0.82 vs 4.73 mm ± 0.57, p <0.001). In the case group, the ONSD was 5.30 mm ± 0.87 in survivors, and 5.21 ± 0.65 in non-survivors (P = 0.670). There was no significant difference between the West Haven HE grade (P = 0.348) and Child-Pugh Score (P = 0.505) with ONSD measurements. CONCLUSION We have shown that ONSD increases in HE patients compared to the control group. ONSD was not related to the Child-Pugh Score, HE grade, and in-hospital mortality.
Collapse
Affiliation(s)
- Nese Colak
- Department of Emergency Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
- * E-mail:
| | - Ozlem Bayrak Basakci
- Department of Emergency Medicine, Okan University School of Medicine, Istanbul, Turkey
| | - Basak Bayram
- Department of Emergency Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Ersin Aksay
- Department of Emergency Medicine, Dokuz Eylül University School of Medicine, Izmir, Turkey
| | - Muhammet Kursat Simsek
- Department of Radiology, Manisa Provincial Health Directorate Merkezefendi Public Hospital, Manisa, Turkey
| | - Nuri Karabay
- Department of Radiology, Dokuz Eylül University School of Medicine, Izmir, Turkey
| |
Collapse
|
5
|
Brasil S, Solla DJF, Nogueira RDC, Teixeira MJ, Malbouisson LMS, Paiva WDS. A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care. J Pers Med 2021; 11:1302. [PMID: 34945774 PMCID: PMC8707681 DOI: 10.3390/jpm11121302] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 11/22/2021] [Accepted: 11/23/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. MATERIALS AND METHODS Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. RESULTS Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman's plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson's correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) to the detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). CONCLUSION B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.
Collapse
Affiliation(s)
- Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Davi Jorge Fontoura Solla
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Ricardo de Carvalho Nogueira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | - Manoel Jacobsen Teixeira
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| | | | - Wellingson da Silva Paiva
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo 01246, Brazil; (D.J.F.S.); (R.d.C.N.); (M.J.T.); (W.d.S.P.)
| |
Collapse
|
6
|
Dalby T, Wohl E, Dinsmore M, Unger Z, Chowdhury T, Venkatraghavan L. Pathophysiology of Cerebral Edema—A Comprehensive Review. JOURNAL OF NEUROANAESTHESIOLOGY AND CRITICAL CARE 2020. [DOI: 10.1055/s-0040-1721165] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
AbstractCerebral edema is a condition where an excess of cerebral water accumulates due to primary neurological or non-neurological causes. Cerebral edema complicates many brain pathologies causing additional injury often in excess of the original neurological insult. Classic descriptions divide cerebral edema into cytotoxic, vasogenic, interstitial, and osmotic subtypes. The interplay of different mechanisms is important in the clinical manifestations. Recent research has advanced our understanding of the molecular pathophysiology of cerebral edema, exposing the central role of aquaporins and specific ion channels. The aim of this review is to provide a comprehensive overview of the molecular pathophysiology of cerebral edema including unique disease specific mechanisms.
Collapse
Affiliation(s)
- Tara Dalby
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Elyana Wohl
- Department of Anesthesia, Notre-Dame Hospital, Montreal, Quebec, Canada
| | - Michael Dinsmore
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Zoe Unger
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Tumul Chowdhury
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| | - Lakshmikumar Venkatraghavan
- Department of Anesthesia and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Ontario, Canada
| |
Collapse
|
7
|
Acute Liver Failure: From Textbook to Emergency Room and Intensive Care Unit With Concomitant Established and Modern Novel Therapies. J Clin Gastroenterol 2019; 53:89-101. [PMID: 30575637 DOI: 10.1097/mcg.0000000000001162] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute liver failure is a rare hepatic emergent situation that affects primarily young people and has often a catastrophic or even fatal outcome. Definition of acute liver failure has not reached a universal consensus and the interval between the appearance of jaundice and hepatic encephalopathy for the establishment of the acute failure is a matter of debate. Among the wide variety of causes, acetaminophen intoxication in western societies and viral hepatitis in the developing countries rank at the top of the etiology list. Identification of the clinical appearance and initial management for the stabilization of the patient are of vital significance. Further advanced therapies, that require intensive care unit, should be offered. The hallmark of treatment for selected patients can be orthotopic liver transplantation. Apart from well-established treatments, novel therapies like hepatocyte or stem cell transplantation, additional new therapeutic strategies targeting acetaminophen intoxication and/or hepatic encephalopathy are mainly experimental, and some of them do not belong, yet, to clinical practice. For clinicians, it is substantial to have the alertness to timely identify the patient and transfer them to a specialized center, where more treatment opportunities are available.
Collapse
|
8
|
Pathogenesis of cerebral edema in patients with acute renal and liver failure and the role of the nephrologist in the management. Curr Opin Nephrol Hypertens 2019; 27:289-297. [PMID: 29771702 DOI: 10.1097/mnh.0000000000000425] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW Acute liver failure (ALF) is a severe and complex illness and one of the most daunting conditions managed in the ICU. Because the renal care is intertwined with multiple disciplines, the aim of this review is to examine the multifactorial pathogenesis of cerebral edema in ALF, covering basic established facts as well as recent advances in our understanding of this condition. RECENT FINDINGS Acetaminophen remains the most common cause of ALF in the United States and many European countries. The incidence of cerebral edema continues to decline owing to earlier detection and improved management. The pathogenesis of cerebral edema has shifted from a unifactorial hypothesis involving the failed liver to a multifactorial cause. Recent evidence focuses on the role of liver-induced systemic inflammation and its implication in increasing the permeability of the blood-brain barrier. The role of brain aquaporin-4 in mediating water entry into the brain is further clarified. Controversial data regarding the effect of acute kidney injury on the brain emerged. Hyponatremia has been shown to worsen the outcome in acute-on-chronic liver failure patients thus validating findings in animal models. New evidence shed the light on the changes in serum osmolality and potential tissue hypoxia during continuous renal replacement therapy and points to the risks associated with such therapy. SUMMARY ALF is a severe systemic illness that is potentially reversible. Understanding the interaction between the multiple failed organs will help the nephrologist provide well tolerated and efficient care.
Collapse
|