Acute renal and liver failure due to acute fatty liver of pregnancy-complicated pre-eclampsia

Uterine arteries pulsatility index by Doppler ultrasound in the prediction of preeclampsia: an updated systematic review and meta-analysis

BACKGROUND

Preeclampsia is a common pregnancy complication with serious potential risks for maternal and neonatal health. Early prediction of preeclampsia is crucial for timely prevention, surveillance, and treatment to improve maternal and neonatal outcomes. This systematic review aimed to summarize the available evidence on the prediction of preeclampsia based on Doppler ultrasound of uterine arteries at different gestational ages.

METHODS

A systematic literature search and meta-analysis were conducted to evaluate the sensitivity and specificity of the pulsatility index of Doppler ultrasound of uterine arteries for predicting preeclampsia. The timing of ultrasound scans within and beyond 20 weeks of gestational age was compared to assess its effect on the sensitivity and specificity of the pulsatility index.

RESULTS

This meta-analysis included 27 studies and 81,673 subjects (3309 preeclampsia patients and 78,364 controls). The pulsatility index had moderate sensitivity (0.586) and high specificity for predicting preeclampsia (0.879) (summary point: sensitivity 0.59; 1-specificity 0.12). Subgroup analysis revealed that ultrasound scans performed within 20 weeks of gestational age did not significantly affect the sensitivity and specificity for predicting preeclampsia. The summary receiver operator characteristic curve showed the pulsatility index's optimal range of sensitivity and specificity.

CONCLUSIONS

The uterine arteries pulsatility index measured by Doppler ultrasound is useful and effective for predicting preeclampsia and should be implemented in the clinical practice. The timing of ultrasound scans at different gestational age ranges does not significantly affect the sensitivity and specificity.

Acute Kidney Injury in Pregnancies Complicated With Preeclampsia or HELLP Syndrome

Acute kidney injury that occurs during pregnancy or in the post-partum period (PR-AKI) is a serious obstetric complication with risk of significant associated maternal and fetal morbidity and mortality. Recent data indicates that the incidence of PR-AKI is increasing, although accurate calculation is limited by the lack of a uniform diagnostic criteria that is validated in pregnancy. Hypertensive and thrombotic microangiopathic disorders of pregnancy have been identified as major contributors to the burden of PR-AKI. As is now accepted regarding preeclampsia, HELLP syndrome and atypical hemolytic uremic syndrome, it is believed that PR-AKI may have long-term renal, cardiovascular and neurocognitive consequences that persist beyond the post-partum period. Further research regarding PR-AKI could be advanced by the development of a pregnancy-specific validated definition and classification system; and the establishment of refined animal models that would allow researchers to further elucidate the mechanisms and sequelae of the disorder.

Acute fatty liver of pregnancy: a retrospective study of 32 cases in South China

OBJECTIVE

To describe 32 cases of acute fatty liver of pregnancy (AFLP) and identify the potential clinical predictors of maternal and fetal outcomes in South China.

METHODS

Thirty-two cases of AFLP previously treated in the First Affiliated Hospital of Nanchang University in the past 10 years were enrolled in the current study.

RESULTS

Sex of fetus and delivery method was the potential clinical predictor of fetal outcome. The main manifestations of AFLP were jaundice (n = 32), nausea and vomiting (n = 28), malaise (n = 25), and ascites (n = 25), and its complications included acute renal failure (n = 26), hepatic encephalopathy (n = 17), infection (n = 10), and postpartum hemorrhage (n = 7). Evidence of fatty changes of liver was demonstrated by B ultrasound and computed tomography (CT). Eighteen patients were recovered due to rapid diagnosis, early termination of pregnancy and supportive treatments.

CONCLUSIONS

Male sex and vaginal delivery was the risk factor of fetal outcome. Detailed history taking and proper management of potential predictors are important in making the decision of prompt delivery and choosing the appropriate delivery method. Further studies are needed to expand our knowledge on this disease.

Combined use of non-biological artificial liver treatments for patients with acute liver failure complicated by multiple organ dysfunction syndrome

BACKGROUND

Acute liver failure (ALF) caused by viral and non-viral hepatitis is often accompanied with severe metabolic disorders, the accumulation of toxic substances and continuous release and accumulation of a large number of endogenous toxins and inflammatory mediators. The present study aimed to investigate the effects of various combined non-biological artificial liver treatments for patients with acute liver failure (ALF) complicated by multiple organ dysfunction syndrome (MODS).

METHODS

Thirty-one patients with mid- or late-stage liver failure complicated by MODS (score 4) were randomly divided into three treatment groups: plasmapheresis (PE) combined with hemoperfusion (HP) and continuous venovenous hemodiafiltration (CVVHDF), PE+CVVHDF, and HP+CVVHDF, respectively. Heart rate (HR) before and after treatment, mean arterial pressure (MAP), respiratory index (PaO2/FiO2), hepatic function, platelet count, and blood coagulation were determined.

RESULTS

Significant improvement was observed in HR, MAP, PaO2/FiO2, total bilirubin (TBIL) and alanine aminotransferase (ALT) levels after treatment (P<0.05). TBIL and ALT decreased more significantly after treatment in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.01). Prothrombin time (PT) and albumin were significantly improved only in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.05). TBIL decreased more significantly in the PE+HP+CVVHDF group than in the HP+CVVHDF and PE+CVVHDF groups (P<0.05). The survival rate of the patients was 58.1% (18/31), viral survival rate 36.4% (4/11), and non-viral survival rate 70% (14/20).

CONCLUSION

Liver function was relatively improved after treatment, but PE+HP+CVVHDF was more efficient for the removal of toxic metabolites, especially bilirubin. The survival rate was significantly higher in the patients with non-viral liver failure than in those with viral liver failure.

Advances in the management of acute liver failure

Acute liver failure (ALF) is an uncommon but dramatic clinical syndrome characterized by hepatic encephalopathy and a bleeding tendency due to abrupt loss of liver function caused by massive or submassive liver necrosis in a patient with a previously healthy liver. The causes of ALF encompass a wide variety of toxic, viral, metabolic, vascular and autoimmune insults to the liver, and identifying the correct cause can be difficult or even impossible. Many patients with ALF develop a cascade of serious complications involving almost every organ system, and death is mostly due to multi-organ failure, hemorrhage, infection, and intracranial hypertension. Fortunately, the outcome of ALF has been improved in the last 3 decades through the specific treatment for the disease of certain etiology, and the advanced intensive care management. For most severely affected patients who fail to recover after treatment, rapid evaluation for transfer to a transplantation center and consideration for liver transplantation is mandatory so that transplantation can be applied before contraindications develop. This review focuses on the recent advances in the understanding of various contributing etiologies, the administration of etiology-specific treatment to alleviate the liver injury, and the management of complications (e.g., encephalopathy, coagulopathy, cardiovascular instability, respiratory failure, renal failure, sepsis and metabolic disturbance) in patients with ALF. Assessment of the need for liver transplantation is also presented.