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Umbaugh DS, Nguyen NT, Curry SC, Rule JA, Lee WM, Ramachandran A, Jaeschke H. The chemokine CXCL14 is a novel early prognostic biomarker for poor outcome in acetaminophen-induced acute liver failure. Hepatology 2024; 79:1352-1364. [PMID: 37910653 PMCID: PMC11061265 DOI: 10.1097/hep.0000000000000665] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 10/12/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND AND AIMS Patients with acetaminophen-induced acute liver failure are more likely to die while on the liver transplant waiting list than those with other causes of acute liver failure. Therefore, there is an urgent need for prognostic biomarkers that can predict the need for liver transplantation early after an acetaminophen overdose. APPROACH AND RESULTS We evaluated the prognostic potential of plasma chemokine C-X-C motif ligand 14 (CXCL14) concentrations in patients with acetaminophen (APAP) overdose (n=50) and found that CXCL14 is significantly higher in nonsurviving patients compared to survivors with acute liver failure ( p < 0.001). Logistic regression and AUROC analyses revealed that CXCL14 outperformed the MELD score, better discriminating between nonsurvivors and survivors. We validated these data in a separate cohort of samples obtained from the Acute Liver Failure Study Group (n = 80), where MELD and CXCL14 had similar AUC (0.778), but CXCL14 demonstrated higher specificity (81.2 vs. 52.6) and positive predictive value (82.4 vs. 65.4) for death or need for liver transplantation. Next, combining the patient cohorts and using a machine learning training/testing scheme to mimic the clinical scenario, we found that CXCL14 outperformed MELD based on AUC (0.821 vs. 0.787); however, combining MELD and CXCL14 yielded the best AUC (0.860). CONCLUSIONS We find in 2 independent cohorts of acetaminophen overdose patients that circulating CXCL14 concentration is a novel early prognostic biomarker for poor outcomes, which may aid in guiding decisions regarding patient management. Moreover, our findings reveal that CXCL14 performs best when measured soon after patient presentation to the clinic, highlighting its importance for early warning of poor prognosis.
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Affiliation(s)
- David S. Umbaugh
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nga T. Nguyen
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Steven C. Curry
- Department of Medical Toxicology, Banner – University Medical Center Phoenix, Phoenix, AZ, USA
- Department of Medicine, and Division of Clinical Data Analytics and Decision Support, University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Jody A. Rule
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William M. Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Anup Ramachandran
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, KS, USA
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Jalil S, Elfeki MA, Kiefer MK, Kuo YF, Singal AK. Waitlist and posttransplant outcomes of pregnancy-related acute liver failure in the United States. Liver Transpl 2024; 30:573-581. [PMID: 38108820 DOI: 10.1097/lvt.0000000000000319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 12/08/2023] [Indexed: 12/19/2023]
Abstract
Data on the liver transplant (LT) outcomes of women with acute liver failure (ALF) due to liver diseases unique to pregnancy (P-ALF) are limited. Using United Network of Organ Sharing (UNOS) data (1987-2021), we analyzed waitlist and post-LT outcomes of ALF in women of childbearing age comparing P-ALF versus ALF due to liver diseases not unique to pregnancy. Baseline characteristics were compared between groups at the time of listing for LT. Of 3542 females aged 16-43 years and listed for LT for ALF, 84 (2%) listed for P-ALF were less likely to be Black (11 vs. 21%, p =0.033), have lower international normalized ratio (2.74 vs. 4.53 p <0.002), but more likely to have respiratory failure (56% vs. 41%, p <0.005), be on pressors (58% vs. 43%, p <0.005), and require dialysis (23% vs. 10%, p <0.001). The cumulative 90-day waitlist mortality (WLM) was lower in P-ALF vs. ALF due to liver diseases not unique to pregnancy (7.4 vs. 16.6%, p <0.001). Posttransplant survival rates at 5 years were similar (82% vs. 79%, p =0.89). In a Fine and Gray regression model controlled for listing year and Model for End-Stage Liver Disease score, 90-day WLM was lower in P-ALF with a sub-HR of 0.42 (95% CI: 0.19-0.94, p =0.035). Of 84 women with P-ALF and listed for LT, 45 listed for hemolysis-elevated liver enzymes-low platelets (HELLP) versus 39 for acute fatty liver of pregnancy had higher 90-day WLM (19.3% vs. 5.7% p <0.005). The 90-day WLM was about 10-fold higher in HELLP versus acute fatty liver of pregnancy with a sub-HR of 9.97 (95% CI: 1.64-60.55, p =0.013). In this UNOS database analysis of ALF among women of childbearing age, the waitlist outcome is better in women with P-ALF compared to women with ALF due to liver diseases not unique to pregnancy. Among women with P-ALF, the 90-day WLM is worse for HELLP versus acute fatty liver of pregnancy. Further studies are needed to improve the management of HELLP and prevent the development of ALF in this subgroup population.
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Affiliation(s)
- Sajid Jalil
- Department of Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Mohamed A Elfeki
- Department of Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
- Department of Medicine, Avera McKennan University Hospital and Transplant Institute, Sioux Falls, Sioux Falls, SD, USA
| | - Miranda K Kiefer
- Department of Medicine, Maternal Fetal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Yong-Fang Kuo
- Department of Biostatistics, University of Texas Medical Branch, Galveston, Texas, USA
| | - Ashwani K Singal
- Department of Medicine, University of Louisville, Louisville, KY, USA
- Department of Medicine, Trager Transplant Center, Jewish Hospital, Louisville, Kentucky, USA
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Tawhari M, Aldalaan A, Alanazi R, Aldharman S, Alnafisah T, Alawad N, Alhejji AM, Alhabeeb AY, Alhamadh MS. Clinical presentation and outcomes of patients with rhabdomyolysis: A tertiary care center experience. Saudi Med J 2024; 45:510-517. [PMID: 38734436 DOI: 10.15537/smj.2024.45.5.20230560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Accepted: 04/12/2024] [Indexed: 05/13/2024] Open
Abstract
OBJECTIVES To evaluate the clinical and laboratory features, complications, and outcomes of patients with rhabdomyolysis in the Saudi population. METHODS Retrospectives descriptive study of adult patients who presented to King Abdulaziz Medical City (KAMC) withrhabdomyolysis between January 2016 and December 2022. RESULTS Most of the participants (84.5%) were male, with a median age of 41 years and a body mass index of 26.5 kg/m2. Medications, mainly statins (22.4%) and illicit drugs (15.5%), constituted the root causes of rhabdomyolysis in the cohort (44.8%). The most common presenting complaints were myalgia (63.8%) and fatigue (37.9%). More than one-third of the participants (32.8%) developed AKI, with 3 patients requiring temporary hemodialysis, and only 8.6% developed acute liver failure (ALF). Intensive care unit (ICU) admission was required for 10 patients (17.2%), and the overall mortality rate was 8.6%. Patients who developed complications (composite outcomes of AKI, ALF, multiorgan failure, or death) had significantly reduced kidney function and higher levels of blood urea nitrogen, anion gap, and uric acid upon admission than those who did not. CONCLUSION This study offers a thorough understanding of clinical and laboratory features, causes, complications, and outcomes of rhabdomyolysis among Saudi patients. The insights gained enhance our understanding of rhabdomyolysis within this population, providing a foundation for future research and improvements in clinical management.
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Affiliation(s)
- Mohammed Tawhari
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Abdulaziz Aldalaan
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Rahaf Alanazi
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Sarah Aldharman
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Turki Alnafisah
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Nawaf Alawad
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Abdullah M Alhejji
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Abdulrahman Yousef Alhabeeb
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Moustafa S Alhamadh
- From the Department of Medicine (Tawhari), King Abdulaziz Medical City, Ministry of the National Guard-Health Affairs; from the College of Medicine (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), King Saud bin Abdulaziz University for Health Sciences, Ministry of the National Guard-Health Affairs; and from King Abdullah International Medical Research Center (Tawhari, Aldalaan, Alanazi, Aldharman, Alawad, Alhejji, Alhabeeb, Alhamadh), Ministry of the National Guard-Health Affairs, Riyadh, Kingdom of Saudi Arabia
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von Meijenfeldt FA, Stravitz RT, Zhang J, Adelmeijer J, Zen Y, Durkalski V, Lee W, Lisman T. Generation of neutrophil extracellular traps in patients with acute liver failure is associated with poor outcome. Hepatology 2022; 75:623-633. [PMID: 34562318 PMCID: PMC9299791 DOI: 10.1002/hep.32174] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 08/11/2021] [Accepted: 09/09/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND AIMS Acute liver failure (ALF) is characterized by significant changes in the hemostatic system and by systemic inflammation. The formation of neutrophil extracellular traps (NETs), in which an activated neutrophil expels its DNA, histones, and granular enzymes, such as myeloperoxidase (MPO), has been associated with immune-mediated and thrombotic diseases. We hypothesized that formation of NETs in patients with ALF contributes to progression of disease. APPROACH AND RESULTS A total of 676 patients with ALF (international normalized ratio [INR], ≥1.5) or severe acute liver injury (ALI; INR, ≥2.0) were recruited from the U.S. ALF Study Group Registry between 2011 and 2018, of whom 308 patients (45.6%) had acetaminophen-induced ALF. Up to 21 days after admission, 483 patients (71.5%) survived without liver transplantation (LT). Levels of cell-free DNA (cfDNA) and the specific NET marker MPO-DNA complexes were measured in plasma samples obtained on admission and compared to levels in healthy controls. In addition, liver tissue obtained at transplantation of 20 ALF patients was stained for NETs. Levels of cfDNA were 7.1-fold, and MPO-DNA complexes 2.5-fold, higher in patients with ALF compared to healthy controls. cfDNA levels were not associated with 21-day transplant-free survival, but were higher in those patients with more-severe disease on admission, as reflected by various laboratory and clinical parameters. MPO-DNA levels were 30% higher in patients with ALF who died or required urgent LT. Liver tissue of ALF patients stained positive for NETs in 12 of 18 evaluable patients. CONCLUSIONS Here, we provide evidence for NET formation in patients with ALF. Elevated plasma levels of MPO-DNA complexes in patients with ALF were associated with poor outcome, which suggests that NET formation contributes to disease progression.
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Affiliation(s)
- Fien A. von Meijenfeldt
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - R. Todd Stravitz
- Hume‐Lee Transplant Center of Virginia Commonwealth UniversityRichmondVirginiaUSA
| | - Jingwen Zhang
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Yoh Zen
- Department of PathologyInstitute of Liver StudiesKing’s College HospitalLondonUK
| | - Valerie Durkalski
- Department of Public Health SciencesMedical University of South CarolinaCharlestonSouth CarolinaUSA
| | - William M. Lee
- University of Texas‐Southwestern Medical CenterDallasTexasUSA
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
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Shrestha DB, Budhathoki P, Sedhai YR, Adhikari A, Poudel A, Aryal B, Baniya R. N-acetyl cysteine versus standard of care for non-acetaminophen induced acute liver injury: a systematic review and meta-analysis. Ann Hepatol 2022; 24:100340. [PMID: 33722689 DOI: 10.1016/j.aohep.2021.100340] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 02/04/2023]
Abstract
The role of N-acetylcysteine (NAC) in the treatment of acetaminophen induced acute liver injury (ALI) is well established but its role in non-acetaminophen induced ALI is still elusive. We conducted this meta-analysis to evaluate the role of NAC in non-acetaminophen induced ALI. We searched electronic databases for studies published till Oct 25, 2020. We used RevMan v5.4 software to analyze the data extracted from selected studies by using Covidence systematic review software. Outcome estimation was done using Odds Ratio (OR) with 95% confidence interval (CI). The heterogeneity in various studies was determined using the I2 test. A total of 11 studies were included in quantitative analysis. Use of NAC in non-acetaminophen induced ALI showed 53% reduction in mortality compared to standard of care (OR, 0.47; CI, 0.29-0.75) and reduced mean duration of hospital stay by 6.52 days (95% CI, -12.91 to -0.13). Similarly, the rate of encephalopathy was 59% lower in the treatment group (OR, 0.41; CI, 0.20-0.83). However, the risk of developing nausea and vomiting (OR, 3.99; CI, 1.42-11.19), and the need for mechanical ventilation (OR 3.88; CI, 1.14-13.29) were significantly higher in the treatment group. These findings conclude use of NAC decreases mortality and hepatic encephalopathy compared to standard of care in patients with non-acetaminophen induced ALI. Although there is an increased risk of nausea and vomiting with the use of NAC, the majority of adverse events are transient and minor.
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Affiliation(s)
| | - Pravash Budhathoki
- Department of Emergency Medicine, Dr. Iwamura Memorial Hospital, Bhaktapur 44800, Nepal
| | - Yub Raj Sedhai
- Department of Internal Medicine, Division of Hospital Medicine, Virginia Commonwealth University, School of Medicine, Richmond, VA, USA.
| | - Anurag Adhikari
- Department of Emergency Medicine, Nepal National Hospital, Kathmandu, Nepal
| | - Ayusha Poudel
- Department of Emergency Medicine, Alka Hospital, Kathmandu, Nepal
| | - Barun Aryal
- Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Ramkaji Baniya
- Our Lady of the Lake Regional Medical Center, Baton Rouge, LA, USA
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Tüfekçi Ö, Özdemir HH, Malbora B, Özbek NY, Yarali N, Erdem A, Evim M, Baytan B, Güneş AM, Karapinar T, Oymak Y, Töret E, Bör Ö, Yilmaz Ş, Ören H, Özdemir GN, Karapinar DY. Hepatitis-Associated Aplastic Anemia: Etiology, Clinical Characteristics and Outcome. J Pediatr Hematol Oncol 2022; 44:e223-e226. [PMID: 34669357 DOI: 10.1097/mph.0000000000002268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 05/27/2021] [Indexed: 11/26/2022]
Abstract
Hepatitis-associated aplastic anemia (HAA) is a form of acquired aplastic anemia (AA) in which bone marrow failure develops after an acute attack of hepatitis. Bone marrow failure leading to AA is generally severe in cases of HAA and fatal if left untreated. This retrospective multicenter study investigated clinical and laboratory characteristics, possible causes, treatment, and outcome of HAA in children. Twenty patients from 8 centers were included in the study. Aspartate aminotransferase and alanine aminotransferase were <3 to 5×upper limit of normal (ULN) in 2 patients, <5 to 10×ULN in 2 patients, and >10×ULN in 16 patients. Acute liver failure developed in 5 (29%) patients. Pancytopenia was simultaneously present in 6 of 20 (30%) patients. Eleven of the 20 patients (55%) were alive, in remission and transfusion free. Those who were alive either had undergone hematopoietic stem cell transplantation and/or immunosuppressive treatment, except 1 patient who had received no treatment. Patients with the diagnosis of acute hepatitis should be evaluated and followed up carefully for presence of cytopenia, so that definitive treatment of AA can be initiated in a timely and appropriate manner when needed.
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Affiliation(s)
- Özlem Tüfekçi
- Department of Pediatric Hematology, Dokuz Eylül University Faculty of Medicine
| | - Hamiyet H Özdemir
- Department of Pediatric Hematology, Ege University Faculty of Medicine
| | - Bariş Malbora
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, The University of Health Sciences, Ankara
| | - Namik Y Özbek
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, The University of Health Sciences, Ankara
| | - Neşe Yarali
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, The University of Health Sciences, Ankara
| | - Arzu Erdem
- Department of Pediatric Hematology/Oncology, Ankara City Hospital, The University of Health Sciences, Ankara
| | - Melike Evim
- Department of Pediatric Hematology, Uludağ University Faculty of Medicine, Bursa
| | - Birol Baytan
- Department of Pediatric Hematology, Uludağ University Faculty of Medicine, Bursa
| | - Adalet M Güneş
- Department of Pediatric Hematology, Uludağ University Faculty of Medicine, Bursa
| | - Tuba Karapinar
- Department of Pediatric Hematology/Oncology, İstinye University Faculty of Medicine, İstanbul, Turkey
| | - Yeşim Oymak
- Department of Pediatric Hematology/Oncology, İstinye University Faculty of Medicine, İstanbul, Turkey
| | - Ersin Töret
- Department of Pediatric Hematology, Osmangazi University Faculty of Medicine, Eskişehir
| | - Özcan Bör
- Department of Pediatric Hematology, Osmangazi University Faculty of Medicine, Eskişehir
| | - Şebnem Yilmaz
- Department of Pediatric Hematology, Dokuz Eylül University Faculty of Medicine
| | - Hale Ören
- Department of Pediatric Hematology, Dokuz Eylül University Faculty of Medicine
| | - Gül N Özdemir
- Department of Pediatric Hematology/Oncology, İstinye University Faculty of Medicine, İstanbul, Turkey
| | - Deniz Y Karapinar
- Department of Pediatric Hematology, Ege University Faculty of Medicine
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Fontana RJ, Stravitz RT, Durkalski V, Hanje J, Hameed B, Koch D, Ganger D, Olson J, Liou I, McGuire BM, Clasen K, Lee WM. Prognostic Value of the 13 C-Methacetin Breath Test in Adults with Acute Liver Failure and Non-acetaminophen Acute Liver Injury. Hepatology 2021; 74:961-972. [PMID: 33660316 PMCID: PMC10683007 DOI: 10.1002/hep.31783] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 01/08/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIMS The 13 C-methacetin breath test (MBT) is a noninvasive, quantitative hepatic metabolic function test. The aim of this prospective, multicenter study was to determine the utility of initial and serial 13 C-MBT in predicting 21-day outcomes in adults with acute liver failure (ALF) and non-acetaminophen acute liver injury (ALI). APPROACH AND RESULTS The 13 C-MBT BreathID device (Exalenz Biosciences, Ltd.) provided the percent dose recovery (PDR) for a duration of 60 minutes after administration of 13 C-methacetin solution as the change in exhaled 13 CO2 /12 CO2 compared with pre-ingestion ratio on study days 1, 2, 3, 5, and 7. Results were correlated with 21-day transplant-free survival and other prognostic indices. A total of 280 subjects were screened for enrollment between May 2016 and August 2019. Median age of the 62 enrolled patients with adequate data was 43 years, 79% were Caucasian, 76% had ALF with the remaining 24% having ALI. The mean PDR peak on day 1 or day 2 was significantly lower in nonsurvivors compared with transplant-free survivors (2.3%/hour vs. 9.1%/hour; P < 0.0001). In addition, serial PDR peaks were consistently lower in nonsurvivors versus survivors (P < 0.0001). The area under the receiver operating characteristic curve (AUROC) of the 13 C-MBT in the combined cohort was 0.88 (95% CI: 0.79-0.97) and higher than that provided by King's College (AUROC = 0.70) and Model for End-Stage Liver Disease scores (AUROC = 0.83). The 13 C-MBT was well tolerated with only two gastrointestinal adverse events reported. CONCLUSIONS The 13 C-MBT is a promising tool to estimate the likelihood of hepatic recovery in patients with ALF and ALI. Use of the PDR peak data from the 13 C-MBT point-of-care test may assist with medical decision making and help avoid unnecessary transplantation in critically ill patients with ALF and ALI.
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Affiliation(s)
- Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - R. Todd Stravitz
- Lee-Hume Transplant Center, Virginia Commonwealth University, Richmond, VA
| | - Valerie Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - James Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - Bilal Hameed
- Department of Medicine, University of California San Francisco, San Francisco, CA
| | - David Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - Daniel Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - Jody Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - Iris Liou
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Kristen Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - William M. Lee
- Department of Internal Medicine, University of Texas Southwestern, Dallas, TX
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Stravitz RT, Fontana RJ, Meinzer C, Durkalski V, Hanje AJ, Olson J, Koch D, Hamid B, Schilsky ML, McGuire B, Ganger D, Liou I, Karvellas CJ, Rule JA, Lisman T, Clasen K, Reuben A, Cripps MW, Lee WM. Coagulopathy, Bleeding Events, and Outcome According to Rotational Thromboelastometry in Patients With Acute Liver Injury/Failure. Hepatology 2021; 74:937-949. [PMID: 33636020 PMCID: PMC10668528 DOI: 10.1002/hep.31767] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 02/01/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Patients with acute liver injury or failure (ALI/ALF) experience bleeding complications uncommonly despite an abnormal hemostatic profile. Rotational thromboelastometry (ROTEM), which assesses clot formation in whole blood, was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival. APPROACH AND RESULTS A total of 200 patients were recruited from sites of the ALF Study Group. Blood collected daily for up to 5 days was analyzed using ROTEM delta devices. Consistent with standard laboratory evidence of hypocoagulability (median international normalized ratio = 2.9 and platelet count = 144 × 109 /L), patients frequently exhibited ROTEM parameters outside the normal range (73% and 62% had abnormalities in clot formation from extrinsic and intrinsic clotting cascades, respectively); however, measures of clot stability were generally normal. Eighteen patients (9%) experienced bleeding events, in whom clot initiation, assembly, and firmness were more severely deranged than patients without bleeding. Abnormal ROTEM parameters were more frequently observed in patients with non-acetaminophen ALI/ALF than those with acetaminophen ALI/ALF (clot initiation [P < 0.001], assembly [P = 0.02], firmness at 10 minutes [P = 0.05], and maximal firmness [P = 0.06]). Patients with more severe systemic complications (high-grade hepatic encephalopathy and need for renal replacement therapy) also had a higher incidence of abnormal ROTEM parameters. Finally, more hypocoagulable ROTEM parameters (clot initiation (P = 0.005), stiffness at 10 minutes (P = 0.05), and maximal stiffness by fibrin assembly (P = 0.004)) were observed in patients who died or underwent liver transplantation than those who survived with their native liver. CONCLUSIONS In patients with ALI/ALF, abnormal ROTEM parameters are frequent and proportional to disease severity. Whether the increased bleeding risk associated with abnormal ROTEM indicates hemostatic failure or is a proxy for disease severity requires additional study.
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Affiliation(s)
- RT Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA
| | - RJ Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - C Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - V Durkalski
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - AJ Hanje
- Department of Medicine, The Ohio State University, Columbus, OH
| | - J Olson
- Division of Gastroenterology, University of Kansas Medical Center, Kansas City, KS
| | - D Koch
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - B Hamid
- Department of Medicine, University of California at San Francisco, San Francisco, CA
| | - ML Schilsky
- Divisions of Digestive Disease and Transplant and Immunology, Yale University, New Haven, CT
| | - B McGuire
- Division of Gastroenterology, University of Alabama, Birmingham, AL
| | - D Ganger
- Division of Gastroenterology, Northwestern University, Chicago, IL
| | - I Liou
- Department of Medicine, University of Washington, Seattle, WA
| | - CJ Karvellas
- Division of Gastroenterology (Liver Unit) and Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada
| | - JA Rule
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
| | - T Lisman
- Department of Surgery, University of Groningen, Groningen, The Netherlands
| | - K Clasen
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - A Reuben
- Department of Medicine, Medical University of South Carolina, Charleston, SC
| | - MW Cripps
- Department of Surgery, University of Texas, Southwestern Medical Center, Dallas, TX
| | - WM Lee
- Department of Internal Medicine, University of Texas, Southwestern Medical Center, Dallas, TX
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9
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Driever EG, Stravitz RT, Zhang J, Adelmeijer J, Durkalski V, Lee WM, Lisman T. VWF/ADAMTS13 Imbalance, But Not Global Coagulation or Fibrinolysis, Is Associated With Outcome and Bleeding in Acute Liver Failure. Hepatology 2021; 73:1882-1891. [PMID: 32767567 PMCID: PMC8251778 DOI: 10.1002/hep.31507] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/03/2020] [Accepted: 07/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS Recent studies of acute liver failure (ALF) in man and animals have suggested that rebalanced hemostasis occurs, with distinct hypercoagulable features clinically evidenced by a low risk of bleeding. Rodent models have shown a link between intrahepatic microthrombus formation and progression of ALF. We sought to confirm these earlier findings in a large series of patients with well-characterized ALF from the Acute Liver Failure Study Group. APPROACH AND RESULTS Citrated plasma samples taken on admission from 676 patients with ALF or acute liver injury (international normalized ratio ≥2.0 without hepatic encephalopathy) were used to determine levels of von Willebrand factor (VWF), a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activity, thrombomodulin-modified thrombin generation, and clot lysis time (CLT) and compared with the levels in 40 healthy controls. Patients had 3-fold increased VWF levels, 4-fold decreased ADAMTS13 activity, similar thrombin generating capacity, and 2.4-fold increased CLT, compared with controls. Increasing disease severity was associated with progressively more elevated VWF levels as well as hypofibrinolysis. Patients who died or underwent liver transplantation within 21 days of admission had higher VWF levels, lower ADAMTS13 activity, but similar thrombin generation and a similar proportion of patients with severe hypofibrinolysis, when compared with transplant-free survivors. Likewise, patients with bleeding complications had higher VWF levels and lower ADAMTS13 activity compared to those without bleeding. Thrombin generation and CLT did not differ significantly between bleeding and nonbleeding patients. CONCLUSIONS Rebalanced hemostatic status was confirmed in a large cohort of patients with acute liver injury/ALF, demonstrating that VWF/ADAMTS13 imbalance is associated with poor outcome and bleeding. The association between VWF/ADAMTS13 imbalance and bleeding suggests that bleeding in ALF relates more to systemic inflammation than a primary coagulopathy.
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Affiliation(s)
- Ellen G. Driever
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - R. Todd Stravitz
- Section of Hepatology and Hume‐Lee Transplant CenterVirginia Commonwealth UniversityRichmondVA
| | - Jingwen Zhang
- Department of BiostatisticsMedical University of South CarolinaCharlestonSC
| | - Jelle Adelmeijer
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
| | - Valerie Durkalski
- Department of BiostatisticsMedical University of South CarolinaCharlestonSC
| | - William M. Lee
- Division of Digestive and Liver DiseasesUniversity of Texas Southwestern Medical CenterDallasTX
| | - Ton Lisman
- Surgical Research LaboratoryDepartment of SurgeryUniversity of GroningenUniversity Medical Center GroningenGroningenthe Netherlands
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10
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Abstract
BACKGROUND Acute liver failure is a rare and serious disease. Acute liver failure may be paracetamol-induced or non-paracetamol-induced. Acute liver failure not caused by paracetamol (acetaminophen) has a poor prognosis with limited treatment options. N-acetylcysteine has been successful in treating paracetamol-induced acute liver failure and reduces the risk of needing to undergo liver transplantation. Recent randomised clinical trials have explored whether the benefit can be extrapolated to treat non-paracetamol-related acute liver failure. The American Association for the Study of Liver Diseases (AASLD) 2011 guideline suggested that N-acetylcysteine could improve spontaneous survival when given during early encephalopathy stages for patients with non-paracetamol-related acute liver failure. OBJECTIVES To assess the benefits and harms of N-acetylcysteine compared with placebo or no N-acetylcysteine, as an adjunct to usual care, in people with non-paracetamol-related acute liver failure. SEARCH METHODS We searched the Cochrane Hepato-Biliary Group Controlled Trials Register (searched 25 June 2020), Cochrane Central Register of Controlled Trials (CENTRAL; 2020, Issue 6) in The Cochrane Library, MEDLINE Ovid (1946 to 25 June 2020), Embase Ovid (1974 to 25 June 2020), Latin American and Caribbean Health Science Information database (LILACS) (1982 to 25 June 2020), Science Citation Index Expanded (1900 to 25 June 2020), and Conference Proceedings Citation Index - Science (1990 to 25 June 2020). SELECTION CRITERIA We included randomised clinical trials that compared N-acetylcysteine at any dose or route with placebo or no intervention in participants with non-paracetamol-induced acute liver failure. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as described in the Cochrane Handbook for Systematic Reviews of Interventions. We conducted meta-analyses and presented results using risk ratios (RR) with 95% confidence intervals (CIs). We quantified statistical heterogeneity by calculating I2. We assessed bias using the Cochrane risk of bias tool and determined the certainty of the evidence using the GRADE approach. MAIN RESULTS We included two randomised clinical trials: one with 183 adults and one with 174 children (birth through age 17 years). We classified both trials at overall high risk of bias. One unregistered study in adults is awaiting classification while we are awaiting responses from study authors for details on trial methodology (e.g. randomisation processes). We did not meta-analyse all-cause mortality because of significant clinical heterogeneity in the two trials. For all-cause mortality at 21 days between adults receiving N-acetylcysteine versus placebo, there was inconclusive evidence of effect (N-acetylcysteine 24/81 (29.6%) versus placebo 31/92 (33.7%); RR 0.88, 95% CI 0.57 to 1.37; low certainty evidence). The certainty of the evidence was low due to risk of bias and imprecision. Similarly, for all-cause mortality at one year between children receiving N-acetylcysteine versus placebo, there was inconclusive evidence of effect (25/92 (27.2%) versus 17/92 (18.5%); RR 1.47, 95% CI 0.85 to 2.53; low certainty evidence). We downgraded the certainty of evidence due to very serious imprecision. We did not meta-analyse serious adverse events and liver transplantation at one year due to incomplete reporting and clinical heterogeneity. For liver transplantation at 21 days in the trial with adults, there was inconclusive evidence of effect (RR 0.72, 95% CI 0.49 to 1.06; low certainty evidence). We downgraded the certainty of the evidence due to serious risk of bias and imprecision. For liver transplantation at one year in the trial with children, there was inconclusive evidence of effect (RR 1.23, 95% CI 0.84 to 1.81; low certainty of evidence). We downgraded the certainty of the evidence due to very serious imprecision. There was inconclusive evidence of effect on serious adverse events in the trial with children (RR 1.25, 95% CI 0.35 to 4.51; low certainty evidence). We downgraded the certainty of the evidence due to very serious imprecision. We did not meta-analyse non-serious adverse events due to clinical heterogeneity. There was inconclusive evidence of effect on non-serious adverse events in adults (RR 1.07, 95% CI 0.79 to 1.45; 173 participants; low certainty of evidence) and children (RR 1.19, 95% CI 0.62 to 2.16; 184 participants; low certainty of evidence). None of the trials reported outcomes of proportion of participants with resolution of encephalopathy and coagulopathy or health-related quality of life. The National Institute of Health in the United States funded both trials through grants. One of the trials received additional funding from two hospital foundations' grants. Pharmaceutical companies provided the study drug and matching placebo, but they did not have input into study design nor involvement in analysis. AUTHORS' CONCLUSIONS The available evidence is inconclusive regarding the effect of N-acetylcysteine compared with placebo or no N-acetylcysteine, as an adjunct to usual care, on mortality or transplant rate in non-paracetamol-induced acute liver failure. Current evidence does not support the guideline suggestion to use N-acetylcysteine in adults with non-paracetamol-related acute liver failure, nor the rising use observed in clinical practice. The uncertainty based on current scanty evidence warrants additional randomised clinical trials with non-paracetamol-related acute liver failure evaluating N-acetylcysteine versus placebo, as well as investigations to identify predictors of response and the optimal N-acetylcysteine dose and duration.
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Affiliation(s)
- Jacky Tp Siu
- Lower Mainland Pharmacy Services, Fraser Health Authority, Vancouver, Canada
| | | | - Ricky D Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, Canada
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11
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Casey LC, Fontana RJ, Aday A, Nelson DB, Rule JA, Gottfried M, Tran M, Lee WM. Acute Liver Failure (ALF) in Pregnancy: How Much Is Pregnancy Related? Hepatology 2020; 72:1366-1377. [PMID: 31991493 PMCID: PMC7384942 DOI: 10.1002/hep.31144] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 01/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Acute liver failure (ALF), characterized by sudden onset of coagulopathy (international normalized ratio [INR] ≥ 1.5) and encephalopathy, may occur during pregnancy either as a pregnancy-associated etiology or an unrelated and coincidental liver injury. The U.S. Acute Liver Failure Study Group, comprised of 33 tertiary care liver centers, has enrolled consecutive patients with ALF or acute liver injury (ALI; INR ≥ 2.0 with no encephalopathy), over two decades. APPROACH AND RESULTS Etiologies, clinical features, and outcomes of 70 of 3,155 patients (2.2%) who developed ALF or ALI during pregnancy were reviewed to determine how many were pregnancy associated (pregnancy-associated liver disease; PAALD) and how many were attributed to other etiologies. Thirty-five of the 70 were considered PAALD, of whom nearly half were attributed to hemolysis, elevated liver enzymes, and low platelets (HELLP) syndrome and half to acute fatty liver of pregnancy (AFLP), although, in some instances, the distinction was unclear. Virtually all with PAALD had been delivered before hepatology referral, mostly by cesarean section. Acetaminophen toxicity accounted for 21 (60% of the remaining cases), with the remainder resulting from a variety of other causes, but not including viral hepatitis A through E. Although recovery with delivery or supportive measures was possible in most cases, 11 of 70 (16%) required liver transplantation and 8 (11%) died. Swansea criteria to diagnose AFLP were met by all patients with PAALD and also by virtually all women with other forms of ALF. CONCLUSIONS Only half of those with ALF during pregnancy appeared to have HELLP or AFLP. Morbidity and mortality for mother and fetus are strongly associated with etiology of liver failure.
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Affiliation(s)
- Lisa C. Casey
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Robert J. Fontana
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI
| | - Ariel Aday
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - David B. Nelson
- Department of Obstetrics and Gynecology, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Jody A. Rule
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston SC
| | - Minh Tran
- Department of Medicine, University of Texas Medical Branch, Galveston TX
| | - William M. Lee
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center at Dallas, Dallas TX
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12
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Van de Louw A, Twomey K, Habecker N, Rakszawski K. Prevalence of acute liver dysfunction and impact on outcome in critically ill patients with hematological malignancies: a single-center retrospective cohort study. Ann Hematol 2020; 100:229-237. [PMID: 32918593 DOI: 10.1007/s00277-020-04197-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 07/20/2020] [Indexed: 12/20/2022]
Abstract
Patients with hematological malignancies (HM) often require ICU admission, and acute respiratory or renal failure are then independent risk factors for mortality. Data are scarce on acute liver dysfunction (ALD), despite HM patients cumulating risk factors. The objective of this retrospective cohort study was to assess the prevalence of ALD in critically ill HM patients and its impact on outcome. Data of all patients with HM admitted to the medical ICU between 2008 and 2018 were extracted from electronic medical records. ALD was defined by ALT > 165 U/L, AST > 230 U/L, or total bilirubin > 4 mg/dL. Univariate and multivariate logistic regressions were used to analyze hospital mortality. Charts of survivors with ALD were reviewed to assess impact of ALD on subsequent anti-cancer treatment. We included 971 patients (60% male), age 64 (54-72) years, of whom 196 (20%) developed ALD. ALD patients were younger, more frequently had liver cirrhosis or acute leukemia, and had increased severity of illness and vital organ support needs. ALD was associated with hospital mortality in univariate (OR 4.14, 95% CI 2.95-5.80, p < 0.001) and multivariate analysis (OR 1.86, 95% CI 1.07-3.24, p = 0.03). Hospital mortality was 46% in ALD patients; among 106 survivors, a third of patients requiring therapy received it as previously planned, and half of the patients were alive at 1 year. In summary, in a large population of critically ill patients with hematological malignancies, 20% developed ALD, which was an independent risk factor for hospital mortality and occasionally altered further anti-cancer treatment.
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Affiliation(s)
- Andry Van de Louw
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA.
| | - Kathleen Twomey
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Nicholas Habecker
- Division of Pulmonary and Critical Care Medicine, Penn State Health Hershey Medical Center, 500 University Dr., Hershey, PA, 17033, USA
| | - Kevin Rakszawski
- Division of Hematology and Oncology, Penn State Health Hershey Medical Center, 500 University Dr, Hershey, PA, 17033, USA
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13
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Fujiwara K, Nakayama N, Kato N, Yokosuka O, Tsubouchi H, Takikawa H, Mochida S. Infectious complications and timing for liver transplantation in autoimmune acute liver failure in Japan: a subanalysis based on nationwide surveys between 2010 and 2015. J Gastroenterol 2020; 55:888-898. [PMID: 32556645 DOI: 10.1007/s00535-020-01699-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Accepted: 06/08/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prognosis of autoimmune acute liver failure (ALF) without liver transplantation (LT) is poor worldwide. We subanalyzed infectious complications of autoimmune ALF using data of nationwide surveys between 2010 and 2015 retrospectively and tried to determine when to evaluate the efficacy of corticosteroid (CS) treatment or abandon it for LT based on objective data. METHODS One hundred and forty-four patients with autoimmune ALF, comprising 79 ALF with coma ≤ I, 52 ALF with coma ≥ II and 13 late onset hepatic failure (LOHF), were analyzed. RESULTS CS was administered to 140 (97%) patients. Thirty-seven (26%) patients had infectious complications. Patients with infection revealed more advanced disease type (p < 0.001) and poorer spontaneous survival (p < 0.001) than those without infection. Median (interquartile range) duration between diagnosis of ALF and onset of infection was 18.5 (11-36) days, and that between introduction of CS and onset of infection was 17 (10.5-36) days. Seventy-nine (55%) recovered without LT, 14 (10%) received LT and 51 (35%) died without LT. Dead or transplanted patients were older (p = 0.0057), and revealed more advanced liver failure (p < 0.001) and more occurrence of infection (p < 0.001). CONCLUSIONS A critical point for evaluating the efficacy of CS treatment and switching to LT is at most 2-week after diagnosis of ALF and introduction of CS. More important, we should accelerate the point and prepare for LT in cases of ALF with coma ≥ II and LOHF, and we should have performed LT by then at the latest in case of failure to improve.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan.
- Faculty of Healthcare Sciences, Chiba Prefectural University of Health Sciences, Chiba, Japan.
| | - Nobuaki Nakayama
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1 Inohana, Chuo-ku, Chiba, Japan
| | | | - Hajime Takikawa
- Faculty of Medical Technology, Teikyo University, Tokyo, Japan
| | - Satoshi Mochida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
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14
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Yu H, Chen Y, Jiang P. Prognostic value of hepatic encephalopathy for survival of patients with liver failure: A systematic review and meta-analysis. Ann Hepatol 2020; 18:607-612. [PMID: 31085039 DOI: 10.1016/j.aohep.2019.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 01/14/2019] [Accepted: 11/29/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND OBJECTIVES The aim of this paper was to evaluate the association of hepatic encephalopathy with survival of patients with liver failure. MATERIALS AND METHODS We retrieved the relevant articles from the PubMed, Embase and Cochrane Library, up to May 2017. The pooled odds ratio (OR) as well as their 95% confidence intervals (CI) was calculated by the software of R package version 3.12. RESULTS Total 13 studies with 2071 liver failure patients were included and reanalyzed in this meta-analysis. The results proved the prognostic value of hepatic encephalopathy for survival of patients with liver failure (OR=5.62, 95%CI=6.30-9.82, P<0.001). The subgroup analyses showed that the type of liver failure and the follow up duration may be the factor influencing the association between hepatic encephalopathy and survival of patients with liver failure. CONCLUSIONS The results proved that hepatic encephalopathy was a prognostic factor of survival in patients with liver failure.
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Affiliation(s)
- Hanqing Yu
- Department of Emergency, Shanghai Pulmonary Hospital of Tongji University, Shanghai, China
| | - Yu Chen
- Department of Emergency, Shanghai Pulmonary Hospital of Tongji University, Shanghai, China
| | - Ping Jiang
- Department of Emergency, Shanghai Pulmonary Hospital of Tongji University, Shanghai, China.
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15
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Abstract
Neonatal acute liver failure (NALF) is a rare disease with a few known primary causes: gestational alloimmune liver disease (GALD), viral infections, metabolic diseases, and ischemic injury. Many cases still do not have a known cause. Laboratory evaluation may suggest a diagnosis. Most of the known causes have disease-specific treatments that improve outcomes. Survival is improving with better knowledge about and treatment options for GALD; however, overall mortality for NALF is still 24%. Liver transplant remains an important option for neonates with an indeterminate cause of NALF and those who do not respond to established treatments.
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Affiliation(s)
- Catherine Larson-Nath
- Pediatric Gastroenterology, Hepatology & Nutrition, University of Minnesota, 2450 Riverside Avenue, Minneapolis, MN 55454, USA
| | - Bernadette E Vitola
- Pediatric Gastroenterology, Hepatology & Nutrition, Medical College of Wisconsin, 8701 Watertown Plank Road, Milwaukee, WI 53226, USA.
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16
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Tan EXX, Wang MX, Pang J, Lee GH. Plasma exchange in patients with acute and acute-on-chronic liver failure: A systematic review. World J Gastroenterol 2020; 26:219-245. [PMID: 31988586 PMCID: PMC6962432 DOI: 10.3748/wjg.v26.i2.219] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 12/21/2019] [Accepted: 01/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) and acute-on-chronic liver (ACLF) carry high short-term mortality rate, and may result from a wide variety of causes. Plasma exchange has been shown in a randomized control trial to improve survival in ALF especially in patients who did not receive a liver transplant. Other cohort studies demonstrated potential improvement in survival in patients with ACLF.
AIM To assess utility of plasma exchange in liver failure and its effect on mortality in patients who do not undergo liver transplantation.
METHODS Databases MEDLINE via PubMed, and EMBASE were searched and relevant publications up to 30 March, 2019 were assessed. Studies were included if they involved human participants diagnosed with liver failure who underwent plasma exchange, with or without another alternative non-bioartificial liver assist device.
RESULTS Three hundred twenty four records were reviewed, of which 62 studies were found to be duplicates. Of the 262 records screened, 211 studies were excluded. Fifty-one articles were assessed for eligibility, for which 7 were excluded. Twenty-nine studies were included for ALF only, and 9 studies for ACLF only. Six studies included both ALF and ACLF patients. A total of 44 publications were included. Of the included publications, 2 were randomized controlled trials, 14 cohort studies, 12 case series, 16 case reports. All of three ALF studies which looked at survival rate or survival days reported improvement in outcome with plasma exchange. In two out of four studies where plasma exchange-based liver support systems were compared to standard medical treatment (SMT) for ACLF, a biochemical improvement was seen. Survival in the non-transplanted patients was improved in all four studies in patients with ACLF comparing plasma exchange vs SMT. Using the aforementioned studies, plasma exchange based therapy in ACLF compared to SMT improved survival in non-transplanted patients at 30 and 90-d with a pooled OR of 0.60 (95%CI 0.46-0.77, P < 0.01).
CONCLUSION The level of evidence for use of high volume plasma exchange in selected ALF cases is high. Plasma exchange in ACLF improves survival at 30-and 90-d in non-transplanted patients. Further well-designed randomized control trials will need to be carried out to ascertain the optimal duration and amount of plasma exchange required and assess if the use of high volume plasma exchange can be extrapolated to patients with ACLF.
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Affiliation(s)
| | - Min-Xian Wang
- Centre for Infectious Disease Epidemiology and Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore
| | - Junxiong Pang
- Centre for Infectious Disease Epidemiology and Research, Saw Swee Hock School of Public Health, National University of Singapore, Singapore 119077, Singapore
| | - Guan-Huei Lee
- National University Health System, Singapore 119228, Singapore
- National University of Singapore, Singapore 119077, Singapore
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17
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Patterson J, Hussey HS, Abdullahi LH, Silal S, Goddard L, Setshedi M, Spearman W, Hussey GD, Kagina B, Muloiwa R. The global epidemiology of viral-induced acute liver failure: a systematic review protocol. BMJ Open 2019; 9:e029819. [PMID: 31473618 PMCID: PMC6720318 DOI: 10.1136/bmjopen-2019-029819] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The burden of viral-induced acute liver failure (ALF) around the world still remains unclear, with little to no data collected regarding the disease incidence in general and synthesised data on the relative contribution of different viruses to the aetiology of ALF is missing in the field. The aim of this review is to estimate the burden (prevalence, incidence, mortality, hospitalisation) of ALF following infection HAV, HBV, HCV, HDV, HEV, EBV), HSV1, HSV2, VZV, parvo-virus B19, HPIVs, YFV, HVV-6, CMV, CA16 and/or HAdVs. Establishing the common aetiologies of viral-induced ALF, which vary geographically, is important so that: (1) treatment can be initiated quickly, (2) contraindications to liver transplant can be identified, (3) prognoses can be deterined more accurately, and most importantly, (4) vaccination against viral ALF aetiologies can be prioritised especially in under-resourced regions with public health risks associated with the relevant attributable diseases. METHODS AND ANALYSIS EBSCOhost, PubMed, ScienceDirect, Scopus and Web of Science databases will be searched for relevant literature published and grey literature from 2009 up to 2019. Published cross-sectional and cohort studies will be eligible for inclusion in this review. Qualifying studies will be formally assessed for quality and risk of bias using a standardised scoring tool. Following standardised data extraction, meta-analyses will be carried out using STATA. Depending on characteristics of included studies, subgroup analyses and meta-regression analyses will be performed. This review will be reported according to Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. ETHICS AND DISSEMINATION No ethics approval is required as the systematic review will use only published data already in the public domain. Findings will be disseminated through publication in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42018110309.
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Affiliation(s)
- Jenna Patterson
- Vaccines for Africa Initiative, University of Cape Town, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Hannah Sophia Hussey
- Vaccines for Africa Initiative, University of Cape Town, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Leila Hussein Abdullahi
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
- Somaliland Country Office, Save the Children International, Nairobi, Kenya
| | - Sheetal Silal
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
- Modelling and Simulation Hub Africa, University of Cape Town, Cape Town, South Africa
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Liz Goddard
- Department of Paediatrics, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Mashiko Setshedi
- Department of Medicine, Division of Gastroenterology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Wendy Spearman
- Department of Medicine, Division of Hepatology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Gregory D Hussey
- Vaccines for Africa Initiative, University of Cape Town, Cape Town, South Africa
- Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - Benjamin Kagina
- Vaccines for Africa Initiative, University of Cape Town, Cape Town, South Africa
- School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Rudzani Muloiwa
- Vaccines for Africa Initiative, University of Cape Town, Cape Town, South Africa
- Department of Paediatrics, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
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Mouchiroud M, Camiré É, Aldow M, Caron A, Jubinville É, Turcotte L, Kaci I, Beaulieu MJ, Roy C, Labbé SM, Varin TV, Gélinas Y, Lamothe J, Trottier J, Mitchell PL, Guénard F, Festuccia WT, Joubert P, Rose CF, Karvellas CJ, Barbier O, Morissette MC, Marette A, Laplante M. The hepatokine Tsukushi is released in response to NAFLD and impacts cholesterol homeostasis. JCI Insight 2019; 4:129492. [PMID: 31391339 PMCID: PMC6693835 DOI: 10.1172/jci.insight.129492] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 06/27/2019] [Indexed: 12/14/2022] Open
Abstract
Nonalcoholic fatty liver disease (NAFLD) prevails in obesity and is linked to several health complications including dyslipidemia and atherosclerosis. How exactly NAFLD induces atherogenic dyslipidemia to promote cardiovascular diseases is still elusive. Here, we identify Tsukushi (TSK) as a hepatokine induced in response to NAFLD. We show that both endoplasmic reticulum stress and inflammation promote the expression and release of TSK in mice. In humans, hepatic TSK expression is also associated with steatosis, and its circulating levels are markedly increased in patients suffering from acetaminophen-induced acute liver failure (ALF), a condition linked to severe hepatic inflammation. In these patients, elevated blood TSK levels were associated with decreased transplant-free survival at hospital discharge, suggesting that TSK could have a prognostic significance. Gain- and loss-of-function studies in mice revealed that TSK impacts systemic cholesterol homeostasis. TSK reduces circulating HDL cholesterol, lowers cholesterol efflux capacity, and decreases cholesterol-to-bile acid conversion in the liver. Our data identify the hepatokine TSK as a blood biomarker of liver stress that could link NAFLD to the development of atherogenic dyslipidemia and atherosclerosis.
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Affiliation(s)
- Mathilde Mouchiroud
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Étienne Camiré
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Manal Aldow
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Alexandre Caron
- Division of Hypothalamic Research, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Éric Jubinville
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Laurie Turcotte
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Inès Kaci
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Marie-Josée Beaulieu
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Christian Roy
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Sébastien M. Labbé
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
- IPS Thérapeutique, Sherbrooke, Québec, Canada
| | - Thibault V. Varin
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
- Institut sur la Nutrition et les Aliments Fonctionnels (INAF), Université Laval, Québec City, Québec, Canada
| | - Yves Gélinas
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Jennifer Lamothe
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Jocelyn Trottier
- Laboratory of Molecular Pharmacology, Endocrinology-Nephrology Axis, Centre de Recherche du Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
- Faculty of Pharmacy, Université Laval, Québec City, Québec, Canada
| | - Patricia L. Mitchell
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Frédéric Guénard
- Institut sur la Nutrition et les Aliments Fonctionnels (INAF), Université Laval, Québec City, Québec, Canada
| | - William T. Festuccia
- Department of Physiology and Biophysics, Institute of Biomedical Sciences, University of São Paulo, São Paulo, Brazil
| | - Philippe Joubert
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
| | - Christopher F. Rose
- Hepato-Neuro Laboratory, Centre Hospitalier de l’Université de Montréal (CRCHUM), Montréal, Québec, Canada
| | - Constantine J. Karvellas
- Liver Unit, Division of Gastroenterology, Department of Critical Care Medicine, School of Public Health Science, University of Alberta, Edmonton, Alberta, Canada
| | - Olivier Barbier
- Laboratory of Molecular Pharmacology, Endocrinology-Nephrology Axis, Centre de Recherche du Centre Hospitalier Universitaire de Québec, Québec City, Québec, Canada
- Faculty of Pharmacy, Université Laval, Québec City, Québec, Canada
| | - Mathieu C. Morissette
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
- Département de Médecine and
| | - André Marette
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
- Institut sur la Nutrition et les Aliments Fonctionnels (INAF), Université Laval, Québec City, Québec, Canada
- Département de Médecine and
| | - Mathieu Laplante
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de Québec – Université Laval (CRIUCPQ), Québec City, Québec, Canada
- Département de Médecine and
- Centre de Recherche sur le Cancer de l’Université Laval, Université Laval, Québec City, Québec, Canada
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He YT, Qi YN, Zhang BQ, Li JB, Bao J. Bioartificial liver support systems for acute liver failure: A systematic review and meta-analysis of the clinical and preclinical literature. World J Gastroenterol 2019; 25:3634-3648. [PMID: 31367162 PMCID: PMC6658398 DOI: 10.3748/wjg.v25.i27.3634] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/03/2019] [Accepted: 06/01/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Acute liver failure (ALF) has a high mortality varying from 80% to 85% with rapid progress in multi-organ system failure. Bioartificial liver (BAL) support systems have the potential to provide temporary support to bridge patients with ALF to liver transplantation or spontaneous recovery. In the past decades, several BAL support systems have been conducted in clinical trials. More recently, concerns have been raised on the renovation of high-quality cell sources and configuration of BAL support systems to provide more benefits to ALF models in preclinical experiments.
AIM To investigate the characteristics of studies about BAL support systems for ALF, and to evaluate their effects on mortality.
METHODS Eligible clinical trials and preclinical experiments on large animals were identified on Cochrane Library, PubMed, and EMbase up to March 6, 2019. Two reviewers independently extracted the necessary information, including key BAL indicators, survival and indicating outcomes, and adverse events during treatment. Descriptive analysis was used to identify the characteristics of the included studies, and a meta-analysis including only randomized controlled trial (RCT) studies was done to calculate the overall effect of BAL on mortality among humans and large animals, respectively.
RESULTS Of the 30 selected studies, 18 were clinical trials and 12 were preclinical experiments. The meta-analysis result suggested that BAL might reduce mortality in ALF in large animals, probably due to the recent improvement of BAL, including the type, cell source, cell mass, and bioreactor, but seemed ineffective for humans [BAL vs control: relative risk (95% confidence interval), 0.27 (0.12-0.62) for animals and 0.72 (0.48-1.08) for humans]. Liver and renal functions, hematologic and coagulative parameters, encephalopathy index, and neurological indicators seemed to improve after BAL, with neither meaningful adverse events nor porcine endogenous retrovirus infection.
CONCLUSION BAL may reduce the mortality of ALF by bridging the gap between preclinical experiments and clinical trials. Clinical trials using improved BAL must be designed scientifically and conducted in the future to provide evidence for transformation.
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Affiliation(s)
- Yu-Ting He
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ya-Na Qi
- Chinese Evidence-based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Bing-Qi Zhang
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Jian-Bo Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
| | - Ji Bao
- Laboratory of Pathology, Key Laboratory of Transplant Engineering and Immunology, NHC, West China Hospital, Sichuan University, Chengdu 610041, Sichuan Province, China
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20
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Spivak I, Arora J, Meinzer C, Durkalski-Mauldin V, Lee WM, Trautwein C, Fontana RJ, Strnad P. Low Serum Hepcidin Is Associated With Reduced Short-Term Survival in Adults With Acute Liver Failure. Hepatology 2019; 69:2136-2149. [PMID: 30582749 DOI: 10.1002/hep.30486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 12/10/2018] [Indexed: 12/19/2022]
Abstract
The liver has an important role in iron homeostasis through the synthesis of the serum transporter transferrin and the iron hormone hepcidin. The aim of this study was to analyze parameters of iron metabolism in a multicenter cohort of adult patients with acute liver failure (ALF) and in an acetaminophen (APAP)-induced ALF mouse model. A representative subset of 121 adults with ALF (including 66 APAP-related patients) had baseline serum samples tested for ferritin, transferrin, iron, and hepcidin. Outcomes at 3 weeks after enrollment were categorized as spontaneous survivor (SS) versus death/transplantation (NSS). Mice were assessed before (controls) and 4 and 18 hours after injection of 300 mg/kg APAP. Patients with ALF as well as APAP-treated mice displayed increased ferritin and diminished serum hepcidin and hepcidin/ferritin ratio. SS had lower iron (29.1% vs. 34.5 µmol/L; P < 0.05) and transferrin saturation (60.9% vs. 79.1%; P < 0.01), but higher hepcidin levels (8.2 vs. 2.7 ng/mL; P < 0.001) and hepcidin/ferritin ratio (0.0047 vs. 0.0009; P < 0.001) than NSS. In a multivariate analysis, a log-transformed hepcidin-containing model displayed similar prognostic power as the established Acute Liver Failure Study Group index (C-statistic 0.87 vs. 0.85) and was better than Model for End-Stage Liver Disease score (C-statistic 0.76). In mice, hepcidin levels inversely correlated with the surrogate of liver injury. Conclusion: Our findings demonstrate that several serum iron parameters significantly associate with 3-week outcomes in adults with ALF. Among them, hepcidin decreases early during experimental APAP-induced ALF, is an independent predictor and might be a useful component of future prognostic scores.
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Affiliation(s)
- Igor Spivak
- Medical Clinic III, University Hospital Aachen, Aachen, Germany
| | - Jyoti Arora
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Caitlyn Meinzer
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | | | - William M Lee
- UT Southwestern Medical Center at Dallas, Dallas, TX
| | | | | | - Pavel Strnad
- Medical Clinic III, University Hospital Aachen, Aachen, Germany
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Mainardi V, Rando K, Valverde M, Olivari D, Castelli J, Rey G, Gerona S. Acute Liver Failure due to Wilson Disease: Eight Years of the National Liver Transplant Program in Uruguay. Ann Hepatol 2019; 18:187-192. [PMID: 31113589 DOI: 10.5604/01.3001.0012.7911] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 07/04/2018] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIM Wilson's disease (WD) is an uncommon cause of acute liver failure (ALF). Our aim was to describe clinical features, diagnostic findings, treatments, and outcomes of patients with ALF due to WD. MATERIAL AND METHODS Retrospective medical record reviews of all patients with ALF due to WD in eight years in Uruguay. RESULTS WD was the cause of six (15%) of thirty-nine ALF cases. All patients were females, with a mean age of 18 years. Four patients presented with hyperacute liver failure and two with acute failure. Jaundice was the main complaint of all patients. Mean total bilirubin (TB), alkaline phosphatase (AP), AST, and ALT were 27.5 mg/dL, 45.5 lU/l, 156 IU/L, and 51 IU/L, respectively. Ceruloplasmin levels were low in four patients, urinary cooper was high in four, and two had Kayser-Fleischer rings. All patients had Coombs-negative hemolytic anemia, acute kidney injury, histochemical identifiable copper, and advanced fibrosis on liver histology. The average MELD score was 36. All patients were treated with d-penicillamine and listed for urgent liver transplantation (LT). Prometheus® was performed in one patient. Three patients died: two without LT and one after LT. Three patients survived: one without LT (New Wilson Index<11) and two with LT. The referral time to the program and the total time (referral plus waiting list time) were longer for non-survivors than for survivors (14 vs. 3 days and 23 vs. 8 respectively). CONCLUSION All cases had typical clinical, analytical and histopathology characteristics. Early referral was determinant of prognosis.
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Affiliation(s)
- Victoria Mainardi
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay.
| | - Karina Rando
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
| | - Marcelo Valverde
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
| | - Daniela Olivari
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
| | - Jorge Castelli
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
| | - Gabriela Rey
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
| | - Solange Gerona
- Hepatic Biliary and Pancreatic National Center - Teaching and Assistance Unit (UDA) and Bi-Intuitional Unit of Liver Transplantation, Military Hospital, Montevideo, Uruguay
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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de Martino RB, Abdala E, Villegas FC, D’Albuquerque LAC, Song ATW. Liver transplantation for acute liver failure due to antitubercular drugs - a single-center experience. Clinics (Sao Paulo) 2018; 73:e344. [PMID: 30020340 PMCID: PMC6015261 DOI: 10.6061/clinics/2018/e344] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 02/22/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Patients receiving treatment for tuberculosis are at risk of developing acute liver failure due to the hepatotoxicity of antitubercular drugs. We aimed to describe our experience with liver transplantation from deceased donors in this situation. METHODS We identified patients undergoing transplantation for acute liver failure due to antitubercular drugs in our prospectively maintained database. RESULTS Of 81 patients undergoing transplantation for acute liver failure, 8 cases were attributed to antitubercular drugs during the period of 2006-2016. Regarding the time of tuberculosis treatment until the onset of jaundice, patients were on antitubercular drugs for a mean of 64.7 days (21-155 days). The model for end-stage liver disease (MELD) score of patients ranged from 32 to 47 (median 38), and seven patients underwent transplantation under vasopressors. The 1-year survival was 50%. Three patients died during the week following transplantation due to septic shock (including a patient with acute liver failure due to hepatic/disseminated tuberculosis), and the remaining patient died 2 months after transplantation due to pulmonary infection. There were 2 cases of mild rejection and 1 case of moderate rejection. Of the surviving patients, all were considered cured of tuberculosis after alternative drugs were given. CONCLUSION Patients arrived very sick and displayed poor survival after deceased donor transplantation.
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Affiliation(s)
- Rodrigo Bronze de Martino
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Edson Abdala
- Laboratorio de Hepatite Virais – LIM-47, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Departamento de Doencas Infecciosas, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Felipe Castro Villegas
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Luiz Augusto Carneiro D’Albuquerque
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Transplante e Cirurgia de Figado - LIM-37, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Alice Tung Wan Song
- Disciplina de Transplante de Figado e Orgaos do Aparelho Digestivo, Departamento de Gastroenterologia, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Laboratorio de Transplante e Cirurgia de Figado - LIM-37, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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Alsina A, Alsina A, Athienitis A, Buggs J, Aslam S, Kemmer N. Is Fulminant Hepatic Failure the Nemesis for Liver Transplant Centers? A Two Decade Psychosocial and Long-Term Outcome Study. Am Surg 2018; 84:1197-1203. [PMID: 30064588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Long-term outcomes in liver transplantation for acute liver failure (ALF) are poorly studied. The aim of the study was to identify psychosocial variables that affect adherence and late survival. Retrospective review of ALF liver transplant (LTx) patients between 1997 and 2017 (n = 47) was conducted. Psychosocial history, life stressors, and ability to participate in transplant were recorded. Survival was calculated using Kaplan-Meier and logistic regression. Eleven patients (31.5%) had poor adherence, four died, all from graft failure. Of 13 with fair and 12 with good adherence, two died, no adherence related. Poor adherence was associated with higher mortality (P = 0.04), but by Kaplan-Meier, their five- and 10-year survival was 78 and 54 per cent, versus fair and good adherence (five years, 83% P = 0.3). Participating in transplant decision improved survival (five years, 80%) versus not participating (five years, 61%; P = 0.03). Of 10 early deaths, three were neurologic and five of sepsis. Overall, one- and five-year survival was 78 and 69 per cent. ALF represents the nemesis of LTx programs. Psychosocial aspects pre-LTx, stressors, and poor adherence affected survival in this series. No improvement over two decades of ALF LTxs was observed. The ethics of transplanting these high-risk patients will be the subject of our future research.
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Fujiwara K, Yasui S, Haga Y, Nakamura M, Yonemitsu Y, Arai M, Kanda T, Oda S, Yokosuka O, Kato N. Early Combination Therapy with Corticosteroid and Nucleoside Analogue Induces Rapid Resolution of Inflammation in Acute Liver Failure due to Transient Hepatitis B Virus Infection. Intern Med 2018; 57:1543-1552. [PMID: 29321429 PMCID: PMC6028684 DOI: 10.2169/internalmedicine.9670-17] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective Patients with acute hepatitis B sometimes develop acute liver failure (ALF), which has a poor prognosis. The efficacy of nucleoside analogue (NA) monotherapy for ALF due to transient hepatitis B virus infection (HBV-ALF) remains controversial. Further investigations are necessary in nations with a shortage of donor livers for liver transplantation. In the present study, we aimed to clarify the efficacy of combination therapy with corticosteroid (CS) and NA in the treatment HBV-ALF. Patients We examined the clinical and biochemical features of 19 patients with HBV-ALF who were treated in the early stage of the disease between 2000 and 2015. Results Fourteen patients received CS and NA (CS + NA group) and 5 received NA monotherapy (NA group). Eleven patients (58%) survived and 8 (42%) died. The survival rates in the CS + NA and NA groups were 64% and 40%, respectively (p=0.60). The mean alanine aminotransferase (ALT) levels declined significantly at week 2 in both groups. The mean PT activities improved significantly at weeks 1 and 2 in the CS + NA group (p<0.05) but not in the NA group. None of the surviving patients developed persistent infection. Conclusion Combination therapy with CS and NA induces the rapid resolution of inflammation leading to a rapid recovery of the liver function. When it is administered at a sufficiently early stage, it would have a survival benefit and prevent persistent infection in HBV-ALF.
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Affiliation(s)
- Keiichi Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Shin Yasui
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Yuuki Haga
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Yutaka Yonemitsu
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Makoto Arai
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Tatsuo Kanda
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Shigeto Oda
- Department of Emergency and Critical Care Medicine, Graduate School of Medicine, Chiba University, Japan
| | - Osamu Yokosuka
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, Japan
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Kim YJ, Lee HJ, Ryoo SM, Ahn S, Sohn CH, Seo DW, Lim KS, Kim WY. Prognostic value of decision criteria for emergency liver transplantation in patients with wild mushroom induced acute liver injury. Hepatobiliary Pancreat Dis Int 2018; 17:210-213. [PMID: 29739648 DOI: 10.1016/j.hbpd.2018.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 03/21/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND The reported mortality rate of mushroom-induced acute liver failure with conventional treatment is 1.4%-16.9%. Emergency liver transplantation may be indicated and can be the only curative treatment option. This study aimed to assess the prognostic value of criteria for emergency liver transplantation in predicting 28-day mortality in patients with mushroom-induced acute liver injury. METHODS A retrospective cohort study was performed between January 2005 and December 2015. All adult patients aged≥18 years admitted with mushroom intoxication at our emergency department were evaluated. All patients with acute liver injury, defined as elevation of serum liver enzymes (>5 times the upper limit of normal, ULN) or moderate coagulopathy (INR > 2.0) were included. The ability of the King's College, Ganzert's, and Escudié's criteria to predict 28-day mortality was evaluated. RESULTS Of the 23 patients with acute liver injury following mushroom intoxication, 10 (43.5%) developed acute liver failure and subsequently died. The mean time interval from ingestion to death was 11.3 ± 6.6 days. Eight patients fulfilled Ganzert's criteria, while 10 patients fulfilled the King's College and Escudié's criteria for emergency liver transplantation. King's College and Escudié's criteria had 100% accuracy in predicting 28-day mortality; however, Escudié's criteria were able to identify fatal cases earlier. CONCLUSIONS Escudié's criteria demonstrated the best performance with 100% accuracy and the ability to promptly identify fatal cases of mushroom-induced acute liver failure.
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Affiliation(s)
- Youn-Jung Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Hyung Joo Lee
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Shin Ahn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Dong-Woo Seo
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea
| | - Won Young Kim
- Department of Emergency Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul 05505, Korea.
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Stravitz RT, Ellerbe C, Durkalski V, Schilsky M, Fontana RJ, Peterseim C, Lee WM. Bleeding complications in acute liver failure. Hepatology 2018; 67:1931-1942. [PMID: 29194678 PMCID: PMC5906191 DOI: 10.1002/hep.29694] [Citation(s) in RCA: 67] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/09/2017] [Accepted: 11/27/2017] [Indexed: 01/09/2023]
Abstract
In patients with acute liver failure (ALF), elevated prothrombin time and thrombocytopenia can fuel a perception of a bleeding tendency. However, the incidence, site, risk factors, and clinical significance of bleeding complications have not been quantified in a large cohort of patients with ALF. We studied 1,770 adult patients enrolled in the ALF Study Group Registry between 1998 and 2016. Bleeding complications and blood component transfusions were collected for 7 days after admission. The relationship of bleeding complications to 21-day mortality was assessed. Despite a median international normalized ratio of 2.7 and platelet count of 96 × 109 /L on admission, bleeding complications were observed in only 187 patients (11%), including 173 spontaneous and 22 postprocedural bleeding episodes. Eighty-four percent of spontaneous bleeding episodes were from an upper gastrointestinal source and rarely resulted in red blood cell transfusion. Twenty patients experienced an intracranial bleed; half of these occurred spontaneously and half after intracranial pressure monitor placement, and this was the proximate cause of death in 20% and 50%, respectively. Bleeders and patients who received red blood cell transfusions were more acutely ill from extrahepatic organ system failure but not from hepatocellular failure. Consistent with this observation, bleeding complications were associated with lower platelet counts but not higher international normalized ratio. Transfusion of any blood component was associated with nearly 2-fold increased death or need for liver transplantation at day 21, but bleeding complications were the proximate cause of death in only 5% of cases. CONCLUSIONS Despite a perceived bleeding diathesis, clinically significant bleeding is uncommon in patients with ALF; bleeding complications in patients with ALF are markers of severe systemic inflammation rather than of coagulopathy and so portend a poor prognosis. (Hepatology 2018;67:1931-1942).
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Affiliation(s)
- R. Todd Stravitz
- Hume-Lee Transplant Center of Virginia Commonwealth University, Richmond, VA
| | - Caitlyn Ellerbe
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - Valerie Durkalski
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - Michael Schilsky
- Division of Gastroenterology and Hepatology, Yale University, New Haven, CT
| | | | - Carolyn Peterseim
- Department of Biostatistics, Medical University of South Carolina, Charleston, SC
| | - William M. Lee
- University of Texas-Southwestern Medical Center, Dallas, TX
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Buechter M, Manka P, Heinemann FM, Lindemann M, Baba HA, Schlattjan M, Canbay A, Gerken G, Kahraman A. Potential triggering factors of acute liver failure as a first manifestation of autoimmune hepatitis-a single center experience of 52 adult patients. World J Gastroenterol 2018; 24:1410-1418. [PMID: 29632422 PMCID: PMC5889821 DOI: 10.3748/wjg.v24.i13.1410] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 02/21/2018] [Accepted: 03/03/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate potential triggering factors leading to acute liver failure (ALF) as the initial presentation of autoimmune hepatitis (AIH). METHODS A total of 565 patients treated at our Department between 2005 and 2017 for histologically-proven AIH were retrospectively analyzed. However, 52 patients (9.2%) fulfilled the criteria for ALF defined by the "American Association for the Study of the Liver (AASLD)". According to this definition, patients with "acute-on-chronic" or "acute-on-cirrhosis" liver failure were excluded. Following parameters with focus on potential triggering factors were evaluated: Patients' demographics, causation of liver failure, laboratory data (liver enzymes, MELD-score, autoimmune markers, virus serology), liver histology, immunosuppressive regime, and finally, outcome of our patients. RESULTS The majority of patients with ALF were female (84.6%) and mean age was 43.6 ± 14.9 years. Interestingly, none of the patients with ALF was positive for anti-liver kidney microsomal antibody (LKM). We could identify potential triggering factors in 26/52 (50.0%) of previously healthy patients presenting ALF as their first manifestation of AIH. These were drug-induced ALF (57.7%), virus-induced ALF (30.8%), and preceding surgery in general anesthesia (11.5%), respectively. Unfortunately, 6 out of 52 patients (11.5%) did not survive ALF and 3 patients (5.7%) underwent liver transplantation (LT). Comparing data of survivors and patients with non-recovery following treatment, MELD-score (P < 0.001), age (P < 0.05), creatinine (P < 0.01), and finally, ALT-values (P < 0.05) reached statistical significance. CONCLUSION Drugs, viral infections, and previous surgery may trigger ALF as the initial presentation of AIH. Advanced age and high MELD-score were associated with lethal outcome.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
- Division of Transplantation Immunology and Mucosal Biology, King’s College, London SE59RJ, United Kingdom
| | | | - Monika Lindemann
- Institute of Transfusion Medicine, University Clinic of Essen, Essen 45147, Germany
| | - Hideo Andreas Baba
- Institute of Pathology, University Clinic of Essen, Essen 45147, Germany
| | - Martin Schlattjan
- Institute of Pathology, University Clinic of Essen, Essen 45147, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology, and Infectious Diseases, Otto-von-Guericke University, Magdeburg 39120, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Clinic of Essen, Essen 45147, Germany
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Nguyen V. Calculated decisions: King's College Criteria for Acetaminophen Toxicity. Emerg Med Pract 2018; 20:S1-S2. [PMID: 29617548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Vincent Nguyen
- Department of Emergency Medicine, Jacobi Medical Center, Albert Einstein College of Medicine, Bronx, New York
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Mainardi V, Rando K, Olivari D, Rey G, Castelli J, Grecco G, Leites A, Harguindeguy M, Gerona S. Mortality Analysis of Acute Liver Failure in Uruguay. Transplant Proc 2018; 50:465-471. [PMID: 29579829 DOI: 10.1016/j.transproceed.2017.12.037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 12/14/2017] [Accepted: 12/15/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Acute liver failure (ALF) is a syndrome with high mortality. OBJECTIVE Describe characteristics and outcomes of patients with ALF in Uruguay, and identify factors associated with mortality. METHODS A retrospective analysis of 33 patients with ALF was performed between 2009 and 2017. RESULTS The patients' median age was 43 years, and 64% were women. Average Model for End-Stage Liver Disease (MELD) score at admission was 33. The median referral time to the liver transplant (LT) center was 7 days. The most common etiologies were viral hepatitis (27%), indeterminate (21%), autoimmune (18%), and Wilson disease (15%). Overall mortality was 52% (71% of transplanted and 46% of nontransplanted patients). Dead patients had higher referral time (10 vs 4 days, P = .008), higher MELD scores at admission (37 vs 28) and highest achieved MELD scores (42 vs 29; P < .001), and higher encephalopathy grade III to IV (94% vs 25%, P < .001) than survivors. Patients without LT criteria (n = 4) had lower MELD score at admission (25 vs 34, P = .001) and highest achieved MELD score (27 vs 37, P = .008) compared with the others. Patients with LT criteria but contraindications (n = 7) had higher MELD scores at admission (38 vs 31, P = .02), highest achieved MELD scores (41 vs 34, P = .03), and longer referral time (10 days) than those without contraindications (3.5 days) or those without LT criteria (7.5 days, P = .02). Twenty-two patients were listed; LT was performed in 7, with a median time on waiting list of 6 days. CONCLUSIONS ALF in Uruguay has high mortality associated with delayed referral to the LT center, MELD score, and encephalopathy. The long waiting times to transplantation might influence mortality.
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Affiliation(s)
- V Mainardi
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay.
| | - K Rando
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - D Olivari
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - G Rey
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay
| | - J Castelli
- National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - G Grecco
- National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - A Leites
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - M Harguindeguy
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
| | - S Gerona
- Hepatic Biliary and Pancreatic National Center-Teaching and Assistance Unit (UDA) from Uruguay University (UDELAR), Montevideo, Uruguay; National Liver Transplant Program, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
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Szymczak M, Kaliciński P, Kowalewski G, Broniszczak D, Markiewicz-Kijewska M, Ismail H, Stefanowicz M, Kowalski A, Teisseyre J, Jankowska I, Patkowski W. Acute liver failure in children-Is living donor liver transplantation justified? PLoS One 2018; 13:e0193327. [PMID: 29474400 PMCID: PMC5825073 DOI: 10.1371/journal.pone.0193327] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/08/2018] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Living donor liver transplantation (LDLT) in patients with acute liver failure (ALF) has become an acceptable alternative to transplantation from deceased donors (DDLT). The aim of this study was to analyze outcomes of LDLT in pediatric patients with ALF based on our center's experience. MATERIAL AND METHODS We enrolled 63 children (at our institution) with ALF who underwent liver transplantation between 1997 and 2016. Among them 24 (38%) underwent a LDLT and 39 (62%) received a DDLT. Retrospectively analyzed patient clinical data included: time lapse between qualification for transplantation and transplant surgery, graft characteristics, postoperative complications, long-term results post-transplantation, and living donor morbidity. Overall, we have made a comparison of clinical results between LDLT and DDLT groups. RESULTS Follow-up periods ranged from 12 to 182 months (median 109 months) for LDLT patients and 12 to 183 months (median 72 months) for DDLT patients. The median waiting time for a transplant was shorter in LDLT group than in DDLT group. There was not a single case of primary non-function (PNF) in the LDLT group and 20 out of 24 patients (83.3%) had good early graft function; 3 patients (12.5%) in the LDLT group died within 2 months of transplantation but there was no late mortality. In comparison, 4 out of 39 patients (10.2%) had PNF in DDLT group while 20 patients (51.2%) had good early graft function; 8 patients (20.5%) died early within 2 months and 2 patients (5.1%) died late after transplantation. The LDLT group had a shorter cold ischemia time (CIT) of 4 hours in comparison to 9.2 hours in the DDLT group (p<0.0001). CONCLUSIONS LDLT is a lifesaving procedure for pediatric patients with ALF. Our experience showed that it may be performed with very good results, and with very low morbidity and no mortality among living donors when performed by experienced teams following strict procedures.
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Affiliation(s)
- Marek Szymczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Piotr Kaliciński
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Grzegorz Kowalewski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Dorota Broniszczak
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | | | - Hor Ismail
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Marek Stefanowicz
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Adam Kowalski
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Joanna Teisseyre
- Department of Pediatric Surgery & Organ Transplantation, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Irena Jankowska
- Department of Gastroenterology, Hepatology and Immunology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Waldemar Patkowski
- Department of General, Transplant and Liver Surgery, Warsaw Medical University, Warsaw, Poland
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Cardoso FS, Gottfried M, Tujios S, Olson JC, Karvellas CJ. Continuous renal replacement therapy is associated with reduced serum ammonia levels and mortality in acute liver failure. Hepatology 2018; 67:711-720. [PMID: 28859230 PMCID: PMC5832542 DOI: 10.1002/hep.29488] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 07/20/2017] [Accepted: 08/23/2017] [Indexed: 12/12/2022]
Abstract
Hyperammonemia has been associated with intracranial hypertension and mortality in patients with acute liver failure (ALF). We evaluated the effect of renal replacement therapy (RRT) on serum ammonia level and outcomes in ALF. This was a multicenter cohort study of consecutive ALF patients from the United States ALF Study Group registry between January 1998 and December 2016. First, we studied the association of ammonia with hepatic encephalopathy (HE) and 21-day transplant-free survival (TFS; n = 1,186). Second, we studied the effect of RRT on ammonia for the first 3 days post study admission (n = 340) and on 21-day TFS (n = 1,186). Higher admission (n = 1,186) median ammonia level was associated with grade 3-4 HE (116 vs. 83 μmol/L) and mortality at day 21 attributed to neurological (181 vs. 90 μmol/L) and all causes (114 vs. 83 μmol/L; P < 0.001 for all). Among 340 patients with serial ammonia levels, 61 (18%) were on continuous RRT (CRRT), 59 (17%) were on intermittent RRT (IRRT), and 220 (65%) received no RRT for the first 2 days. From days 1 to 3, median ammonia decreased by 38%, 23%, and 19% with CRRT, IRRT, and no RRT, respectively. Comparing to no RRT use, whereas ammonia reduction with CRRT was significant (P = 0.007), with IRRT it was not (P = 0.75). After adjusting for year of enrollment, age, etiology, and disease severity, whereas CRRT (odds ratio [OR], 0.47 [95% confidence interval {CI}, 0.26-0.82]) was associated with reduction in 21-day transplant-free all-cause mortality, IRRT (OR, 1.68 [95% CI, 1.04-2.72]) was associated with an increase. Conclusion: In a large cohort of ALF patients, hyperammonemia was associated with high-grade HE and worse 21-day TFS. CRRT was associated with a reduction in serum ammonia level and improvement of 21-day TFS. (Hepatology 2018;67:711-720).
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Affiliation(s)
- Filipe S. Cardoso
- Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal
| | - Michelle Gottfried
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, United States
| | - Shannan Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
| | - Jody C. Olson
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, United States
| | - Constantine J. Karvellas
- Departments of Critical Care and Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada
- Corresponding author/reprints: Constantine J. Karvellas MD SM FRCPC, Associate Professor of Medicine, Division of Gastroenterology (Liver Unit), Division of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G-2X8, Phone: (780) 248-1555, Fax: (780) 492-5643,
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Abstract
Acute liver failure (ALF) requires urgent attention to identify etiology and determine prognosis, in order to assess likelihood of survival or need for transplantation. Identifying idiosyncratic drug-induced liver injury (iDILI) may be particularly difficult, but the illness generally follows a subacute course, allowing time to assess outcome and find a liver graft if needed. Not all drugs that cause iDILI lead to ALF; the most common are antibiotics including anti-tuberculous medications, non-steroidal anti-inflammatory agents and herbal and dietary supplements (HDS). Determining causality remains challenging particularly if altered mentation is present; identifying the causative agent depends in part on knowing the propensity of the drugs that have been taken in the proper time interval, plus excluding other causes. In general, iDILI that reaches the threshold of ALF will more often than not require transplantation, since survival without transplant is around 25%. Treatment consists of withdrawal of the presumed offending medication, consideration of N-acetylcysteine (NAC), as well as intensive care. Corticosteroids have not proven useful except perhaps in instances of apparent autoimmune hepatitis caused by a limited number of agents. Recently developed prognostic scoring systems may also aid in predicting outcome in this setting.
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Affiliation(s)
- Shannan R Tujios
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - William M Lee
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Li YW, Zhang C, Sheng QJ, Bai H, Ding Y, Dou XG. Mesenchymal stem cells rescue acute hepatic failure by polarizing M2 macrophages. World J Gastroenterol 2017; 23:7978-7988. [PMID: 29259373 PMCID: PMC5725292 DOI: 10.3748/wjg.v23.i45.7978] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/01/2017] [Accepted: 11/01/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate whether M1 or M2 polarization contributes to the therapeutic effects of mesenchymal stem cells (MSCs) in acute hepatic failure (AHF).
METHODS MSCs were transfused into rats with AHF induced by D-galactosamine (DGalN). The therapeutic effects of MSCs were evaluated based on survival rate and hepatocyte proliferation and apoptosis. Hepatocyte regeneration capacity was evaluated by the expression of the hepatic progenitor surface marker epithelial cell adhesion molecule (EpCAM). Macrophage polarization was analyzed by M1 markers [CD68, tumor necrosis factor alpha (TNF-α), interferon-γ (IFN-γ), inducible nitric oxide synthase (INOS)] and M2 markers [CD163, interleukin (IL)-4, IL-10, arginase-1 (Arg-1)] in the survival and death groups after MSC transplantation.
RESULTS The survival rate in the MSC-treated group was increased compared with the DPBS-treated control group (37.5% vs 10%). MSC treatment protected rats with AHF by reducing apoptotic hepatocytes and promoting hepatocyte regeneration. Immunohistochemical analysis showed that MSC treatment significantly increased the expression of EpCAM compared with the control groups (P < 0.001). Expression of EpCAM in the survival group was significantly up-regulated compared with the death group after MSC transplantation (P = 0.003). Transplantation of MSCs significantly improved the expression of CD163 and increased the gene expression of IL-10 and Arg-1 in the survival group. IL-4 concentrations were significantly increased compared to the death group after MSC transplantation (88.51 ± 24.51 pg/mL vs 34.61 ± 6.6 pg/mL, P < 0.001). In contrast, macrophages showed strong expression of CD68, TNF-α, and INOS in the death group. The concentration of IFN-γ was significantly increased compared to the survival group after MSC transplantation (542.11 ± 51.59 pg/mL vs 104.07 ± 42.80 pg/mL, P < 0.001).
CONCLUSION M2 polarization contributes to the therapeutic effects of MSCs in AHF by altering levels of anti-inflammatory and pro-inflammatory factors.
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Affiliation(s)
- Yan-Wei Li
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Chong Zhang
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Qiu-Ju Sheng
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Han Bai
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Yang Ding
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
| | - Xiao-Guang Dou
- Department of Infectious Diseases, Shengjing Hospital of China Medical University, Shenyang 110022, Liaoning Province, China
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Patel N, Hoffman CM, Goldman BI, Bentley K, Burack WR, Evans AG. Green Inclusions in Neutrophils and Monocytes Are an Indicator of Acute Liver Injury and High Mortality. Acta Haematol 2017; 138:85-90. [PMID: 28813697 DOI: 10.1159/000477794] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 05/28/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Nisha Patel
- Department of Pathology and Laboratory Medicine, University of Rochester School of Medicine and Dentistry, Rochester, NY, USA
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Rodriguez K, Srivaths PR, Tal L, Watson MN, Riley AA, Himes RW, Desai MS, Braun MC, Akcan Arikan A. Regional citrate anticoagulation for continuous renal replacement therapy in pediatric patients with liver failure. PLoS One 2017; 12:e0182134. [PMID: 28792509 PMCID: PMC5549692 DOI: 10.1371/journal.pone.0182134] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Accepted: 07/12/2017] [Indexed: 01/20/2023] Open
Abstract
Pediatric liver failure patients frequently develop multiple organ failure and require continuous renal replacement therapy (CRRT) as part of supportive therapy in the pediatric intensive care unit. While many centers employ no anticoagulation for fear of bleeding complications, balanced coagulation disturbance predisposes these patients to clotting as well as bleeding, making maintenance of longer circuit life to deliver adequate dialysis clearance challenging. Regional citrate anticoagulation (RCA) is an attractive option as it avoids systemic anticoagulation, but since citrate metabolism is impaired in liver failure, concerns about toxicity has limited its use. Pediatric data on RCA with liver failure is very scarce. We aimed to establish safety and efficacy of RCA in pediatric liver failure patients on CRRT. Retrospective review of pediatric patients with liver failure receiving CRRT over 30 months. Demographic data and CRRT related data were collected by chart review. Citrate accumulation (CA) was defined as total calcium (mg/dl) /ionized calcium (mmol/L) ratio >2.5 for > 48 hours. Efficacy was assessed by filter life. Safety was assessed by frequency of adverse events ((AEs) defined as bleeding, hemodynamic instability, arrhythmias). Fifty-one patients (median age 3.5 (IQR 0.75-14.2) years) received 861 CRRT days; 70% experienced at least one episode of CA, only 37% were recorded as such in the medical record. AE rate was 93/1000 CRRT days and did not differ between CA days and others. Median filter life was 66 hours (IQR 29-74); 63% filters lasted longer than 48 hrs. Though common, CA was not associated with increased AEs on in pediatric liver failure patients on CRRT receiving RCA. Filter life was adequate. RCA appears an effective anticoagulation for CRRT in pediatric liver failure. Application of a structured definition would increase recognition of CA to allow timely intervention.
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Affiliation(s)
- Keila Rodriguez
- Baylor College of Medicine, Department of Pediatrics, Houston, Texas, United States of America
| | - Poyyapakkam R. Srivaths
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Leyat Tal
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Mary N Watson
- Texas Children’s Hospital, Houston, Texas, United States of America
| | - Alyssa A. Riley
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ryan W. Himes
- Baylor College of Medicine, Department of Pediatrics, Liver Section, Houston, Texas, United States of America
| | - Moreshwar S. Desai
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
| | - Michael C. Braun
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
| | - Ayse Akcan Arikan
- Baylor College of Medicine, Department of Pediatrics, Renal Section, Houston, Texas, United States of America
- Baylor College of Medicine, Department of Pediatrics, Section of Critical Care Medicine, Houston, Texas, United States of America
- * E-mail:
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Couchonnal E, Rivet C, Ducreux S, Dumortier J, Bosch A, Boillot O, Collardeau-Frachon S, Dubois R, Hervieu V, André P, Scoazec JY, Lachaux A, Dubois V, Guillaud O. Deleterious impact of C3d-binding donor-specific anti-HLA antibodies after pediatric liver transplantation. Transpl Immunol 2017; 45:8-14. [PMID: 28782692 DOI: 10.1016/j.trim.2017.08.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2016] [Revised: 08/01/2017] [Accepted: 08/02/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND The prevalence and clinical impact of anti-HLA donor-specific antibodies (DSA) after liver transplantation (LT) have not been extensively studied, especially in pediatric population. METHODS The present cross-sectional study included 100 patients who underwent a first LT in childhood. Anti HLA immunization study was performed at a single time point during routine follow-up using Luminex® single antigen tests with classical anti-IgG conjugate and anti-C3d conjugate. RESULTS The main indication for LT was biliary atresia (52%) and median age at LT was 4.6years. The median time between LT and DSA assessment was 7.8years (range 1-21years). DSA was identified in twenty-four patients (24%) after LT, with a prevalence of 8%, 28%, 33%, 50%, respectively 0-5years, 5-10years, 10-15years and >15years after LT. DSA were mainly class II (23/24) with a mean MFI of 9.731±5.489 and 18 (79.3%) were C3d-binding DSA. Multivariate analysis disclosed that time elapsed since LT (p<0.01) and history of fulminant hepatitis (p=0.04) were significantly associated with a higher rate of DSA. Liver function tests (at time of DSA assessment) were not different according to the presence or not of DSA (or C3d-binding DSA). Regarding histology, the DSA group had a higher rate of chronic rejection, cirrhosis and centrilobular fibrosis or cirrhosis. In addition, patients with C3d-binding DSA and high MFI (>10,000) had a significant poorer long-term graft survival (p=0.03). CONCLUSION In our pediatric cohort of LT, prevalence of DSA was high and increased regularly with time. Presence of C3d positive-DSA with high MFI was associated with a higher rate of graft loss.
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Affiliation(s)
- Eduardo Couchonnal
- Unité de Transplantation hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Service d'hépatologie-gastroentérologie et nutrition pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Christine Rivet
- Service d'hépatologie-gastroentérologie et nutrition pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Stéphanie Ducreux
- Etablissement Français du Sang, Laboratoire d'Histocompatibilité, Lyon, France
| | - Jérôme Dumortier
- Unité de Transplantation hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France.
| | - Alexie Bosch
- Unité de Transplantation hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Olivier Boillot
- Unité de Transplantation hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Sophie Collardeau-Frachon
- Université Claude Bernard Lyon 1, Lyon, France; Service de Pathologie, Groupement hospitalier Est, Hospices Civils de Lyon, Bron, France
| | - Rémi Dubois
- Chirurgie uro-génitale, viscérale, thoracique, néonatale et transplantation, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - Valérie Hervieu
- Université Claude Bernard Lyon 1, Lyon, France; Service d'Anatomie Pathologique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Patrice André
- Université Claude Bernard Lyon 1, Lyon, France; Laboratoire de Virologie, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, Lyon, France
| | - Jean-Yves Scoazec
- Université Claude Bernard Lyon 1, Lyon, France; Service d'Anatomie Pathologique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Alain Lachaux
- Service d'hépatologie-gastroentérologie et nutrition pédiatriques, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France; Université Claude Bernard Lyon 1, Lyon, France
| | - Valérie Dubois
- Etablissement Français du Sang, Laboratoire d'Histocompatibilité, Lyon, France
| | - Olivier Guillaud
- Unité de Transplantation hépatique, Hôpital Edouard Herriot, Hospices Civils de Lyon, Lyon, France
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Fan Z, EnQiang C, Yao DL, LiBo Y, Hong L, Lang B, Ping F, Hong T. Neutrophil-lymphocyte ratio predicts short term mortality in patients with hepatitis B virus-related acute-on-chronic liver failure treated with an artificial liver support system. PLoS One 2017; 12:e0175332. [PMID: 28426800 PMCID: PMC5398520 DOI: 10.1371/journal.pone.0175332] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 03/25/2017] [Indexed: 02/05/2023] Open
Abstract
Aim Hepatitis B virus-related acute-on-chronic liver failure has high short-term mortality. Artificial liver support systems (ALSS) may improve outcome and avoid liver transplantation, but predicting short-term prognosis in such patients is difficult. This study aimed to determine whether the neutrophil–lymphocyte ratio (NLR), an inflammation marker, predicted mortality in patients treated with ALSS. Methods A total of 560 patients with hepatitis B virus-related acute-on-chronic liver failure were enrolled, 338 were treated with ALSS and the others treated with standard of care(SOC). Clinical variables and the NLR were evaluated for prognostic value. Results Thirty-day mortality was 28.4% in ALSS and 55.4% in SOC patients. The NLR was lower in survivors than in ALSS or SOC patients who died. Univariate and multivariate analysis found that NLR and the chronic liver failure sequential organ failure assessment scores(CLIF-SOFA) were independently associated with 30-day mortality. Among patients with NLRs ≤ 3, 3–6, and >6, 30-day mortality was 7.7%,23.1%, and 69.2% in ALSS and 25.5%, 50.0%, and 75.0% in SOC patients. Among patients with NLRs ≤ 3 or 3–6, mortality was lower in ALSS than in SOC patients (P < 0.01). Mortality rates of ALSS and SOC patients with NLRs > 6 did not different (P >0.05). The area under curve of NLR and CLIF-SOFA was 0.82 and 0.88 in ALSS group, 0.78 and 0.86 in SOC group. The results suggest that liver function in most patients with NLRs ≤ 3 recovered with ALSS treatment, and patients with NLRs > 6 needed emergency liver transplantation. Conclusion NLR was an independent predictor of mortality in ALSS patients and may assist physicians in determining treatment options.
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Affiliation(s)
- Zeng Fan
- Centre of Infectious Diseases, West China Hospital, Sichuan University
- Department of intensive care unit, Hospital of the University of Electronic Science, Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Chen EnQiang
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Du Ling Yao
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Yan LiBo
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Li Hong
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Bai Lang
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Feng Ping
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Tang Hong
- Centre of Infectious Diseases, West China Hospital, Sichuan University
- * E-mail:
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Tittarelli R, Pellegrini M, Scarpellini MG, Marinelli E, Bruti V, di Luca NM, Busardò FP, Zaami S. Hepatotoxicity of paracetamol and related fatalities. Eur Rev Med Pharmacol Sci 2017; 21:95-101. [PMID: 28379590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Paracetamol, also known as acetaminophen, is the most commonly used antipyretic and pain reliever and since 1955 it is available over-the-counter as a single formulation or in combination with other substances and, as indicated by the World Health Organization, it can be used in all the three steps of pain intensity. Paracetamol toxicity is one of the most common causes of poisoning worldwide. While paracetamol is described as relatively nontoxic when administered in therapeutic doses, it is known to cause toxicity when taken in a single or repeated high dose, or after chronic ingestion. Repeated supratherapeutic misuse, non-intentional misuse, and intentional ingestion may all result in hepatic toxicity, the main cause of acute liver failure (ALF) in the United States and Europe. Since paracetamol is responsible for nearly half of the cases in the US of acute liver failure and remains the leading cause of liver transplantation, continued awareness promotion, education and research should be constantly undertaken. We herein review the literature on paracetamol toxicity with particular attention to aspects of liver damage and related fatalities.
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Affiliation(s)
- R Tittarelli
- Unit of Forensic Toxicology (UoFT), Department of Anatomical, Histological, Forensic and Orthopedic Sciences, Sapienza University of Rome, Rome, Italy.
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Abstract
Drug-induced liver injury (DILI) can be predictable or idiosyncratic and has an estimated incidence of approximately 20 cases per 100,000 persons per year. DILI is a common cause of acute liver failure in the United States. No accurate tests for diagnosing DILI exist, and its diagnosis is based on exclusion of other conditions. Managing DILI includes discontinuing the suspected causative agent and in selected cases administering an antidote. Liver support systems are used for long-term support or as a bridge to transplantation and are effective for improving encephalopathy, hyperbilirubinemia, and other liver-related conditions, but whether they improve survival remains uncertain.
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Affiliation(s)
- Humberto C Gonzalez
- Department of Transplant Surgery/Center of Advanced Liver Disease, Methodist University Hospital, University of Tennessee Health Science Center, 1211 Union Avenue, Suite 340, Memphis, TN 38104, USA
| | - Syed-Mohammed Jafri
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Stuart C Gordon
- Division of Gastroenterology and Hepatology, Henry Ford Health System, 2799 West Grand Boulevard, Detroit, MI 48202, USA.
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McCarthy M. Adverse events raise concerns over safety of new hepatitis C drugs. BMJ 2017; 356:j490. [PMID: 28137772 DOI: 10.1136/bmj.j490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Jochum C, Maischack F, Anastasiou OE, Verheyen J, Timm J, Bechmann L, Gerken G, Canbay A. Treatment of fulminant acute Hepatitis B with nucles(t)id analogues is safe and does not lead to secondary chronification of Hepatitis B. Z Gastroenterol 2016; 54:1306-1311. [PMID: 27936480 DOI: 10.1055/s-0042-120418] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Background: Acute hepatitis B virus (HBV) infection is still a major cause of acute liver failure (ALF), necessitating a high rate of emergency liver transplantation (LTx). Acute infection is followed by high viral replication rates leading to hepatocyte death and, ultimately, ALF. The objective of treating HBV-induced ALF thus is to eliminate, or significantly suppress, HBV replication and therefore reduce cell death and support regeneration. Objective: In this retrospective study, we want to evaluate the timing, the safety, and the long-term virological outcome of this approach. Methods/results: In this study, we included 32 patients (16 female and 16 males; median age 39.5 years) with ALF due to hepatitis B, who were transferred to the university hospital Essen, Germany between January 2009 and December 2013. Before treatment, transaminases were highly elevated, bilirubin was increased, and elevated international normalized ratio (INR) revealed impaired liver function. HBV-DNA and HBsAg were positive. All 32 patients received oral antiviral treatment (3 lamivudine, 21 entecavir, and 8 tenofovir) between 1 day and 4 months after diagnosis of acute hepatitis B. One patient died, 2 were transplanted, one died shortly after LTx the other patient survived after LTx. These 3 patients received treatment in a state of advanced liver failure, and 1 patient 4 months after initial diagnosis of hepatitis B. Twenty-nine patients survived without LTx. Five patients were discharged without further follow-up. All 24 remaining patients became HBV-DNA negative in median of 100 days. Twenty-two patients were followed further, and all patients lost their HBsAg in median of 108 days. Sixteen of the 22 patients experienced a seroconversion to anti-HBs in median of 137 days. Four patients who were followed for 1 more year after HBsAg did not develop anti-HBs. None of the patients developed chronic hepatitis B. Conclusion: Immediate treatment of HBV-induced ALF with nucleos(t)id-analogues (NUCs) appears save and prevents LTx and death, and there is no indication for increased chronicity.
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Affiliation(s)
- C Jochum
- Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - F Maischack
- Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - O E Anastasiou
- Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - J Verheyen
- Institute for Virology, University Hospital Essen, Germany
| | - J Timm
- Institut für Virologie, Universitatsklinikum Dusseldorf, Germany
| | - L Bechmann
- Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - G Gerken
- Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - A Canbay
- Gastroenterology and Hepatology, University Hospital Essen, Germany
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Rabinowich L, Wendon J, Bernal W, Shibolet O. Clinical management of acute liver failure: Results of an international multi-center survey. World J Gastroenterol 2016; 22:7595-7603. [PMID: 27672280 PMCID: PMC5011673 DOI: 10.3748/wjg.v22.i33.7595] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 03/03/2016] [Accepted: 03/30/2016] [Indexed: 02/06/2023] Open
Abstract
AIM To assess the practice of caring for acute liver failure (ALF) patients in varying geographic locations and medical centers.
METHODS Members of the European Acute Liver Failure Consortium completed an 88-item questionnaire detailing management of ALF. Responses from 22 transplantation centers in 11 countries were analyzed, treating between 300 and 500 ALF cases and performing over 100 liver transplants (LT) for ALF annually. The questions pertained to details of the institution and their clinical activity, standards of care, referral and admission, ward- based care versus intensive care unit (ICU) as well as questions regarding liver transplantation - including criteria, limitations, and perceived performance. Clinical data was also collected from 13 centres over a 3 mo period.
RESULTS The interval between referral and admission of ALF patients to specialized units was usually less than 24 h and once admitted, treatment was provided by a multidisciplinary team. Principles of care of patients with ALF were similar among centers, particularly in relation to recognition of severity and care of the more critically ill. Centers exhibited similarities in thresholds for ICU admission and management of severe hepatic encephalopathy. Over 80% of centers administered n-acetyl-cysteine to ICU patients for non-paracetamol-related ALF. There was significant divergence in the use of prophylactic antibiotics and anti-fungals, lactulose, nutritional support and imaging investigations in admitted patients and in the monitoring and treatment of intra-cranial pressure (ICP). ICP monitoring was employed in 12 centers, with the most common indications being papilledema and renal failure. Most patients listed for transplantation underwent surgery within an average waiting time of 1-2 d. Over a period of 3 mo clinical data from 85 ALF patients was collected. Overall patient survival at 90-d was 76%. Thirty six percent of patients underwent emergency LT, with a 90% post transplant survival to hospital discharge, 42% survived with medical management alone.
CONCLUSION Alongside similarities in principles of care of ALF patients, major areas of divergence were present in key areas of diagnosis, monitoring, treatment and decision to transplant.
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Amir AZ, Ling SC, Naqvi A, Weitzman S, Fecteau A, Grant D, Ghanekar A, Cattral M, Nalli N, Cutz E, Kamath B, Jones N, De Angelis M, Ng V, Avitzur Y. Liver transplantation for children with acute liver failure associated with secondary hemophagocytic lymphohistiocytosis. Liver Transpl 2016; 22:1245-53. [PMID: 27216884 DOI: 10.1002/lt.24485] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/27/2016] [Accepted: 04/30/2016] [Indexed: 12/12/2022]
Abstract
Hemophagocytic lymphohistiocytosis (HLH) is a rare life-threatening systemic disease, characterized by overwhelming stimulation of the immune system and categorized as primary or secondary types. Occasionally, acute liver failure (ALF) may dominate the clinical presentation. Given the systemic nature of HLH and risk of recurrence, HLH is considered by many a contraindication to liver transplantation (LT). The aim of this study is to review our single-center experience with LT in children with secondary HLH and ALF (HLH-ALF). This is a cross-sectional, retrospective study of children with secondary HLH-ALF that underwent LT in 2005-2014. Of 246 LTs, 9 patients (3 males; median age, 5 years; range, 0.7-15.4 years) underwent LT for secondary HLH-ALF. Disease progression was rapid with median 14 days (range, 6-27 days) between first symptoms and LT. Low fibrinogen/high triglycerides, elevated ferritin, hemophagocytosis on liver biopsy, and soluble interleukin 2 receptor levels were the most commonly fulfilled diagnostic criteria; HLH genetic studies were negative in all patients. Immunosuppressive therapy after LT included corticosteroids adjusted to HLH treatment protocol and tacrolimus. Thymoglobulin (n = 5), etoposide (n = 4), and alemtuzumab (n = 2) were used in cases of recurrence. Five (56%) patients experienced HLH recurrence, 1 requiring repeat LT, and 3 died. Overall graft and patient survival were 60% and 67%, respectively. Six patients are alive and well at a median of 24 months (range, 15-72 months) after transplantation. In conclusion, LT can be beneficial in selected patients with secondary HLH-ALF and can restore good health in an otherwise lethal condition. Liver Transplantation 22 1245-1253 2016 AASLD.
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Affiliation(s)
- Achiya Z Amir
- Division of Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Simon C Ling
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Ahmed Naqvi
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Weitzman
- Haematology and Oncology, University of Toronto, Toronto, Ontario, Canada
| | - Annie Fecteau
- General Surgery, University of Toronto, Toronto, Ontario, Canada
| | - David Grant
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Anand Ghanekar
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Mark Cattral
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nadya Nalli
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Ernest Cutz
- Pathology, University of Toronto, Toronto, Ontario, Canada
| | - Binita Kamath
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Nicola Jones
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Maria De Angelis
- Transplant and Regenerative Medicine Centre, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Vicky Ng
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
| | - Yaron Avitzur
- Paediatric Gastroenterology, Hepatology and Nutrition, University of Toronto, Toronto, Ontario, Canada
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Zider AD, Zopey R, Garg R, Wang X, Wang TS, Deng JC. Prognostic significance of infections in critically ill adult patients with acute liver injury: a retrospective cohort study. Liver Int 2016; 36:1143-50. [PMID: 26801954 PMCID: PMC6023407 DOI: 10.1111/liv.13073] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Accepted: 01/08/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS Patients with acute liver failure have high rates of infections, likely from defects in immune function. Whether infections are independently associated with poor outcomes is unclear. We hypothesized that patients with acute liver injury who developed infections were at increased risk of adverse outcomes. METHODS We conducted a retrospective analysis of 150 critically ill adult patients admitted with acute liver dysfunction at a single academic institution between 2005 and 2011. We excluded patients with immunocompromised states, patients with chronic liver disease and patients who died or were discharged within 48 h of admission. Our primary endpoint was a 30-day event-free survival, with events defined as either death or liver transplantation. Our secondary endpoint was length of stay. Univariate and multivariate analyses were performed to determine associations between presence of infection and our primary and secondary endpoints. RESULTS Of our cohort of 150 patients, 62 (41%) were infected and 88 (59%) were not infected. Of the infected patients, 45% died or underwent transplantation, compared to 22% for the non-infected patients (P = 0.003). Univariate and multivariate analyses demonstrated that infections in patients with acute liver dysfunction were an independent predictor of poor outcome (i.e. death or transplantation). In addition, specific types of infection, including pneumonia, independently led to a 48% increase in length of stay (P = 0.002). CONCLUSIONS Infections in patients with acute liver dysfunction are associated with increased risk of death or transplant and increased hospital length of stay.
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Affiliation(s)
- Alexander D Zider
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Radhika Zopey
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Ronak Garg
- Department of Internal Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Xiaoyan Wang
- Department of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Tisha S Wang
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Jane C Deng
- Division of Pulmonary and Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
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Knight SR, Oniscu GC, Devey L, Simpson KJ, Wigmore SJ, Harrison EM. Use of Renal Replacement Therapy May Influence Graft Outcomes following Liver Transplantation for Acute Liver Failure: A Propensity-Score Matched Population-Based Retrospective Cohort Study. PLoS One 2016; 11:e0148782. [PMID: 26930637 PMCID: PMC4773220 DOI: 10.1371/journal.pone.0148782] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Accepted: 01/22/2016] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Acute kidney injury is associated with a poor prognosis in acute liver failure but little is known of outcomes in patients undergoing transplantation for acute liver failure who require renal replacement therapy. METHODS A retrospective analysis of the United Kingdom Transplant Registry was performed (1 January 2001-31 December 2011) with patient and graft survival determined using Kaplan-Meier methods. Cox proportional hazards models were used together with propensity-score based full matching on renal replacement therapy use. RESULTS Three-year patient and graft survival for patients receiving renal replacement therapy were 77.7% and 72.6% compared with 85.1% and 79.4% for those not requiring renal replacement therapy (P<0.001 and P = 0.009 respectively, n = 725). In a Cox proportional hazards model, renal replacement therapy was a predictor of both patient death (hazard ratio (HR) 1.59, 95% CI 1.01-2.50, P = 0.044) but not graft loss (HR 1.39, 95% CI 0.92-2.10, P = 0.114). In groups fully matched on baseline covariates, those not receiving renal replacement therapy with a serum creatinine greater than 175 μmol/L had a significantly worse risk of graft failure than those receiving renal replacement therapy. CONCLUSION In patients being transplanted for acute liver failure, use of renal replacement therapy is a strong predictor of patient death and graft loss. Those not receiving renal replacement therapy with an elevated serum creatinine may be at greater risk of early graft failure than those receiving renal replacement therapy. A low threshold for instituting renal replacement therapy may therefore be beneficial.
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Affiliation(s)
- Stephen R. Knight
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Gabriel C. Oniscu
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Luke Devey
- Pipeline Futures Group, GSK, 1250 South Collegeville Rd, Collegeville, Pennsylvania, 19426, United States of America
| | - Kenneth J. Simpson
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Stephen J. Wigmore
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
| | - Ewen M. Harrison
- Scottish Liver Transplant Unit, Royal Infirmary of Edinburgh, Edinburgh, EH16 4SA, United Kingdom
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Mendizabal M, Silva MO. Liver transplantation in acute liver failure: A challenging scenario. World J Gastroenterol 2016; 22:1523-1531. [PMID: 26819519 PMCID: PMC4721985 DOI: 10.3748/wjg.v22.i4.1523] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 10/14/2015] [Accepted: 11/19/2015] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure is a critical medical condition defined as rapid development of hepatic dysfunction associated with encephalopathy. The prognosis in these patients is highly variable and depends on the etiology, interval between jaundice and encephalopathy, age, and the degree of coagulopathy. Determining the prognosis for this population is vital. Unfortunately, prognostic models with both high sensitivity and specificity for prediction of death have not been developed. Liver transplantation has dramatically improved survival in patients with acute liver failure. Still, 25% to 45% of patients will survive with medical treatment. The identification of patients who will eventually require liver transplantation should be carefully addressed through the combination of current prognostic models and continuous medical assessment. The concerns of inaccurate selection for transplantation are significant, exposing the recipient to a complex surgery and lifelong immunosuppression. In this challenging scenario, where organ shortage remains one of the main problems, alternatives to conventional orthotopic liver transplantation, such as living-donor liver transplantation, auxiliary liver transplant, and ABO-incompatible grafts, should be explored. Although overall outcomes after liver transplantation for acute liver failure are improving, they are not yet comparable to elective transplantation.
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Anastasiou O, Sydor S, Sowa JP, Manka P, Katsounas A, Syn WK, Führer D, Gieseler RK, Bechmann LP, Gerken G, Moeller LC, Canbay A. Higher Thyroid-Stimulating Hormone, Triiodothyronine and Thyroxine Values Are Associated with Better Outcome in Acute Liver Failure. PLoS One 2015; 10:e0132189. [PMID: 26147961 PMCID: PMC4493082 DOI: 10.1371/journal.pone.0132189] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2015] [Accepted: 06/10/2015] [Indexed: 12/15/2022] Open
Abstract
Introduction Changes in thyroid hormone levels, mostly as non-thyroidal illness syndrome (NTIS), have been described in many diseases. However, the relationship between acute liver failure (ALF) and thyroid hormone levels has not yet been clarified. The present study evaluates potential correlations of select thyroid functional parameters with ALF. Methods 84 consecutively recruited ALF patients were grouped according to the outcome of ALF (spontaneous recovery: SR; transplantation or death: NSR). TSH, free thyroxine (fT4), free triiodothyronine (fT3), T4, and T3 were determined. Results More than 50% of patients with ALF presented with abnormal thyroid parameters. These patients had greater risk for an adverse outcome than euthyroid patients. SR patients had significantly higher TSH, T4, and T3 concentrations than NSR patients. Albumin concentrations were significantly higher in SR than in NSR. In vitro T3 treatment was not able to rescue primary human hepatocytes from acetaminophen induced changes in mRNA expression. Conclusions In patients with ALF, TSH and total thyroid hormone levels differed significantly between SR patients and NSR patients. This might be related to diminished liver-derived transport proteins, such as albumin, in more severe forms of ALF. Thyroid parameters may serve as additional indicators of ALF severity.
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Affiliation(s)
- Olympia Anastasiou
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Svenja Sydor
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Jan-Peter Sowa
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
- Regeneration and Repair Group, The Institute of Hepatology, London, WC1E 6HX, United Kingdom
| | - Antonios Katsounas
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Wing-Kin Syn
- Regeneration and Repair Group, The Institute of Hepatology, London, WC1E 6HX, United Kingdom
- Liver Unit, Barts Health NHS Trust, London, United Kingdom
| | - Dagmar Führer
- Department of Endocrinology and Metabolism, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Robert K. Gieseler
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
- Rodos BioTarget GmbH, Medical Park Hannover, 30625, Hannover, Germany
| | - Lars P. Bechmann
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Lars C. Moeller
- Department of Endocrinology and Metabolism, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg, Essen, 45122, Essen, Germany
- * E-mail:
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Moray G, Tezcaner T, Akdur A, Özçay F, Sezgin A, Kırnap M, Yıldırım S, Arslan G, Haberal M. Results of pediatric liver transplant: a single-center experience. EXP CLIN TRANSPLANT 2015; 13 Suppl 1:59-63. [PMID: 25894129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
OBJECTIVES Liver transplant is an established curative therapy for children with chronic end-stage liver disease or acute liver failure. In this study, we aimed to evaluate pediatric liver transplant in terms of outcomes, complications, and long-term followup results. MATERIALS AND METHODS Pediatric patients who had liver transplant in our institution were included. We retrospectively evaluated demographic features including body weight, Child-Pugh score, etiology of liver disease, graft source, perioperative outcomes, perioperative complications, postoperative complications, and long-term results. Outcomes of treatment of complications and revision transplant were evaluated. RESULTS Between September 2001 and December 2013, there were 188 pediatric liver transplants performed in our institution. Most grafts (90.9%) were obtained from living-related donors. There were 13 patients (6.9%) who had an intervention because of a hemorrhage postoperatively. Biliary leakage was observed in 33 patients (17.5%) and biliary stricture during follow-up was observed in 32 patients (17%). Thrombosis rates in the hepatic artery and portal vein were 12.3% and 0.5%. Revision transplant was performed in 11 patients (5.8%); reason for revision transplant was rejection in 50% patients. The remaining children were alive with good graft functioning after treatment of complications and revision transplant. The overall 5- and 10-year survival rates were 82.3% and 78.9%. CONCLUSIONS The overall outcomes of pediatric liver transplant at our center are very promising. With improved care of younger children and the combined efforts of the parents and medical team, the number of the children receiving transplants will increase in the future.
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Affiliation(s)
- Gökhan Moray
- From the Department of General Surgery, Baskent University, School of Medicine, Ankara, Turkey
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Jitraruch S, Dhawan A, Hughes RD, Filippi C, Soong D, Philippeos C, Lehec SC, Heaton ND, Longhi MS, Mitry RR. Alginate microencapsulated hepatocytes optimised for transplantation in acute liver failure. PLoS One 2014; 9:e113609. [PMID: 25438038 PMCID: PMC4249959 DOI: 10.1371/journal.pone.0113609] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 10/27/2014] [Indexed: 11/24/2022] Open
Abstract
Background and Aim Intraperitoneal transplantation of alginate-microencapsulated human hepatocytes is an attractive option for the management of acute liver failure (ALF) providing short-term support to allow native liver regeneration. The main aim of this study was to establish an optimised protocol for production of alginate-encapsulated human hepatocytes and evaluate their suitability for clinical use. Methods Human hepatocyte microbeads (HMBs) were prepared using sterile GMP grade materials. We determined physical stability, cell viability, and hepatocyte metabolic function of HMBs using different polymerisation times and cell densities. The immune activation of peripheral blood mononuclear cells (PBMCs) after co-culture with HMBs was studied. Rats with ALF induced by galactosamine were transplanted intraperitoneally with rat hepatocyte microbeads (RMBs) produced using a similar optimised protocol. Survival rate and biochemical profiles were determined. Retrieved microbeads were evaluated for morphology and functionality. Results The optimised HMBs were of uniform size (583.5±3.3 µm) and mechanically stable using 15 min polymerisation time compared to 10 min and 20 min (p<0.001). 3D confocal microscopy images demonstrated that hepatocytes with similar cell viability were evenly distributed within HMBs. Cell density of 3.5×106 cells/ml provided the highest viability. HMBs incubated in human ascitic fluid showed better cell viability and function than controls. There was no significant activation of PBMCs co-cultured with empty or hepatocyte microbeads, compared to PBMCs alone. Intraperitoneal transplantation of RMBs was safe and significantly improved the severity of liver damage compared to control groups (empty microbeads and medium alone; p<0.01). Retrieved RMBs were intact and free of immune cell adherence and contained viable hepatocytes with preserved function. Conclusion An optimised protocol to produce GMP grade alginate-encapsulated human hepatocytes has been established. Transplantation of microbeads provided effective metabolic function in ALF. These high quality HMBs should be suitable for use in clinical transplantation.
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Affiliation(s)
- Suttiruk Jitraruch
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Anil Dhawan
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
- * E-mail: (AD); (RRM)
| | - Robin D. Hughes
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Celine Filippi
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Daniel Soong
- British Heart Foundation Centre of Excellence Cardiovascular Division, King's College London School of Medicine, London, United Kingdom
| | - Christina Philippeos
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Sharon C. Lehec
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Nigel D. Heaton
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Maria S. Longhi
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
| | - Ragai R. Mitry
- Institute of Liver Studies, King's College London School of Medicine, London, United Kingdom
- * E-mail: (AD); (RRM)
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