[Acute liver failure]

Mechanisms and aetiology-dependent treatment of acute liver failure

This review compiles the mechanisms of acute liver failure (ALF) as well as the current and potential therapeutic approaches, including aetiology-specific treatment, and the issues encountered with such approaches. On a cellular level, ALF is characterized by massive hepatocyte death due to different types of cellular demise. Compensatory hyperplasia and functional recovery are possible when the regenerative capacity is sufficient to sustain hepatic function. ALF has a high mortality of about 30% and can lead to death in a very short time despite maximum therapeutic intervention. Besides aetiology-specific therapy and intensive care, the therapeutic option of emergency liver transplantation has significantly improved the prognosis of patients with ALF. However, due to limiting factors such as organ shortage, many patients die on the waiting list. In addition to graft assessment, machine perfusion may have the potential to recondition marginal organs and thus expand the organ donor pool.

Impact of acute respiratory distress syndrome on outcome in critically ill patients with liver cirrhosis

We investigated the occurrence and outcome of respiratory failure and ARDS in critically ill patients with liver cirrhosis. This is a retrospective analysis of patients with liver cirrhosis at an ICU during an 8-Year period. An assessment of acute on chronic liver failure as well as the presence and grade of ARDS within the first 72 h of admission to the ICU was performed. A total of 735 patients during the study period. Median age was 58 (50-69) years and 61% (n = 447) were male. 57% (n = 421) of the patients received mechanical ventilation (MV). Liver specific as well as ICU scores on admission were significantly higher in patients with MV. Necessity of vasopressor support (86%vs.25%, p < 0.001) and RRT (50%vs.11%, p < 0.001) was more frequent in patients with MV. The incidence of ARDS within the first 72 h of admission was 8% (n = 61). We observed a 28-day mortality or liver transplantation rate of 54% (n = 196) and 66% (n = 66%) in patients with MV and ARDS, respectively. After 90-days 63% (n = 226) with MV and 70% (n = 43) with ARDS were dead or received liver transplantation. ARDS is a prognostic factor for mortality in patients with liver cirrhosis admitted to the ICU. One out of ten critically ill cirrhotic patients develop ARDS within 72 h after admission. Although mortality rates are high initially critical care therapy should not be withheld and must be reevaluated regularly.

Single-center experience in 127 adult patients, mono or dual artificial liver support therapy, in patients with acute liver failure

Background

Acute liver failure (ALF) is a serious condition characterized by sudden liver dysfunction, jaundice and hepatic encephalopathy. Its mortality rate of approximately 80% underscores the urgent need for effective treatments. Supportive extracorporeal therapies (SET), which temporarily support liver function and remove toxins, have shown promise in improving outcomes in acute liver failure (ALF). The aim of this study was to compare the outcomes of dual supportive extracorporeal therapy (SET) and mono supportive extracorporeal therapy in patients with acute liver failure.

Methods

A total of 127 patients with acute liver failure were included in this retrospective, single-center study. Of these, 62 patients received dual supportive extracorporeal therapy and 65 patients received mono supportive extracorporeal therapy. Primary endpoints were survival without the need for liver transplantation and mortality. Secondary endpoints included resolution of encephalopathy and normalization of International Normalized Ratio (INR).

Results

In the dual supportive extracorporeal therapy group, 59.6% of patients survived without the need for liver transplantation, while 27.4% achieved recovery with liver transplantation. The mortality rate in this group was 12.9%. Significant regression of encephalopathy grade was observed in 87% of patients, and the 1 year mortality rate for liver transplant recipients was 10.7%. In the mono supportive extracorporeal therapy group, 61.5% of patients experienced a successful recovery without the need for liver transplantation, with a mortality rate of 29.2%. Significant improvement in the grade of encephalopathy was observed in 70.7% of patients.

Conclusion

Both dual supportive extracorporeal therapy (CVVHDF and PE) and mono supportive extracorporeal therapy (PE) were associated with significant improvements in renal and hepatic biochemical parameters, blood ammonia levels, and neurological status in patients with acute liver failure associated with grade III-IV hepatic encephalopathy. In particular, dual support was associated with improved hemodynamic stability, lactic acidosis and acid-base balance. Survival in acute liver failure in our retrospective cohort using a protocolized approach to extracorporeal therapies is higher compared to previously published large ALF studies. This protocolized approach warrants further prospective studies.

[Gastrointestinal and hepatic emergencies in acute and emergency care]

Acute gastrointestinal emergencies are one of the most common presentations to the emergency department. If the main symptom is acute abdominal pain, this is referred to as "acute abdomen". An acute abdomen demands urgent attention and treatment and can be caused by different pathologies (e.g., peptic ulcer disease, acute pancreatitis, diverticulitis). Hepatic emergencies include acute liver failure and acute-on-chronic liver failure. Due to the large number of possible differential diagnoses with variable clinical symptoms, rapid diagnosis of the underlying etiology of gastrointestinal and liver emergencies is a major challenge in daily clinical practice. A structured approach and prompt initiation of adequate diagnostic and treatment measures are essential in order to reduce mortality.

Identification of key genes and infiltrating immune cells among acetaminophen-induced acute liver failure and HBV-associated acute liver failure

BACKGROUND

Acute liver failure (ALF) is a life-threatening complication that is relatively uncommon. ALF causes severe hepatocyte damage and necrosis, which can lead to liver dysfunction and even multi-organ failure. A growing body of evidence suggests that immune cell infiltration and some abnormally expressed genes are associated with ALF development. However, in ALF, they have yet to be thoroughly investigated.

METHODS

The Gene Expression Omnibus (GEO) database was used to obtain microarray datasets such as GSE74000, GSE120652, GSE38941, and GSE14668, which were then examined via GEO2R to determine differentially expressed genes (DEGs) associated with ALF. Metascape was employed to annotate the underlined genes using Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) analyses. The mechanism of IGF1 in 2 different kinds of ALF including acetaminophen-induced ALF and hepatitis B virus (HBV)-induced ALF was studied using gene set enrichment analysis (GSEA). Next, immune cell infiltration was investigated and differentiated in ALF using CIBERSORT.

RESULTS

Six genes (HAO2, IGF1, PLA2G7, SC5D, GNE, SLC1A1) were found to be abnormally expressed in the 2 distinct types of ALF i.e., acetaminophen-induced ALF and HBV-induced ALF. IGF1 was identified as a hub gene in ALF and was found to be associated with several developmental cascades including immune responses, inflammatory responses, and intracellular calcium homeostasis. Additionally, the number of CD4 naive T cells, CD8 T cells, and follicular helper T cells was increased in acetaminophen-induced ALF, whereas the number of activated NK cells, resting NK cells, and plasma cells was increased in HBV-induced ALF.

CONCLUSIONS

The present study determined a potential molecular target, namely IGF1, in acetaminophen-induced ALF and HBV-induced ALF, which may provide novel insights into the pathophysiology and management of ALF. Concurrently, the putative immunological pathways have been found.

[Acute liver failure]

Acute liver failure (ALF) is a rare, but life-threatening disease that is characterized by the acute onset of jaundice, coagulopathy, and hepatic encephalopathy (HE) in patients without pre-existing liver disease. Main causes in Germany are drug toxicity, acetaminophen overdose, and viral hepatitis (A, B, E). For the initial assessment of patients with ALF and the diagnostic algorithm, the early detection of HE, exclusion of liver cirrhosis, immediate diagnosis of the underlying etiology, and evaluation for the necessity of liver transplantation (LT) are critical. Intensive care therapeutic measures aim at preventing or treating complications of ALF. Potentially, plasmapheresis (full plasma exchange) offers a survival benefit for ALF patients who do not undergo LT. The King's College criteria and the Clichy criteria are used as prognostic tools for the indication for LT.

[Acute liver failure]

Acute liver failure (ALF) is a rare, but life-threatening disease that is characterized by the acute onset of jaundice, coagulopathy, and hepatic encephalopathy (HE) in patients without pre-existing liver disease. Main causes in Germany are drug toxicity, acetaminophen overdose, and viral hepatitis (A, B, E). For the initial assessment of patients with ALF and the diagnostic algorithm, the early detection of HE, exclusion of liver cirrhosis, immediate diagnosis of the underlying etiology, and evaluation for the necessity of liver transplantation (LT) are critical. Intensive care therapeutic measures aim at preventing or treating complications of ALF. Potentially, plasmapheresis (full plasma exchange) offers a survival benefit for ALF patients who do not undergo LT. The King's College criteria and the Clichy criteria are used as prognostic tools for the indication for LT.

[Acute-on-chronic liver failure: a diagnostic and therapeutic challenge for intensive care]

Das akut-auf-chronische Leberversagen („acute-on-chronic liver failure“, ACLF) ist ein emergentes Krankheitssyndrom, das durch einen oder mehrere akute Trigger bei vorgeschädigter Leber ausgelöst wird und vom progressiven hepatalen und nichthepatalen Organversagen, einem gravierenden Risiko infektiöser Komplikationen sowie hoher kurzfristiger Letalität gekennzeichnet ist. Wenngleich pathophysiologisch noch weitgehend unverstanden erfordert das ACLF frühzeitige diagnostische und therapeutische Maßnahmen, die sich auf zugrunde liegende Ursachen sowie das Verhindern von Komplikationen richten, um die Prognose betroffener Patienten zu verbessern.