Management of acute liver failure in infants and children: Consensus statement of the pediatric gastroenterology chapter, Indian academy of pediatrics

Bacterial and Fungal Infections in Pediatric Acute Liver Failure and Their Impact on Clinical Outcomes

OBJECTIVES

The current study aimed to explore the prevalence, predictors and outcomes of infections in pediatric acute liver failure (PALF).

METHODS

Data were retrieved from a prospectively maintained database of patients admitted with PALF between January 2012 and June 2024. "Sepsis" was defined as the presence of systemic inflammatory response syndrome with suspected or proven infection. Patients with positive bacterial and/or fungal cultures were labeled as "culture-positive sepsis." Outcome variables included native liver survival (NLS) and overall survival (OS) at day 28.

RESULTS

A total of 422 patients of PALF were included in the study of whom 195 (46.21%) fulfilled the criteria of sepsis and 71 (16.8%) had culture-positive sepsis. Bronchoalveolar fluid (37/81, 45.7%) was the commonest site of culture positivity followed by blood (29, 35.8%). More than 80% of cultures grew Gram-negative organisms with a high prevalence of carbapenem (77.1%) and multidrug (60%) resistance. These organisms were sensitive to colistin and newer beta-lactam combinations. Intensive care unit (ICU) stay, mechanical ventilation, grade 3-4 hepatic encephalopathy and use of extracorporeal liver support systems were associated with culture-positive sepsis. Patients with culture-negative sepsis had lower NLS and OS, whereas patients with culture-positive sepsis had outcomes comparable with patients without sepsis. However, culture-positive severe sepsis patients had significantly lowered NLS (33.3%) and OS (42.9%) at day 28.

CONCLUSION

There is a high prevalence of carbapenem and multidrug-resistant sepsis in PALF. ICU stay and use of extracorporeal support are factors independently associated with sepsis. While culture-positive sepsis did not significantly affect survival, patients with severe sepsis had lower NLS and OS.

The Role of Predictive Models in the Assessment of the Poor Outcomes in Pediatric Acute Liver Failure

OBJECTIVES

In children, acute liver failure (ALF) is a severe condition with high mortality. As some patients need liver transplantation (LT), it is essential to predict the fatal evolution and to refer them early for LT if needed. Our study aimed to evaluate the prognostic criteria and scores for assessing the outcome in children with ALF.

METHODS

Data of 161 children with ALF (54.66% female, mean age 7.66 ± 6.18 years) were analyzed based on final evolution (32.91% with fatal evolution or LT) and etiology. We calculated on the first day of hospitalization the PELD score (109 children), MELD, and MELD-Na score (52 children), and King's College Criteria (KCC) for all patients. The Nazer prognostic index and Wilson index for predicting mortality were calculated for nine patients with ALF in Wilson's disease (WD).

RESULTS

PELD, MELD, and MELD-Na scores were significantly higher in patients with fatal evolution (21.04 ± 13.28 vs. 13.99 ± 10.07, p = 0.0023; 36.20 ± 19.51 vs. 20.08 ± 8.57, p < 0.0001; and 33.07 ± 8.29 vs. 20.08 ± 8.47, p < 0.0001, respectively). Moreover, age, bilirubin, albumin, INR, and hemoglobin significantly differed in children with fatal evolution. Function to etiology, PELD, MELD, MELD-Na, and KCC accurately predicted fatal evolution in toxic ALF (25.33 vs. 9.90, p = 0.0032; 37.29 vs. 18.79, p < 0.0001; 34.29 vs. 19.24, p = 0.0002, respectively; with positive predicting value 100%, negative predicting value 88.52%, and accuracy 89.23% for King's College criteria). The Wilson index for predicting mortality had an excellent predictive strength (100% sensibility and specificity), better than the Nazer prognostic index.

CONCLUSIONS

Prognostic scores may be used to predict the fatal evolution of ALF in children in correlation with other parameters or criteria. Early estimation of the outcome of ALF is essential, mainly in countries where emergency LT is problematic, as the transfer to a specialized center could be delayed, affecting survival chances.

Pediatric acute liver failure: An experience of a pediatric intensive care unit from resource limited settings

INTRODUCTION

Pediatric acute liver failure is a rare and serious disease. Though liver transplantation is considered as the established treatment option for patients who are unlikely to recover with medical management, however, with the advancement of medical care there has been an increase in spontaneous regeneration of liver, obviating the need for liver transplantation. We identified the etiologies, outcome and prognostic factors of acute liver failure and the validity of the existing liver transplantation criteria to predict the outcome of pediatric acute liver failure.

MATERIALS AND METHODS

This was a retrospective study done from January 2014 to December 2019 in a tertiary pediatric critical care unit in South India. All children aged between 1 month to 18 years admitted with acute liver failure were enrolled.

RESULTS

Of 125 children with acute liver failure, the main etiologies were infections (32%), indeterminate (23%), paracetamol toxicity (21%), metabolic (13%) and others (11%). Dengue was the most common infection (55%). The median pediatric logistic organ dysfunction score at admission was 12 (4-27). Of 125 patients, 63.2% (n = 79) had spontaneous regeneration which was higher in paracetamol induced (92.3%) compared to non-paracetamol induced acute liver failure (55.5%). Only two patients underwent liver transplantation and 35% died. Peak alanine transaminase and use of inotropes significantly predicted the outcome of disease. Of 38 children meeting King's College Hospital criteria for liver transplantation, 57.9% had spontaneous regeneration and 36.8% died. Of 74 children meeting INR > 4 criteria, 54% (n = 40) had spontaneous regeneration and 43.2% died. INR >4 criteria was more sensitive than King's College Hospital criteria for predicting the need for liver transplantation.

CONCLUSION

Pediatric acute liver failure is caused by varied etiologies and infections were the commonest cause. Despite having a seriously ill cohort of patients, medical management resulted in spontaneous regeneration in the majority of children with acute liver failure. The use of inotropes, advanced hepatic encephalopathy, and peak alanine transaminase were predictors of poor outcome in children with acute liver failure and these patients could be considered for liver transplantation as available. Therefore, we may need to develop better predictors of pediatric acute liver failure in resource limited settings.

Atypical Manifestations of Dengue Fever in Children

Objective The burden of dengue fever (DF) is increasing rapidly worldwide. Several atypical manifestations of DF are being increasingly reported but there are no clear guidelines on their definition and management. Their timely detection and appropriate management might improve outcomes. We describe here our experience in managing atypical manifestations of DF in children and their outcomes in a teaching hospital in South India.

Methods A retrospective chart review of children (1 month–18 years) hospitalized, between August 2017 and March 2018 with a diagnosis of DF (NS1 antigen or immunoglobulin M antibodies positivity), was done. The clinical details of the atypical manifestations are described.

Results During the study period, 925 children were hospitalized with DF, of which 94 (10.16%) had severe dengue and 2 (0.21%) died. Among the 925 children, 7 (0.75%) had cardiac, 5 (0.54%) had neurological, 5 (0.54%) had hepatic, and 31 (3.3%) had immunological (infection-associated immune dysregulation) manifestations.

Conclusion Most children with atypical manifestations of DF recover with supportive management. There is a need for a clear definition of atypical manifestations so that large prospective multicenter studies on incidence, optimum management, and outcomes can be done.

Indian National Association for the Study of Liver Consensus Statement on Acute Liver Failure (Part-2): Management of Acute Liver Failure

Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.

Twin-to-twin transfusion syndrome as a cause of neonatal acute liver failure

Background

Acute liver failure (ALF) is a rare condition during neonatal period.

Objective

To report a case of recipient twin with fulminant ALF secondary to hydrops fetalis caused by twin-to-twin transfusion syndrome (TTTS).

Method

The patient was admitted to the neonatal intensive care unit (NICU) for respiratory failure requiring mechanical ventilation and fulminant ALF with prolonged international normalized ratio (INR) and elevated liver enzymes with highest aspartate aminotransferase of 4,580 U/L.

Results

Laboratory investigation for secondary causes of liver failure was not revealing. Her liver enzymes and coagulation levels were dramatically normalized as the clinical symptoms of hypervolemia improved within 1 week.

Conclusion

TTTS can be a possible cause of neonatal ALF. Early detection with proper management of TTTS is important to avoid adverse outcomes. However, pathogenesis of hepatic dysfunction in TTTS is rarely described, and further studies are needed to help understanding the correlation between liver diseases and TTTS.

Neonatal cholestasis: recent insights

Background

Neonatal physiological jaundice is a common benign condition that rarely extends behind the second week of life; however, it may interfere with the diagnosis of a pathological condition termed neonatal cholestasis (NC). The latter is a critical, uncommon problem characterized by conjugated hyperbilirubinaemia. This review aims to highlight the differences between physiological and pathological jaundice, identify different causes of NC, and provide a recent approach to diagnosis and management of this serious condition.

Main text

NC affects 1/2500 live births, resulting in life-threatening complications due to associated hepatobiliary or metabolic abnormalities. NC is rarely benign and indicates the presence of severe underlying disease. If jaundice extends more than 14 days in full-term infants or 21 days in preterm infants, the serum bilirubin level fractionated into conjugated (direct) and unconjugated (indirect) bilirubin should be measured. A stepwise diagnostic approach starts with obtaining a complete history, and a physical examination which are valuable for the rapid diagnosis of the underlying disease. The most frequently diagnosed causes of NC are biliary atresia (BA) and idiopathic neonatal hepatitis (INH). The early diagnosis of NC ensures more accurate management and better prognosis. Despite the unavailability of any specific treatments for some causes of NC, the patient can benefit from nutritional management and early medical intervention. Future research should attempt to shed light on methods of screening for NC, especially for causes that can be effectively treated either through proper nutritional support, appropriate chemotherapeutic management, or timely surgical intervention.

Conclusion

Further attention should be paid for diagnosis and treatment of NC as it may be misdiagnosed as physiological jaundice; this may delay the proper management of the underlying diseases and aggravates its complications.

Neurocritical care monitoring of encephalopathic children with acute liver failure: A systematic review

Research on non-invasive neuromonitoring specific to PALF is limited. This systematic review identifies and synthesis the existing literature on non-invasive approaches to monitoring for neurological sequelae in patients with PALF. A series of literature searches were performed to identify all publications pertaining to five different non-invasive neuromonitoring modalities, in line with PRISMA guidelines. Each modality was selected on the basis of its potential for direct or indirect measurement of cerebral perfusion; studies on electroencephalographic monitoring were therefore not sought. Data were recorded on study design, patient population, comparator groups, and outcomes. A preponderance of observational studies was observed, most with a small sample size. Few incorporated direct comparisons of different modalities; in particular, comparison to invasive intracranial pressure monitoring was largely lacking. The integration of current evidence is considered in the context of the clinically significant distinctions between pediatric and adult ALF, as well as the implications for planning of future investigations to best support the evidence-based clinical care of these patients.

Prognostic parameters of pediatric acute liver failure and the role of plasma exchange

BACKGROUND

This study investigated the prognostic parameters and beneficial effects of repeat plasma exchange in children with acute liver failure (ALF).

METHODS

Twenty-three patients under 18 years of age admitted to National Taiwan University Hospital due to ALF from 2003 to 2016 were included in this retrospective analysis.

RESULTS

Among the patients, 11 (48%) had native liver recovery (NLR), 9 (39.1%) died without liver transplant, and 3 (12.9%) received liver transplantation. The NLR group showed a lower proportion of idiopathic cases, lower peak ammonia level, higher peak alpha fetoprotein (AFP) level, and they had plasma exchange fewer times than the other groups. Receiver operating characteristic curve analyses yielded optimal cutoff values of plasma exchange (≤6 times), peak ammonia level (<190 μmol/L), and peak AFP level for predicting NLR in children with ALF.

CONCLUSION

Pediatric ALF with idiopathic etiology, high peak ammonia level, and low peak AFP level are associated with fewer cases of NLR. Plasma exchange for more than six times probably offers little benefit with regard to patient survival if liver transplantation is not performed promptly.

Caralluma umbellata Haw. protects liver against paracetamol toxicity and inhibits CYP2E1

Introduction: Paracetamol is a potent hepatotoxin and may cause severe acute hepatocellular injury. The present study was intended to assess the hepatoprotective potential of Caralluma umbellata Haw. (Asclepiadaceae) (C. umbellata ) against paracetamol-induced hepatotoxicity in vitro and in vivo experimental models. Methods: Preliminary analysis for antioxidant and hepatoprotective property was evaluated for methanolic (MCU), aqueous (ACU) and hydro methanolic (HCU) extracts of C. umbellata using in vitro cell-free antioxidant such as DPPH, ABTS, nitric oxide, lipid peroxidation models and cell-based hepatoprotective study using BRL3A cells. In vivo, hepatoprotective activity was studied in paracetamol treated male Wistar albino rats. Furthermore, molecular mechanism behind the protective effect of MCU was explored by RT PCR technique by utilizing cytochrome P450 (CYP) CYP2E1. Results:C. umbellata extracts especially, MCU showed a better antioxidant property. MCU offered significant dose-dependent protection against paracetamol-induced hepatic damage in both in vitro and in vivo assays by improving all the biochemical findings towards the normal range. In a mechanism-based study, MCU has offered significant down-regulation (p < 0.05) of CYP2E1. These findings were in line with the hepatoprotective activity findings where MCU showed significant protection. Conclusion: In conclusion, these findings suggest that MCU possess hepatoprotective activity. One of the possible mechanisms behind the protective effect of MCU is found to be inhibition of CYP2E1.

Management of Pediatric Acute Liver Failure in a Region With Insufficient Deceased Donor Support: A Single-Center Experience

OBJECTIVES

Acute liver failure is a rapidly progressive and life-threatening disease in children, whose clinical features differ from those of adults.

MATERIALS AND METHODS

This is a review of a single center's experience with pediatric acute liver failure in a region with insufficient deceased donor support. The study is a retrospective review and analysis of 22 pediatric patients with acute liver failure between January 2007 and May 2013.

RESULTS

The cause of acute liver failure was indeterminate in 45.4% of cases. Listing for liver transplant was required in 72.7% of patients, whereas 27.3% developed spontaneous remission. In the patients placed on the liver transplant wait list, 75% underwent liver transplant and 25% died before undergoing liver transplant. The presence of ascites, high-grade encephalopathy, and laboratory findings including high lactate dehydrogenase and phosphorous levels and international normalized ratio were significant parameters in selecting patients needing liver transplants. All liver transplants were from living donors. One- and 3-year patient survival rates after liver transplant were 75% and 75%. No serious donor complications occurred.

CONCLUSIONS

Living-donor liver transplant may be the only option to save the lives of pediatric patients with acute liver failure, especially in regions with insufficient deceased-donor support. Timely referral to a multidisciplinary transplant center, expedient evaluation of living donors, and appropriate timing of transplant are crucial for a successful outcome.

Ischaemic Markers in Acute Hepatic Injury

INTRODUCTION

Hepatic injury of varied aetiology may progress to Acute Liver Failure (ALF). Compromised microcirculation is thought to be a deciding factor of hepatic hypoxia may be involved in disease progression that needs early detection. Ischaemia markers like serum Ischaemia- modified albumin (IMA), ALT-LDH ratio and ALT-LDH index have been suggested for its detection at early stage.

AIM

To find out the association of Ischaemia markers like serum IMA, ALT-LDH ratio and ALT-LDH index in acute hepatic injury cases.

MATERIALS AND METHODS

Forty one diagnosed acute liver injury cases of varied aetiology admitted in Department of Medicine, and Gastroenterology of SCB Medical College, Cuttack were enrolled in the study along with 30 age and sex matched healthy controls. Blood collected at time of admission and at time of discharge (1(st) day and 7(th) day) were evaluated for FPG, RFT, LFT, Serum Albumin along with serum LDH, IMA, PT-INR and platelet count.

RESULT

Serum bilirubin, hepatic enzymes, IMA, PT-INR was more markedly raised in cases than controls on the 1(st) day of admission. ALT-LDH ratio and index were significantly low in complicated cases. However, on responding to treatment the ALT-LDH index on 7(th) day registered a rise in comparison to the 1(st) day, while serum IMA revealed an insignificant decline showing improvement in hepatic hypoxia. ALT-LDH ratio remains more or less same on response to treatment.

CONCLUSION

Serum IMA and ALT-LDH Index reveals association with disease process in Acute Hepatic Injury cases both clinically and biochemically and can be used as supportive parameters for the diagnosis of disease process.