Prognostic Models in Acute Liver Failure

Comparative Analysis of Plasmapheresis Versus Plasmapheresis Combined With Continuous Renal Replacement Therapy in Adult Liver Failure: A Retrospective Observational Study

BACKGROUND

Liver failure constitutes a critical medical condition marked by the rapid decline in hepatic functions. Novel therapeutic approaches, including therapeutic plasma exchange (TPE) and continuous venovenous hemodiafiltration (CVVHDF), have emerged as promising modalities for mitigating the effects of this condition by facilitating detoxification and enhancing liver function. The efficacy of these interventions, whether administered individually or in combination, is a prominent area of investigation in the management of liver failure among adult populations. This study aims to evaluate the role and effectiveness of TPE, both as a standalone treatment and in conjunction with CVVHDF, in the management of liver failure in adult patients.

METHODS

This retrospective study was conducted in a Liver Transplant Intensive Care Unit (LTICU), focusing on the medical records of adult patients aged 35 to 62 years. The patient cohort consisted of individuals admitted between January 1, 2021, and June 1, 2024, due to acute liver failure or acute-on-chronic liver failure. The analysis specifically included patients who underwent therapeutic plasma exchange (TPE) or those who received continuous renal replacement therapy in conjunction with TPE. For the statistical analysis, a P-value of less than .05 was deemed indicative of statistical significance. The study encompassed a total of 47 patients with liver failure, comprising 23 males and 24 females. Among these patients, 25 (53.2%) received only TPE, while 22 (46.8%) were treated with a combination of TPE and continuous venovenous hemodiafiltration (CVVHDF).

RESULTS

In the cohort of patients who received only therapeutic plasma exchange (TPE), the median International Normalized Ratio (INR) improved significantly, decreasing from 2 (1.6-2.6) to 1.3 (1.1-1.7). Similarly, alanine aminotransferase levels reduced from 351 (66-1482) to 166 (71-367), while aspartate aminotransferase levels decreased from 259 (132-1392) to 86 (35-160). In the group receiving a combination of TPE and continuous venovenous hemodiafiltration (CVVHDF), notable reductions were also observed: INR decreased from 3 (2.4-4.7) to 1.5 (1.3-2.4), alanine aminotransferase levels dropped from 691 (59-2397) to 162 (70-1060), and aspartate aminotransferase levels fell from 916 (134-1828) to 69 (45-503). These changes were statistically significant, with P-values of less than .05 for each parameter in both treatment groups. Overall, 21 patients achieved survival without requiring a liver transplant, while 7 patients underwent liver transplantation, resulting in a transplant-free survival rate of 44.7%.

CONCLUSION

The findings from our study on the management of liver failure in adults demonstrate that both therapeutic plasma exchange (TPE) administered alone and in conjunction with continuous venovenous hemodiafiltration (CVVHDF) are effective treatment modalities, particularly as a bridging strategy to liver transplantation. The observed transplant-free survival rate of 44.7% underscores the significant clinical advantages of these therapies. However, to enhance the validity of these results and their applicability in broader clinical contexts, additional multicenter studies are essential for further exploration of these treatment approaches in liver failure management.

Association between lactate-to-albumin ratio and mortality in hepatic failure: a retrospective cohort study

BACKGROUND

Liver failure has a high mortality rate, and currently, there is no convenient risk predictor. The lactate-to-albumin ratio (LAR) has emerged as a promising predictor in various critical illnesses. However, its potential role in predicting all-cause mortality in patients with liver failure remains unexplored. Therefore, this study aims to investigate the correlation between LAR and all-cause mortality in patients suffering from liver failure.

METHODS

We retrospectively analyzed data from patients with liver failure who were admitted to the intensive care unit (ICU) between 2008 and 2019, which were gathered from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. LAR was calculated from the ratio obtained from the first measurement taken within 24 h of admission. The optimal LAR threshold was determined using the Youden index. With LAR categorized into low, middle, and high groups based on tertiles, Kaplan - Meier analysis was employed to compare mortality risks among three patient groups. Multivariate Cox proportional hazards regression models were utilized to evaluate the association between LAR and all-cause mortality in hepatic failure patients within hospital admission. Additionally, receiver operating characteristic (ROC) and smoothing curve analysis were used to assess the predictive ability, sensitivity, and specificity of LAR for all-cause mortality in patients with liver failure, and the area under the curve (AUC) was calculated. A smooth curve fitting approach and threshold effect analysis were employed to detect the potentially non-linear relationship between the LAR and the risk of all-cause mortality in patients with hepatic failure. Finally, subgroup analyses were performed to assess the relationship between LAR and prognosis across different types of liver failure.

RESULTS

A total of 902 patients with hepatic failure were included in this study. They were divided into survivors group (611 patients) and non-survivors group (291 patients) according to whether they survived during hospitalization, and the mortality rate of patients was 32.26%. The Kaplan-Meier survival curves illustrating patients in hepatic failure with elevated LAR showed a significantly heightened risk of in-hospital mortality (P < 0.001). We identified a non-linear relationship between LAR and the risk of hospital mortality after adjusting for potential confounders and the inflection point of LAR to be 1.33. LAR was shown to be an independent predictor of all-cause mortality within hospitalization in patients with hepatic failure by multivariate COX regression analysis (HR, 1.66; 95% CI, 1.35-2.05; P < 0.0001). The optimal cutoff value for separating the survival and death groups according to ROC was found to be 0.97. The AUC value for LAR was 0.755 (95% CI: 0.721, 0.789), which was higher than that for arterial blood lactate (AUC = 0.725) and serum albumin (AUC = 0.680) alone. It was not inferior even when compared to MELD (AUC = 0.677).

CONCLUSION

LAR has demonstrated good predictive value for all-cause mortality among liver failure patients in our retrospective study.

Practical Utility of Serum Ammonia in Children With Acute Liver Failure: A Biomarker of Outcome

Background

Hyperammonemia is a recognized biochemical abnormality in acute liver failure (ALF). Our aim was to determine a cutoff value for serum ammonia in children with ALF to predict their outcomes while conventional UK liver transplant (LT) listing criteria were applied.

Methods

We reviewed and analyzed the data of 68 patients with ALF who presented to our center from January 2014 to December 2018; inherited defects of ammonia metabolism were excluded. Patients were divided into 3 groups: Gr 1, LT (30 patients); Gr2, native liver survival (27 patients); and Gr 3, mortality (11 patients).

Results

Highest ammonia levels during admission before intervention were higher in the LT and mortality group than in the native liver survival group (P = 0.011) with levels of 140 µmol/L showing a specificity of 100% as a predictor for LT/mortality. Sixty-two percent of patients with ALF developed encephalopathy; grades 3 and 4 in almost one-third. Encephalopathy was more common in Gr1 patients, followed by Gr3, whereas Gr2 were the least likely to develop encephalopathy. Ammonia levels were significantly higher in encephalopathic patients than in nonencephalopathic (P = 0.001). Serum ammonia of 80.5 µmol/L predicted encephalopathy with 80% sensitivity and 75% specificity.

Conclusions

Serum ammonia level of >80 µmol/L can be used as an alert to ongoing encephalopathy although encephalopathy signs may be missing or subtle and a surrogate marker for earlier interventions for extracorporeal therapies. Moreover, levels >140 µmol/L predict the need for LT or death.

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.

Liver transplantation in acute liver failure: Dilemmas and challenges

Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage.

Association of 5-Hydroxytryptamine 3 Receptor Antagonists With the Prognosis of Liver Failure

Liver failure is a severe clinical syndrome with high mortality. 5-Hydroxytryptamine 3 receptor antagonists (5-HT3RAs) can reduce liver damage in animal models. We investigated whether 5-HT3RAs may improve the prognosis of liver failure. We analyzed the 28 and 90 days mortality of liver failure patients in relation to the use of 5-HT3RAs using data from a tertiary hospital in northwest China. According to the use of 5-HT3RAs, 419 patients with liver failure (46 acute, 93 sub-acute, 44 chronic, 236 acute on chronic) were divided into 5-HT3RA group (n = 105) and control group (n = 314). 5-HT3RAs were associated with decreased 28 days (HR 0.18, 95% CI 0.10-0.34, p < 0.001) and 90 days (HR 0.21, 95% CI 0.13-0.33, p < 0.001) mortality. After propensity score matching (PSM) (n = 67 in each group), 5-HT3RAs were still significantly associated with reduced 28 days (HR 0.10, 95%CI 0.04-0.26, p < 0.001) and 90 days (HR 0.16, 95%CI 0.08-0.31, p < 0.001) mortality. 5-HT3RA group patients had significantly higher 28 and 90 days survivals than controls both before and after PSM (all p < 0.001). This study shows that 5-HT3RAs are associated with increased survival of liver failure patients and thus may be used to treat liver failure if the findings are confirmed by additional studies.

The Crashing Toxicology Patient

This article examines, using an organ-systems based approach, rapid diagnosis, resuscitation, and critical care management of the crashing poisoned patient in the emergency department. The topics discussed in this article include seizures and status epilepticus, respiratory failure, cardiovascular collapse and mechanical circulatory support, antidotes and drug-specific therapies, acute liver failure, and extracorporeal toxin removal.

Timing of liver transplantation for pediatric acute liver failure due to mushroom poisoning: a case report and literature review

Background

Pediatric acute liver failure is a rare, life-threatening illness. Mushroom poisoning is a rare etiology. For patients with irreversible pediatric acute liver failure, liver transplantation is the ultimate lifesaving therapy. However, it is difficult to determine the optimal timing of transplantation. Here, we present a case of pediatric acute liver failure due to mushroom poisoning in northeastern China. He was treated with liver transplantation and recovered. To our knowledge, there are few reports about liver transplantation for pediatric acute liver failure caused by mushroom poisoning in mainland China.

Case presentation

The patient was a previously healthy 9-year-old boy who gradually developed nausea, vomiting, jaundice and coma within 5 days after ingesting mushrooms. He was diagnosed with mushroom poisoning and acute liver failure. He was treated with conservative care but still deteriorated. On the 7th day after poisoning, he underwent LT due to grade IV hepatic encephalopathy. Twenty days later, he recovered and was discharged. A review of the literature revealed that the specific criteria and optimal timing of transplantation remain to be determined.

Conclusions

Patients with pediatric acute liver failure should be transferred to a center with a transplant unit early. Once conservative treatment fails, liver transplantation should be performed.

Crizotinib-induced acute fatal liver failure in an Asian ALK-positive lung adenocarcinoma patient with liver metastasis: A case report

BACKGROUND

Crizotinib-induce hepatotoxicity is rare and non-specific, and severe hepatotoxicity can develop into fatal liver failure. Herein, we report a case of fatal crizotinib-induced liver failure in a 37-year-old Asian patient.

CASE SUMMARY

The patient complained of dyspnea and upper abdominal pain for a week in August 2017. He was diagnosed with anaplastic lymphoma kinase-rearranged lung adenocarcinoma combined with multiple distant metastases. Crizotinib was initiated as a first-line treatment at a dosage of 250 mg twice daily. No adverse effects were seen until day 46. On day 55, he was admitted to the hospital with elevated liver enzymes aspartate aminotransferase (AST) (402 IU/L), alanine aminotransferase (ALT) (215 IU/L) and total bilirubin (145 μmol/L) and was diagnosed with crizotinib-induced fulminant liver failure. Despite crizotinib discontinuation and intensive supportive therapy, the level of AST (1075 IU/L), ALT (240 IU/L) and total bilirubin (233 μmol/L) continued to rapidly increase, and he died on day 60.

CONCLUSION

Physicians should be aware of the potential fatal adverse effects of crizotinib.

Mesenchymal Stem Cells for Liver Regeneration in Liver Failure: From Experimental Models to Clinical Trials

The liver centralizes the systemic metabolism and thus controls and modulates the functions of the central and peripheral nervous systems, the immune system, and the endocrine system. In addition, the liver intervenes between the splanchnic and systemic venous circulation, determining an abdominal portal circulatory system. The liver displays a powerful regenerative potential that rebuilds the parenchyma after an injury. This regenerative mission is mainly carried out by resident liver cells. However, in many cases this regenerative capacity is insufficient and organ failure occurs. In normal livers, if the size of the liver is at least 30% of the original volume, hepatectomy can be performed safely. In cirrhotic livers, the threshold is 50% based on current practice and available data. Typically, portal vein embolization of the part of the liver that is going to be resected is employed to allow liver regeneration in two-stage liver resection after portal vein occlusion (PVO). However, hepatic resection often cannot be performed due to advanced disease progression or because it is not indicated in patients with cirrhosis. In such cases, liver transplantation is the only treatment possibility, and the need for transplantation is the common outcome of progressive liver disease. It is the only effective treatment and has high survival rates of 83% after the first year. However, donated organs are becoming less available, and mortality and the waiting lists have increased, leading to the initiation of living donor liver transplantations. This type of transplant has overall complications of 38%. In order to improve the treatment of hepatic injury, much research has been devoted to stem cells, in particular mesenchymal stem cells (MSCs), to promote liver regeneration. In this review, we will focus on the advances made using MSCs in animal models, human patients, ongoing clinical trials, and new strategies using 3D organoids.

Comparison of Prognostic Models in Acute Liver Failure: Decision is to be Dynamic

Background and aims

Acute liver failure (ALF) is a rare disease entity with a high mortality. Management is dependent on accurate prognostication.

Materials and methods

One hundred consecutive patients presenting with ALF were prospectively evaluated. The King's college criteria (KCC), ALF early dynamic model (ALFED), sequential organ failure assessment (SOFA) score, and acute physiology and health evaluation II (APACHE II) scores were compared to predict mortality.

Results

There were significant differences in means of all the scores between survivors and nonsurvivors. The SOFA 48 hours had the highest area under receiver operating characteristic curve (AUC) (0.857) closely followed by the ALFED score (0.844). The optimal cutoff for the SOFA score at 48 hours to predict subsequent survival outcome is ≥10 and for the ALFED score is ≥5. Sequential organ failure assessment 48 hours had a good sensitivity of 87%, and the ALFED score showed a good specificity of 84%. The decision curve analysis showed that between a threshold probability of 0.13 and 0.6, use of the SOFA score provided the maximum net benefit and at threshold probabilities of >0.6, the use of ALFED score provided the maximum clinical benefit.

Conclusion

Dynamic scoring results in better prognostication in ALF. The SOFA 48 hours and ALFED score have good prognostication value in nonacetaminophen-induced liver failure.

How to cite this article

Saluja V, Sharma A, Pasupuleti SSR, Mitra LG, Kumar G, Agarwal PM. Comparison of Prognostic Models in Acute Liver Failure: Decision is to be Dynamic. Indian J Crit Care Med 2019;23(12):574–581.