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Coirier V, Quelven Q, Guillot P, Delamaire F, Houssel-Debry P, Maamar A, Painvin B, Gacouin A, Lesouhaitier M, Rayar M, Grulois I, Terzi N, Tadié JM, Camus C. Adverse Events and Outcomes of High-volume Plasma Exchange in 50 Acute Liver Failure Patients: A Monocentric Retrospective Real-world Study. J Clin Exp Hepatol 2025; 15:101934. [PMID: 39268478 PMCID: PMC11387678 DOI: 10.1016/j.jceh.2024.101934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 07/10/2024] [Indexed: 09/15/2024] Open
Abstract
Background and aims Acute liver failure (ALF) is a condition that mostly requires Intensive Care Unit (ICU) admission and sometimes necessitates emergency liver transplantation. High-volume plasma exchange (HVPE) may improve transplant-free survival (TFS) in ALF. Our study assessed complications of HVPE therapy and outcome in ALF patients. Methods We conducted a single-center retrospective study of all patients admitted to the ICU for ALF and who underwent HVPE between June 2016 and June 2021. The plasmapheresis technique used was centrifugation, and the volume exchanged was calculated as 15% of the ideal body weight. Dedicated staff prospectively collected clinical adverse effects, while biological data were retrospectively collected. The primary outcome was the rate of severe adverse effects (SAE, defined as severe manifestations of hypotension, allergy, metabolic disturbances or other life-threatening event) that occurred during HVPE sessions. Factors influencing day-21 TFS were also studied. Results One hundred twenty sessions were performed in 50 patients. The main etiology for ALF was paracetamol (52% of the patients). During the session, hemoglobin, platelet, transaminases, ammonia and bilirubin decreased, coagulation factors increased, and creatinine and lactate remained unchanged. At least one SAE was reported for 32 out of 120 sessions (26.7% [19%-35.5%], mostly severe alkalosis [24/117], hypotension [4/120] and hypocalcemia [4/119]). Arterial pH ≤ 7.43 following HVPE and paracetamol etiology were negatively and positively associated with day-21 TFS, respectively. Conclusion Severe adverse effects were frequent during HVPE performed for ALF, mainly severe alkalosis, hypotension and hypocalcemia. Post-HVPE, pH and paracetamol etiology were prognosis markers.
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Affiliation(s)
- Valentin Coirier
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Quentin Quelven
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Pauline Guillot
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Flora Delamaire
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Pauline Houssel-Debry
- Université de Rennes, Faculté de Médecine, Rennes, France
- Service des Maladies du Foie, CHU de Rennes, Rennes, France
| | - Adel Maamar
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Benoît Painvin
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Arnaud Gacouin
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Mathieu Lesouhaitier
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Michel Rayar
- Université de Rennes, Faculté de Médecine, Rennes, France
- Service de Chirurgie Hépatobiliaire et Digestive, CHU de Rennes, Rennes, France
| | | | - Nicolas Terzi
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Jean-Marc Tadié
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
| | - Christophe Camus
- Maladies Infectieuses et Réanimation Médicale, CHU de Rennes, Rennes, France
- Université de Rennes, Faculté de Médecine, Rennes, France
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Clouston AD, Gouw ASH, Tiniakos D, Bedossa P, Brunt EM, Callea F, Dienes HP, Goodman ZD, Hubscher SG, Kakar S, Kleiner DE, Lackner C, Park YN, Roberts EA, Schirmacher P, Terracciano L, Torbenson M, Wanless IR, Zen Y, Burt AD. Severe acute liver disease in adults: Contemporary role of histopathology. Histopathology 2024; 85:549-561. [PMID: 38773813 DOI: 10.1111/his.15212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 04/11/2024] [Accepted: 05/02/2024] [Indexed: 05/24/2024]
Abstract
Liver biopsies have consistently contributed to our understanding of the pathogenesis and aetiologies of acute liver disease. As other diagnostic modalities have been developed and refined, the role of biopsy in the management of patients with acute liver failure (ALF), acute-on-chronic liver failure (ACLF) and acute hepatitis, including acute liver injury (ALI), has changed. Liver biopsy remains particularly valuable when first-line diagnostic algorithms fail to determine aetiology. Despite not being identified as a mandatory diagnostic tool in recent clinical guidelines for the management of ALF or ACLF, many centres continue to undertake biopsies given the relative safety of transjugular biopsy in this setting. Several studies have demonstrated that liver biopsy can provide prognostic information, particularly in the context of so-called indeterminate hepatitis, and is extremely useful in excluding conditions such as metastatic tumours that would preclude transplantation. In addition, its widespread use of percutaneous biopsies in cases of less severe acute liver injury, for example in the establishment of a diagnosis of acute presentation of autoimmune hepatitis or confirmation of a probable or definite drug-induced liver injury (DILI), has meant that many centres have seen a shift in the ratio of specimens they are receiving from patients with chronic to acute liver disease. Histopathologists therefore need to be equipped to deal with these challenging specimens. This overview provides an insight into the contemporary role of biopsies (as well as explant and autopsy material) in diagnosing acute liver disease. It outlines up-to-date clinical definitions of liver injury and considers recent recommendations for the diagnosis of AIH and drug-induced, autoimmune-like hepatitis (DI-AIH).
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Affiliation(s)
- Andrew D Clouston
- Centre for Liver Disease Research, School of Medicine (Southern), University of Queensland, Princess Alexandra Hospital, Ipswich, Australia
| | - Annette S H Gouw
- Department of Pathology and Medical Biology, University Medical Center Groningen, Groningen, the Netherlands
| | - Dina Tiniakos
- Department of Pathology, Aretaieion Hospital, Medical School, National & Kapodistrian University of Athens, Athens, Greece
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Elizabeth M Brunt
- Pathology and Immunology, Washington University School of Medicine, St Louis, MO, USA
| | | | - Hans-Peter Dienes
- Institute of Pathology, Meduniwien, Medical University of Vienn, Wien, Austria
| | - Zachary D Goodman
- Center for Liver Diseases, Inova Fairfax Hospital, Falls Church, VA, USA
| | - Stefan G Hubscher
- Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sanjay Kakar
- Department of Pathology, University of California, San Francisco, CA, USA
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Carolin Lackner
- Institute of Pathology, Medical University of Graz, Graz, Austria
| | - Young N Park
- Department of Pathology, Yonsei University College of Medicine, Seoul, Korea
| | - Eve A Roberts
- Division of Gastroenterology, Hepatology and Nutrition, The Hospital for Sick Children, Toronto, ON, Canada
| | | | - Luigi Terracciano
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- IRCCS Humanitas Research Hospital, Milan, Italy
| | - Michael Torbenson
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Ian R Wanless
- Department of Pathology, Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Alastair D Burt
- Faculty of Medical Sciences, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
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3
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Wang X, Zheng MY, He HY, Zhu HL, Zhao YF, Chen YH, Xu ZY, Yang JH, Sun DL. Quality Evaluation of Guidelines for the Diagnosis and Treatment of Liver Failure. Crit Care Med 2024; 52:1624-1632. [PMID: 38832833 PMCID: PMC11392122 DOI: 10.1097/ccm.0000000000006346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
OBJECTIVES This study aimed to systematically assess the methodological quality and key recommendations of the guidelines for the diagnosis and treatment of liver failure (LF), furnishing constructive insights for guideline developers and equipping clinicians with evidence-based information to facilitate informed decision-making. DATA SOURCES Electronic databases and manual searches from January 2011 to August 2023. STUDY SELECTION Two reviewers independently screened titles and abstracts, then full texts for eligibility. Fourteen guidelines were included. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted data and checked by two others. Methodological quality of the guidelines was appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Of the 14 guidelines, only the guidelines established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60%, thereby meriting clinical recommendations. It emerged that there remains ample room for enhancement in the quality of the guidelines, particularly within the domains of stakeholder engagement, rigor, and applicability. Furthermore, an in-depth scrutiny of common recommendations and supporting evidence drawn from the 10 adult LF guidelines unveiled several key issues: controversy exists in the recommendation, the absence of supporting evidence and confusing use of evidence for recommendations, and a preference in evidence selection. CONCLUSIONS There are high differences in methodological quality and recommendations among LF guidelines. Improving these existing problems and controversies will benefit existing clinical practice and will be an effective way for developers to upgrade the guidelines.
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Affiliation(s)
- Xia Wang
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Meng-Yao Zheng
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hai-Yu He
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Hui-Ling Zhu
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Ya-Fang Zhao
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yu-Hang Chen
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Zhi-Yuan Xu
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jin-Hui Yang
- Department of Gastroenterology, Second Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Da-Li Sun
- Department of Gastrointestinal Surgery, Second Affiliated Hospital of Kunming Medical University, Kunming, China
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Sarin Zacharia G, Jacob A. Ammonia in liver diseases: A glimpse into the controversies and consensus. Arab J Gastroenterol 2024:S1687-1979(24)00078-9. [PMID: 39294031 DOI: 10.1016/j.ajg.2024.07.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/20/2024] [Accepted: 07/26/2024] [Indexed: 09/20/2024]
Abstract
Ammonia is a byproduct of the metabolism of nitrogen-containing micro and macromolecules. The key source of bodily ammonia in humans is the small intestine, from diet, luminal bacterial activity, and deamination of glutamine in enterocytes. It is disposed of from the system, mainly in the liver, through the urea cycle. Physiologically, ammonia plays a minor role in acid-base homeostasis. It is the critical molecule implicated in the pathogenesis of hepatic encephalopathy. Liver disease is the most common cause of hyperammonemia, while others include urea cycle defects, infections, and drugs. The diagnostic utility of ammonia in liver diseases has met with increasing skepticism but holds good in urea cycle defects. Additionally, the accuracy of ammonia assay depends on a myriad of patient and technical factors, making the test unreliable if not performed meticulously. Most scientific societies currently fall short of recommending ammonia for diagnostic purposes in chronic liver disease. Despite this fact, ammonia continues to be one of the most frequently requested assays in patients with suspected hepatic encephalopathy, contributing to significant non-productive health expenditure. However, ammonia level does have a prognostic role in liver diseases, especially in acute liver failure. Ammonia-lowering strategies are the cornerstone of the management of hepatic encephalopathy. These strategies include medications that attenuate ammoniagenesis and ammonia scavengers. This review examines the role of ammonia in hepatic encephalopathy, its diagnostic and prognostic implications in liver diseases, challenges associated with ammonia assay, and current therapeutic strategies for ammonia-lowering in clinical practice.
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Bhatti ABH, Ul Haq N, Mehmood N, Hassan D, Ahmed A, Malik WT, Zia HH, Salih M, Khan NY, Ilyas A, Khan NA. Impact of Renal Replacement Therapy on Outcomes of Living Donor Liver Transplantation for Acute Liver Failure: A Cohort Study. Int J Hepatol 2024; 2024:8422308. [PMID: 39268546 PMCID: PMC11392576 DOI: 10.1155/2024/8422308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Revised: 07/30/2024] [Accepted: 08/21/2024] [Indexed: 09/15/2024] Open
Abstract
Despite the promising role of renal replacement therapy (RRT) in acute liver failure (ALF), high-risk patients need liver transplantation and remain at risk for death due to cerebral complications. The objective of this study was to report outcomes of living donor liver transplantation (LDLT) for ALF with perioperative RRT. This was a single-center retrospective cohort study. Out of 1167 LDLTs, 24 patients had ALF and met the King's College criteria for transplantation. They were categorized into no-RRT (n = 13) and RRT (n = 11) groups. We looked at 1-year posttransplant survival in these patients. The median serum ammonia level at the time of transplant in the no-RRT and RRT groups was 259.5 mcg/dL (222.7-398) and 70.6 mcg/dL (58.1-92.6) (p = 0.005). In the RRT group, serum ammonia level < 100 mcg/dL was achieved in all patients. Seven (53.8%) patients in the no-RRT group and 11/11 (100%) in the RRT group were extubated and regained full consciousness after LDLT (p = 0.013). The 90-day mortality was 6/13 (46.1%) and 2/11 (18.1%) (p = 0.211). There was no brainstem herniation-related mortality in the RRT group, that is, 5/13 (38.4%) and 0/11 (0%) (p = 0.030). The 1-year posttransplant survival was also significantly higher in the RRT group (p = 0.031). The use of RRT lowers serum ammonia levels and might reduce posttransplant mortality due to brainstem herniation.
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Affiliation(s)
- Abu Bakar Hafeez Bhatti
- Department of HPB Surgery and Liver Transplantation Shifa International Hospital, Islamabad, Pakistan
| | - Nauman Ul Haq
- Department of HPB Surgery and Liver Transplantation Shifa International Hospital, Islamabad, Pakistan
| | - Nayyer Mehmood
- Department of Nephrology Shifa International Hospital, Islamabad, Pakistan
| | - Danyal Hassan
- Department of Nephrology Shifa International Hospital, Islamabad, Pakistan
| | - Arsalan Ahmed
- Department of Neurology Shifa International Hospital, Islamabad, Pakistan
| | - Wasim Tariq Malik
- Department of Neurology Shifa International Hospital, Islamabad, Pakistan
| | - Haseeb Haider Zia
- Department of HPB Surgery and Liver Transplantation Shifa International Hospital, Islamabad, Pakistan
| | - Mohammad Salih
- Department of Gastroenterology and Hepatology Shifa International Hospital, Islamabad, Pakistan
| | - Nusrat Yar Khan
- Department of HPB Surgery and Liver Transplantation Shifa International Hospital, Islamabad, Pakistan
| | - Abid Ilyas
- Department of Surgical Critical Care Shifa International Hospital, Islamabad, Pakistan
| | - Nasir Ayub Khan
- Department of Anesthesiology Shifa International Hospital, Islamabad, Pakistan
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Conlon C, Li YJ, Ahmad J, Barnhart H, Fontana RJ, Ghabril M, Hayashi PH, Kleiner DE, Lee WM, Navarro V, Odin JA, Phillips EJ, Stolz A, Vuppalanchi R, Halegoua-DeMarzio D. Clinical characteristics and HLA associations of azithromycin-induced liver injury. Aliment Pharmacol Ther 2024; 60:787-795. [PMID: 38988034 DOI: 10.1111/apt.18160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 05/30/2024] [Accepted: 07/01/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Azithromycin (AZ) is a widely used antibiotic. The aim of this study was to characterise the clinical features, outcomes, and HLA association in patients with drug-induced liver injury (DILI) due to AZ. METHODS The clinical characteristics of individuals with definite, highly likely, or probable AZ-DILI enrolled in the US Drug-Induced Liver Injury Network (DILIN) were reviewed. HLA typing was performed using an Illumina MiSeq platform. The allele frequency (AF) of AZ-DILI cases was compared to population controls, other DILI cases, and other antibiotic-associated DILI cases. RESULTS Thirty cases (4 definite, 14 highly likely, 12 probable) of AZ-DILI were enrolled between 2004 and 2022 with a median age of 46 years, 83% white, and 60% female. Median duration of AZ treatment was 5 days. Latency was 18.5 days. 73% were jaundiced at presentation. The injury pattern was hepatocellular in 60%, cholestatic in 27%, and mixed in 3%. Ten cases (33%) were severe or fatal; 90% of these were hepatocellular. Two patients required liver transplantation. One patient with chronic liver disease died of hepatic failure. Chronic liver injury developed in 17%, of which 80% had hepatocellular injury at onset. HLA-DQA1*03:01 was significantly more common in AZ-DILI versus population controls and amoxicillin-clavulanate DILI cases (AF: 0.29 vs. 0.11, p = 0.001 and 0.002, respectively). CONCLUSION Azithromycin therapy can lead to rapid onset of severe hepatic morbidity and mortality in adult and paediatric populations. Hepatocellular injury and younger age were associated with worse outcomes. HLA-DQA1*03:01 was significantly more common in AZ cases compared to controls.
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Affiliation(s)
- Caroline Conlon
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Yi-Ju Li
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Jawad Ahmad
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Huiman Barnhart
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Marwan Ghabril
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - David E Kleiner
- National Cancer Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - William M Lee
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Victor Navarro
- Jefferson Health, Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Joseph A Odin
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Andrew Stolz
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Raj Vuppalanchi
- Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dina Halegoua-DeMarzio
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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7
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Fernández J, Bassegoda O, Toapanta D, Bernal W. Acute liver failure: A practical update. JHEP Rep 2024; 6:101131. [PMID: 39170946 PMCID: PMC11337735 DOI: 10.1016/j.jhepr.2024.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 05/17/2024] [Accepted: 05/22/2024] [Indexed: 08/23/2024] Open
Abstract
Acute liver failure is a rare and dynamic condition, with a broad aetiology and an incompletely understood pathophysiology. Management of this life-threatening disease requires critical care and organ support and frequently early liver transplantation. Proper identification, prevention and treatment of complications such as intracranial hypertension and sepsis are critical to optimising outcomes. The identification of the cause of acute liver failure and the prompt initiation of the aetiological treatment can also improve prognosis. Survival has progressively improved in parallel to advances in medical treatment. Intracranial hypertension complicating hepatic encephalopathy is less frequent than in the past and intracranial pressure monitoring now relies on non-invasive techniques. Current prognostic models have good accuracy to identify patients who will die without liver transplantation but are not able to identify those in whom transplantation is futile. New prognostic markers to select patients for transplantation are still in the pipeline. Therapeutic plasma exchange and, in some centers, early renal replacement therapy are well established treatments for the disease. The use of other artificial liver devices in clinical practice is not supported by evidence. This review is intended to provide a clinical update on the management of acute liver failure, incorporating the most recent advances in the field.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
- EF Clif, EASL-CLIF Consortium, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Spain
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, United Kingdom
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8
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Riveiro-Barciela M, Barreira-Díaz A, Esteban P, Rota R, Álvarez-Navascúes C, Pérez-Medrano I, Mateos B, Gómez E, De-la-Cruz G, Ferre-Aracil C, Horta D, Díaz-González Á, Ampuero J, Díaz-Fontenla F, Salcedo M, Ruiz-Cobo JC, Londoño MC. Rituximab is a safe and effective alternative treatment for patients with autoimmune hepatitis: Results from the ColHai registry. Liver Int 2024; 44:2303-2314. [PMID: 38809086 DOI: 10.1111/liv.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND AIMS Small series suggest that rituximab could be effective as treatment for autoimmune hepatitis (AIH), although data are scarce. We aimed to evaluate the efficacy and safety of rituximab in different cohorts of patients with AIH. METHODS Multicentre retrospective analysis of the 35 patients with AIH and its variant forms treated with rituximab and included in the ColHai registry between 2015 and 2023. RESULTS Most patients were female (83%), 10 (29%) had cirrhosis and four (11.4%) variant forms of AIH. Indication for rituximab were as follows: 14(40%) refractory AIH, 19(54%) concomitant autoimmune or haematological disorder, 2(6%) intolerance to prior treatments. In three (9%) subjects with a concomitant disorder, rituximab was the first therapy for AIH. Overall, 31 (89%) patients achieved or maintained complete biochemical response (CBR), including the three in first-line therapy. No difference in CBR was observed according to rituximab indication (refractory AIH 86% vs. concomitant disorders 90%, p = .824) or cirrhosis (80% vs. 92%, p = .319). Rituximab was associated with a significant reduction in corticosteroids (median dose: prior 20 vs. post 5 mg, p < .001) and the discontinuation of ≥1 immunosuppressant in 47% of patients. Flare-free rate at 1st, 2nd and 3rd year was 86%, 73% and 62% respectively. Flares were not associated with the development of liver failure and were successfully managed with repeated doses of rituximab and/or increased corticosteroids. Three (9%) patients experienced infusion-related adverse events (1 anaphylaxis and 2 flu-like symptoms) and five (14%) infections. CONCLUSION Rituximab is safe and effective in patients with refractory AIH and those treated due to concomitant autoimmune or haematological disorders.
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Affiliation(s)
- Mar Riveiro-Barciela
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Eppendorf, Germany
| | - Ana Barreira-Díaz
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Paula Esteban
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - Rosa Rota
- Liver Unit, Gastroenterology Department, Hospital Universitario de Bellvitge, IDIBELL, L'hospitalet, Spain
| | | | - Indhira Pérez-Medrano
- Gastroenterology Department, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Beatriz Mateos
- Gastroenterology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Elena Gómez
- Gastroenterology Department, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Gema De-la-Cruz
- Gastroenterology Department, Complejo Hospitalario Universitario de Toledo, Toledo, Spain
| | - Carlos Ferre-Aracil
- Gastroenterology and Hepatology Department, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain
| | - Diana Horta
- Gastroenterology Department, Hospital Universitari Mutua de Terrassa, Terrassa, Spain
| | - Álvaro Díaz-González
- Gastroenterology and Hepatology Department, Clinical and Translational Research in Digestive Diseases, Valdecilla Research Institute (IDIVAL), Marqués de Valdecilla University Hospital, Santander, Spain
| | - Javier Ampuero
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Gastroenterology Department, Hospital Universitario Virgen del Rocio, Institute of Biomedicine of Sevilla (IBIS), Sevilla, Spain
- Department of Medicine, University of Sevilla, Sevilla, Spain
| | - Fernando Díaz-Fontenla
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Magdalena Salcedo
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- Gastroenterology Department, Hospital General Universitario Gregorio Marañón, Universidad Complutense de Madrid, Madrid, Spain
| | - Juan-Carlos Ruiz-Cobo
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- Liver Unit, Internal Medicine Department, Hospital Universitari Vall d'Hebron, Vall d'Hebron Barcelona Hospital Campus, Barcelona, Spain
| | - María-Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Instituto de Salud Carlos III, Madrid, Spain
- European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Eppendorf, Germany
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
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Kaya E, Nekarda P, Traut I, Aurich P, Canbay A, Katsounas A. [When should a liver disease patient be admitted to the intensive care unit?]. Med Klin Intensivmed Notfmed 2024; 119:470-477. [PMID: 39017943 DOI: 10.1007/s00063-024-01160-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 05/27/2024] [Accepted: 06/04/2024] [Indexed: 07/18/2024]
Abstract
Liver diseases are a significant global cause of morbidity and mortality. Liver cirrhosis can result in severe complications such as bleeding, hepatic encephalopathy (HE), and infections. Implementing a clear strategy for intensive care unit (ICU) admission management improves patient outcomes. Hemodynamically significant esophageal/gastric variceal bleeding (E/GVB) and grade 4 HE, when accompanied by the need for renal replacement therapy (RRT), are definitive indications for ICU admission. E/GVB, spontaneous bacterial peritonitis (SBP), and infections with multidrug-resistant organisms (MDRO) require close and stringent critical assessment. Patients with severe hepatorenal syndrome (HRS) or respiratory failure have increased baseline mortality and most likely benefit from early ICU treatment. Rapid identification of sepsis in patients with liver cirrhosis is a crucial criterion for ICU admission. Prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management. In addition, "Liver Units" provide an intermediate care (IMC) level for patients with liver diseases who require close monitoring but do not need immediate intensive care.
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Affiliation(s)
- Eda Kaya
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Patrick Nekarda
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Isabella Traut
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Philipp Aurich
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Ali Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Antonios Katsounas
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland.
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10
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Brozat JF, Pohl J, Engelmann C, Tacke F. [Liver transplantation in acute and acute-on-chronic liver failure]. Med Klin Intensivmed Notfmed 2024; 119:484-492. [PMID: 39043956 DOI: 10.1007/s00063-024-01158-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 06/04/2024] [Indexed: 07/25/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) are diseases with a rapidly progressive course and high mortality. Apart from treating the underlying triggers and intensive care measures, there are very limited therapeutic options for either condition. Liver transplantation is often the only life-saving treatment, but it cannot always be employed due to contraindications and severe disease progression. ACLF is characterized by underlying liver cirrhosis and typical triggers such as bacterial infections, bleeding, or alcohol binges. ALF occurs in previously healthy livers, usually as a result of purely hepatotoxic events. Disease differences are also reflected in the course and regulations of liver transplantation. Newer prognostic parameters and prioritization programs for ACLF can help improve both waiting list mortality and outcomes after transplantation.
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Affiliation(s)
- Jonathan F Brozat
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Julian Pohl
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Cornelius Engelmann
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland
| | - Frank Tacke
- Medizinische Klinik mit Schwerpunkt Hepatologie und Gastroenterologie, Charité - Universitätsmedizin Berlin, Campus Charité Mitte (CCM) und Campus Virchow-Klinikum (CVK), Augustenburger Platz 1, 15335, Berlin, Deutschland.
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11
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Yang GH, Yoon YI, Hwang S, Kim KH, Ahn CS, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Lee SG. Clinical significance and outcomes of adult living donor liver transplantation for acute liver failure: a retrospective cohort study based on 15-year single-center experience. Ann Surg Treat Res 2024; 107:167-177. [PMID: 39282101 PMCID: PMC11390282 DOI: 10.4174/astr.2024.107.3.167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 07/01/2024] [Accepted: 07/01/2024] [Indexed: 09/18/2024] Open
Abstract
Purpose This study aimed to describe adult living donor liver transplantation (LDLT) for acute liver failure and evaluate its clinical significance by comparing its surgical and survival outcomes with those of deceased donor liver transplantation (DDLT). Methods We retrospectively reviewed the medical records of 267 consecutive patients (161 LDLT recipients and 106 DDLT recipients) aged 18 years or older who underwent liver transplantation between January 2006 and December 2020. Results The mean periods from hepatic encephalopathy to liver transplantation were 5.85 days and 8.35 days for LDLT and DDLT, respectively (P = 0.091). Among these patients, 121 (45.3%) had grade III or IV hepatic encephalopathy (living, 34.8% vs. deceased, 61.3%; P < 0.001), and 38 (14.2%) had brain edema (living, 16.1% vs. deceased, 11.3%; P = 0.269) before liver transplantation. There were no significant differences in in-hospital mortality (living, 11.8% vs. deceased, 15.1%; P = 0.435), 10-year overall survival (living, 90.8% vs. deceased, 84.0%; P = 0.096), and graft survival (living, 83.5% vs. deceased, 71.3%; P = 0.051). However, postoperatively, the mean intensive care unit stay was shorter in the LDLT group (5.0 days vs. 9.5 days, P < 0.001). In-hospital mortality was associated with vasopressor use (odds ratio [OR], 3.40; 95% confidence interval [CI], 1.45-7.96; P = 0.005) and brain edema (OR, 2.75; 95% CI, 1.16-6.52; P = 0.022) of recipient at the time of transplantation. However, LDLT (OR, 1.26; 95% CI, 0.59-2.66; P = 0.553) was not independently associated with in-hospital mortality. Conclusion LDLT is feasible for acute liver failure when organs from deceased donors are not available.
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Affiliation(s)
- Geun-Hyeok Yang
- Division of Hepatobiliary Surgery and Transplantation, Department of Surgery, Kyunghee University Hospital at Gangdong, Kyunghee University College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Roedl K, Fuhrmann V. [Liver diseases in the intensive care unit]. Med Klin Intensivmed Notfmed 2024; 119:449-457. [PMID: 38937335 DOI: 10.1007/s00063-024-01157-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
The frequency of liver diseases in the intensive care unit has increased significantly in recent years and is now observed in up to 20% of critically ill patients. The occurrence of liver disease is associated with significantly increased morbidity and mortality. Two groups of liver diseases in the intensive care unit can be distinguished. First, the group of "primary hepatic dysfunctions", which includes primary acute liver failure as well as acute-on-chronic liver failure in patients with pre-existing liver cirrhosis. The second group of "secondary or acquired liver diseases" includes cholestatic liver diseases, as well as hypoxic liver injury and mixed forms, as well as other rarer liver diseases. Due to the diversity of liver diseases and the very different triggers, sufficient knowledge of the underlying changes (including hemodynamic changes, inflammatory states or drug-related) is essential. Early recognition, diagnosis, and treatment of the underlying disease are essential for all liver dysfunction in critically ill patients in the intensive care unit. This review article aims to take a closer look at liver diseases in the intensive care unit and provides insight into diagnostics and treatment options.
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Affiliation(s)
- Kevin Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Valentin Fuhrmann
- Abteilung für Innere Medizin und Gastroenterologie, Heilig-Geist-Krankenhaus, Köln, Deutschland
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13
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Berg T, Aehling NF, Bruns T, Welker MW, Weismüller T, Trebicka J, Tacke F, Strnad P, Sterneck M, Settmacher U, Seehofer D, Schott E, Schnitzbauer AA, Schmidt HH, Schlitt HJ, Pratschke J, Pascher A, Neumann U, Manekeller S, Lammert F, Klein I, Kirchner G, Guba M, Glanemann M, Engelmann C, Canbay AE, Braun F, Berg CP, Bechstein WO, Becker T, Trautwein C. S2k-Leitlinie Lebertransplantation der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1397-1573. [PMID: 39250961 DOI: 10.1055/a-2255-7246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/11/2024]
Affiliation(s)
- Thomas Berg
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Niklas F Aehling
- Bereich Hepatologie, Medizinischen Klinik II, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Tony Bruns
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martin-Walter Welker
- Medizinische Klinik I Gastroent., Hepat., Pneum., Endokrin. Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Tobias Weismüller
- Klinik für Innere Medizin - Gastroenterologie und Hepatologie, Vivantes Humboldt-Klinikum, Berlin, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
| | - Frank Tacke
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Pavel Strnad
- Medizinische Klinik III, Universitätsklinikum Aachen, Aachen, Deutschland
| | - Martina Sterneck
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Hamburg, Hamburg, Deutschland
| | - Utz Settmacher
- Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Daniel Seehofer
- Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Eckart Schott
- Klinik für Innere Medizin II - Gastroenterologie, Hepatologie und Diabetolgie, Helios Klinikum Emil von Behring, Berlin, Deutschland
| | | | - Hartmut H Schmidt
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Deutschland
| | - Hans J Schlitt
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | - Johann Pratschke
- Chirurgische Klinik, Charité Campus Virchow-Klinikum - Universitätsmedizin Berlin, Berlin, Deutschland
| | - Andreas Pascher
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Münster, Münster, Deutschland
| | - Ulf Neumann
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Essen, Deutschland
| | - Steffen Manekeller
- Klinik und Poliklinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie, Universitätsklinikum Bonn, Bonn, Deutschland
| | - Frank Lammert
- Medizinische Hochschule Hannover (MHH), Hannover, Deutschland
| | - Ingo Klein
- Chirurgische Klinik I, Universitätsklinikum Würzburg, Würzburg, Deutschland
| | - Gabriele Kirchner
- Klinik und Poliklinik für Chirurgie, Universitätsklinikum Regensburg und Innere Medizin I, Caritaskrankenhaus St. Josef Regensburg, Regensburg, Deutschland
| | - Markus Guba
- Klinik für Allgemeine, Viszeral-, Transplantations-, Gefäß- und Thoraxchirurgie, Universitätsklinikum München, München, Deutschland
| | - Matthias Glanemann
- Klinik für Allgemeine, Viszeral-, Gefäß- und Kinderchirurgie, Universitätsklinikum des Saarlandes, Homburg, Deutschland
| | - Cornelius Engelmann
- Charité - Universitätsmedizin Berlin, Medizinische Klinik m. S. Hepatologie und Gastroenterologie, Campus Virchow-Klinikum (CVK) und Campus Charité Mitte (CCM), Berlin, Deutschland
| | - Ali E Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum, Bochum, Deutschland
| | - Felix Braun
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
| | - Christoph P Berg
- Innere Medizin I Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen, Tübingen, Deutschland
| | - Wolf O Bechstein
- Klinik für Allgemein- und Viszeralchirurgie, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Becker
- Klinik für Allgemeine Chirurgie, Viszeral-, Thorax-, Transplantations- und Kinderchirurgie, Universitätsklinikum Schlewswig-Holstein, Kiel, Deutschland
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14
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Lal BB, Khanna R, Sood V, Alam S, Nagral A, Ravindranath A, Kumar A, Deep A, Gopan A, Srivastava A, Maria A, Pawaria A, Bavdekar A, Sindwani G, Panda K, Kumar K, Sathiyasekaran M, Dhaliwal M, Samyn M, Peethambaran M, Sarma MS, Desai MS, Mohan N, Dheivamani N, Upadhyay P, Kale P, Maiwall R, Malik R, Koul RL, Pandey S, Ramakrishna SH, Yachha SK, Lal S, Shankar S, Agarwal S, Deswal S, Malhotra S, Borkar V, Gautam V, Sivaramakrishnan VM, Dhawan A, Rela M, Sarin SK. Diagnosis and management of pediatric acute liver failure: consensus recommendations of the Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition (ISPGHAN). Hepatol Int 2024:10.1007/s12072-024-10720-3. [PMID: 39212863 DOI: 10.1007/s12072-024-10720-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 08/08/2024] [Indexed: 09/04/2024]
Abstract
Timely diagnosis and management of pediatric acute liver failure (PALF) is of paramount importance to improve survival. The Indian Society of Pediatric Gastroenterology, Hepatology, and Nutrition invited national and international experts to identify and review important management and research questions. These covered the definition, age appropriate stepwise workup for the etiology, non-invasive diagnosis and management of cerebral edema, prognostic scores, criteria for listing for liver transplantation (LT) and bridging therapies in PALF. Statements and recommendations based on evidences assessed using the modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) system were developed, deliberated and critically reappraised by circulation. The final consensus recommendations along with relevant published background information are presented here. We expect that these recommendations would be followed by the pediatric and adult medical fraternity to improve the outcomes of PALF patients.
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Affiliation(s)
- Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
| | - Aabha Nagral
- Department of Gastroenterology, Jaslok Hospital and Research Center, Mumbai, India
- Apollo Hospital, Navi Mumbai, India
| | - Aathira Ravindranath
- Department of Pediatric Gastroenterology, Apollo BGS Hospital, Mysuru, Karnataka, India
| | - Aditi Kumar
- Department of Pediatrics, All India Institute of Medical Sciences, Bhubaneswar, India
| | - Akash Deep
- Department of Pediatric Intensive Care, King's College Hospital, London, UK
| | - Amrit Gopan
- Department of Pediatric Gastroenterology and Hepatology, Sir H.N Reliance Foundation Hospital, Mumbai, India
| | - Anshu Srivastava
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Arjun Maria
- Division of Pediatric Gastroenterology, Hepatology and Nutrition, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Arti Pawaria
- Department of Pediatric Hepatology and Gastroenterology, Amrita Institute of Medical Sciences, Faridabad, India
| | - Ashish Bavdekar
- Department of Pediatrics, KEM Hospital and Research Centre, Pune, India
| | - Gaurav Sindwani
- Department of Organ Transplant Anesthesia and Critical Care, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Kalpana Panda
- Department of Pediatrics, Institute of Medical Sciences & SUM Hospital, Bhubaneshwar, India
| | - Karunesh Kumar
- Department of Pediatric Gastroenterology and Liver Transplantation, Indraprastha Apollo Hospitals, New Delhi, India
| | | | - Maninder Dhaliwal
- Department of Pediatric Intensive Care, Amrita Institute of Medical Sciences, Faridabad, India
| | - Marianne Samyn
- Department of Pediatric Hepatology, King's College Hospital, London, UK
| | - Maya Peethambaran
- Department of Pediatric Gastroenterology and Hepatology, VPS Lakeshore Hospital, Kochi, Kerala, India
| | - Moinak Sen Sarma
- Department of Pediatric Gastroenterology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Moreshwar S Desai
- Department of Paediatric Critical Care and Liver ICU, Baylor College of Medicine &Texas Children's Hospital, Houston, TX, USA
| | - Neelam Mohan
- Department of Pediatric Gastroenterology and Hepatology, Medanta the Medicity Hospital, Gurugram, India
| | - Nirmala Dheivamani
- Department of Paediatric Gastroenterology, Institute of Child Health and Hospital for Children, Egmore, Chennai, India
| | - Piyush Upadhyay
- Department of Pediatrics, Dr. Ram Manohar Lohia Institute of Medical Sciences, Lucknow, India
| | - Pratibha Kale
- Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rohan Malik
- Department of Pediatric Gastroenterology and Hepatology, All India Institute of Medical Sciences, New Delhi, India
| | - Roshan Lal Koul
- Department of Neurology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Snehavardhan Pandey
- Department of Pediatric Hepatology and Liver Transplantation, Sahyadri Superspeciality Hospital Pvt Ltd Pune, Pune, India
| | | | - Surender Kumar Yachha
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Sakra World Hospital, Bangalore, India
| | - Sadhna Lal
- Division of Pediatric Gastroenterology and Hepatology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahana Shankar
- Division of Pediatric Gastroenterology and Hepatology, Department of Pediatrics, Mazumdar Shaw Medical Centre, Narayana Health City, Bangalore, India
| | - Sajan Agarwal
- Department of Pediatric Gastroenterology and Hepatology, Gujarat Gastro Hospital, Surat, Gujarat, India
| | - Shivani Deswal
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplant, Narayana Health, DLF Phase 3, Gurugram, India
| | - Smita Malhotra
- Department of Pediatric Gastroenterology and Hepatology, Indraprastha Apollo Hospitals, New Delhi, India
| | - Vibhor Borkar
- Department of Paediatric Hepatology and Gastroenterology, Nanavati Max Super Speciality Hospital, Mumbai, Maharashtra, India
| | - Vipul Gautam
- Department of Pediatric Gastroenterology, Hepatology and Liver Transplantation, Max Superspeciality Hospital, New Delhi, India
| | | | - Anil Dhawan
- Department of Pediatric Hepatology, King's College Hospital, London, UK
| | - Mohamed Rela
- Department of Liver Transplantation and HPB (Hepato-Pancreatico-Biliary) Surgery, Dr. Rela Institute & Medical Center, Chennai, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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15
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Delle Cave V, Di Dato F, Calvo PL, Spagnuolo MI, Iorio R. Successful treatment of acute liver failure due to Wilson's disease: Serendipity or fortuity? World J Hepatol 2024; 16:1111-1119. [PMID: 39221095 PMCID: PMC11362907 DOI: 10.4254/wjh.v16.i8.1111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2024] [Revised: 05/28/2024] [Accepted: 06/18/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Acute liver failure (ALF) may be the first and most dramatic presentation of Wilson's disease (WD). ALF due to WD (WD-ALF) is difficult to distinguish from other causes of liver disease and is a clear indication for liver transplantation. There is no firm recommendation on specific and supportive medical treatment for this condition. AIM To critically evaluate the diagnostic and therapeutic management of WD-ALF patients in order to improve their survival with native liver. METHODS A retrospective analysis of patients with WD-ALF was conducted in two pediatric liver units from 2018 to 2023. RESULTS During the study period, 16 children (9 males) received a diagnosis of WD and 2 of them presented with ALF. The first was successfully treated with an unconventional combination of low doses of D-penicillamine and zinc plus steroids, and survived without liver transplant. The second, exclusively treated with supportive therapy, needed a hepatotransplant to overcome ALF. CONCLUSION Successful treatment of 1 WD-ALF patient with low-dose D-penicillamine and zinc plus steroids may provide new perspectives for management of this condition, which is currently only treated with liver transplantation.
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Affiliation(s)
- Valeria Delle Cave
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy
| | - Fabiola Di Dato
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy
| | - Pier Luigi Calvo
- Pediatric Gastroenterology Unit, Regina Margherita Children's Hospital, Azienda Ospedaliera-Universitaria Città della Salute e della Scienza, Turin 10126, Italy
| | - Maria Immacolata Spagnuolo
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy
| | - Raffaele Iorio
- Department of Translational Medical Science, Section of Pediatrics, University of Naples Federico II, Naples 80131, Italy.
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16
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Maiwall R, Kulkarni AV, Arab JP, Piano S. Acute liver failure. Lancet 2024; 404:789-802. [PMID: 39098320 DOI: 10.1016/s0140-6736(24)00693-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/13/2024] [Accepted: 04/03/2024] [Indexed: 08/06/2024]
Abstract
Acute liver failure (ALF) is a life-threatening disorder characterised by rapid deterioration of liver function, coagulopathy, and hepatic encephalopathy in the absence of pre-existing liver disease. The cause of ALF varies across the world. Common causes of ALF in adults include drug toxicity, hepatotropic and non-hepatotropic viruses, herbal and dietary supplements, antituberculosis drugs, and autoimmune hepatitis. The cause of liver failure affects the management and prognosis, and therefore extensive investigation for cause is strongly suggested. Sepsis with multiorgan failure and cerebral oedema remain the leading causes of death in patients with ALF and early identification and appropriate management can alter the course of ALF. Liver transplantation is the best current therapy, although the role of artificial liver support systems, particularly therapeutic plasma exchange, can be useful for patients with ALF, especially in non-transplant centres. In this Seminar, we discuss the cause, prognostic models, and management of ALF.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Juan Pablo Arab
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, Richmond, VA, USA; Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University and Hospital of Padova, Padova, Italy
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17
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Yu S, Li J, He T, Zheng H, Wang S, Sun Y, Wang L, Jing J, Wang R. Age-related differences in drug-induced liver injury: a retrospective single-center study from a large liver disease specialty hospital in China, 2002-2022. Hepatol Int 2024; 18:1202-1213. [PMID: 38898191 PMCID: PMC11297843 DOI: 10.1007/s12072-024-10679-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 04/06/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND AND AIMS Drug-induced liver injury (DILI) is a prevalent adverse reaction in clinical settings. However, there is limited research on age-related differences in DILI. We performed a large-scale retrospective study to delineate the characteristics of DILI across different age groups. METHODS We collected data on a total of 17,946 patients with confirmed DILI hospitalized at the Fifth Medical Center of the People's Liberation Army (PLA) General Hospital in Beijing, China, from January 1, 2002, to December 31, 2022. The patients were stratified based on age into the following groups: children (< 18 years), young adults (18-44 years), middle-aged individuals (45-64 years), and elderly individuals (≥ 65 years). We gathered demographic information, medical histories, laboratory results, disease severity assessments, and mortality statistics for all patients. RESULTS Overall, the distribution of DILI cases across different age groups was as follows: 6.57% were children, 24.82% were young adults, 49.06% were middle-aged individuals, and 19.54% were elderly individuals. The percentage of females increased with age, rising from 36.47% in the pediatric group to 60.51% in the elderly group. Notably, central nervous system agents (15.44%) and anti-infectious agents (21.80%) were more commonly associated with DILI in children, while cardiovascular agents (10.58%) and herbal dietary supplements or traditional medicines (H/TMs) (26.29%) were more prevalent among elderly people with DILI. Among all age groups, hepatocellular-type DILI was more common in the pediatric group (p < 0.001), whereas cholestatic-type DILI and chronic DILI were more prevalent in the elderly group (p < 0.001). Acute liver failure (ALF) and fatal outcomes were more prevalent in the pediatric and elderly groups, particularly in the pediatric group (2.04%, p = 0.041; 0.85%, p = 0.007, respectively). CONCLUSIONS Children and elderly individuals face a higher risk of adverse outcomes following DILI.
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Affiliation(s)
- Simiao Yu
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China.
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China.
| | - Jiahui Li
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China
| | - Tingting He
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China
| | - Haocheng Zheng
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Sici Wang
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, 100029, China
| | - Yongqiang Sun
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China
| | - Liping Wang
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China
| | - Jing Jing
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China.
| | - Ruilin Wang
- Department of Hepatology and Traditional Chinese Medicine, The Fifth Medical Center, PLA General Hospital, 100 West Fourth Ring Middle Road, Fengtai District, Beijing, 100039, China.
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18
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Xu X, Ding H, Jia J, Wei L, Duan Z, Tang C, Linghu E, Nan Y, Han Y, Xu J, Zhuang H. Chinese guidelines on the management of ascites in cirrhosis : Chinese Society of Hepatology, Chinese Medical Association. Hepatol Int 2024; 18:1071-1089. [PMID: 38980598 DOI: 10.1007/s12072-024-10697-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 05/03/2024] [Indexed: 07/10/2024]
Abstract
In 2023, Chinese Society of Hepatology of Chinese Medical Association convened a panel of experts to update the Chinese guidelines on the management of ascites and associated complications in cirrhosis which was launched in 2017 and renamed this guidelines as "Guidelines on the Management of Ascites in Cirrhosis." This comprehensive resource offers essential recommendations for the diagnosis and treatment of cirrhotic ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome.
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Affiliation(s)
- Xiaoyuan Xu
- Department of Gastroenterology, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China.
| | - Huiguo Ding
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jidong Jia
- Liver Disease Center, Beijing Friendship Hospital, Capital Medical University, No. 95, Yong'an Road, Xicheng District, Beijing, China
| | - Lai Wei
- Hepatobiliary and Pancreatic Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, No. 168, Litang Road, Changping District, Beijing, China
| | - Zhongping Duan
- Liver Disease Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Chengwei Tang
- Department of Gastroenterology, West China Hospital, Sichuan University, No. 37, Guoxue Lane, Wuhou District, Chengdu, Sichuan Province, China
| | - Enqiang Linghu
- Digestive Department, First Medical Center of Chinese, PLA General Hospital, No. 28, Fuxing Road, Haidian District, Beijing, China
| | - Yuemin Nan
- Department of Integrated Traditional Chinese and Western Medicine for Liver Diseases, the Third Hospital of Hebei Medical University, No. 139, Ziqiang Road, Shijiazhuang, Hebei Province, China
| | - Ying Han
- Liver Disease and Digestive Center, Beijing Youan Hospital, Capital Medical University, No. 8, West Headline Outside You'anmen, Fengtai District, Beijing, China
| | - Jinghang Xu
- Department of Infectious Diseases, Peking University First Hospital, No. 8, Xishiku St. Xicheng District, Beijing, China
| | - Hui Zhuang
- Department of Pathogenic Biology, Peking University Health Science Center, No. 38, Xueyuan Road, Haidian District, Beijing, China
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19
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Sasaki T, Kakisaka K, Kuroda H, Matsumoto T. Nutritional management for acute liver failure. Hepatol Res 2024; 54:736-744. [PMID: 38949571 DOI: 10.1111/hepr.14090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2024] [Revised: 06/04/2024] [Accepted: 06/14/2024] [Indexed: 07/02/2024]
Abstract
Acute liver failure (ALF) induces increased energy expenditure and disrupts the metabolism of essential nutrients. Hepatic encephalopathy is a complication of ALF with a poor prognosis and mainly involves the metabolic disturbance of amino acids in its pathogenesis. In this review, we discuss the nutritional management for ALF in consideration of the pathophysiology of ALF with respect to the impairment of hepatocyte function. It is known that enteral nutrition is recommended for patients with ALF, while parenteral nutrition is recommended for patients who cannot tolerate enteral nutrition. As ALF leads to a hypermetabolic state, the energy intake is recommended to cover 1.3 times the resting energy expenditure. Because of the high risk of hypoglycemia associated with disturbances in glucose metabolism, substantial glucose intake is recommended. Along with the deterioration of glucose metabolism, protein metabolism is also disrupted. As patients with ALF have increased systemic protein catabolism together with decreased protein synthesis, appropriate amounts of amino acids or protein under monitoring serum ammonia levels are recommended. In conclusion, nutritional management based on the understanding of nutritional pathophysiology is a pivotal therapeutic approach for patients with ALF. The approach should be individualized in the acute phase, the recovery phase, and the pretransplant phase.
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Affiliation(s)
- Tokio Sasaki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Keisuke Kakisaka
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Hidekatsu Kuroda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
| | - Takayuki Matsumoto
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Iwate Medical University, School of Medicine, Yahaba, Japan
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20
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Kulkarni AV, Gustot T, Reddy KR. Liver transplantation for acute liver failure and acute-on-chronic liver failure. Am J Transplant 2024:S1600-6135(24)00435-0. [PMID: 39094950 DOI: 10.1016/j.ajt.2024.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
Acute liver failure (ALF) and acute-on-chronic liver (ACLF) are distinct phenotypes of liver failure and, thus, need to be compared and contrasted for appropriate management. There has been a significant improvement in the outcomes of these patients undergoing liver transplantation (LT). Survival post-LT for ALF and ACLF ranges between 90% and 95% and 80% and 90% at 1 year, futility criteria have been described in both ALF and ACLF where organ failures define survival. Plasma exchange and continuous renal replacement therapy may serve as bridging therapies. Identifying the futility of LT is as necessary as the utility of LT in patients with ALF and ACLF. The role of regenerative therapies such as granulocyte colony-stimulating factors in ACLF and hepatocyte and xenotransplantation in both conditions remains uncertain. Measures to increase the donor pool through increasing deceased donor transplants in Asian countries, living donations in Western countries, auxiliary liver transplants, and ABO-incompatible liver transplants are necessary to improve the survival of these patients. In this review, we discuss the similarities and differences in clinical characteristics and the timing and outcomes of LT for ALF and ACLF, briefly highlighting the role of bridging therapies and providing an overview of recent advances in the management of ALF and ACLF.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, India
| | - Thierry Gustot
- Liver Transplant Unit, Department of Gastroenterology, Hepato-Pancreatology and Digestive Oncology, HUB Hôpital Erasme, Brussels, Belgium; Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium; Inserm Unité 1149, Centre de Recherche sur l'inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, USA.
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21
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Cardoso FS, Toapanta D, Jimenez N, Fidalgo P, Figueiredo A, Valdivieso M, Germano N, Rule JA, Lee WM, Abraldes JG, Reverter E, Karvellas CJ. Ammonia and urea metabolism in acute liver failure: A multicentre cohort study. Liver Int 2024. [PMID: 39016195 DOI: 10.1111/liv.16043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 06/29/2024] [Accepted: 07/06/2024] [Indexed: 07/18/2024]
Abstract
BACKGROUND & AIMS Ammonia is metabolized into urea in the liver. In acute liver failure (ALF), ammonia has been associated with survival. However, urea variation has been poorly studied. METHODS Observational cohort including ALF patients from Curry Cabral Hospital (Lisbon, Portugal) and Clinic Hospital (Barcelona, Spain) between 10/2010 and 01/2023. The United States ALF Study Group cohort was used for external validation. Primary exposures were serum ammonia and urea on ICU admission. Primary endpoint was 30-day transplant-free survival (TFS). Secondary endpoint was explanted liver weight. RESULTS Among 191 ALF patients, median (IQR) age was 46 (32; 57) years and 85 (44.5%) were males. Overall, 86 (45.0%) patients were transplanted and 75 (39.3%) died. Among all ALF patients, following adjustment for age, sex, body weight, and aetiology, higher ammonia or lower urea was independently associated with higher INR on ICU admission (p < .009). Among all ALF patients, following adjustment for sex, aetiology, and lactate, higher ammonia was independently associated with lower TFS (adjusted odds ratio (95% confidence interval [CI]) = 0.991 (0.985; 0.997); p = .004). This model predicted TFS with good discrimination (area under receiver operating curve [95% CI] = 0.78 [0.75; 0.82]) and reasonable calibration (R2 of 0.43 and Brier score of 0.20) after external validation. Among transplanted patients, following adjustment for age, sex, actual body weight, and aetiology, higher ammonia (p = .024) or lower (p < .001) urea was independently associated with lower explanted liver weight. CONCLUSIONS Among ALF patients, serum ammonia and urea were associated with ALF severity. A score incorporating serum ammonia predicted TFS reasonably well.
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Affiliation(s)
- Filipe S Cardoso
- Transplant Unit, Intensive Care Unit, Nova Medical School, Curry Cabral Hospital, Lisbon, Portugal
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
| | - David Toapanta
- Liver ICU, Liver Unit, Clinic Hospital, Barcelona, Spain
| | | | - Pedro Fidalgo
- Intensive Care Unit, São Francisco Xavier Hospital, Lisbon, Portugal
| | - António Figueiredo
- Pathological Anatomy Department, Curry Cabral Hospital, Lisbon, Portugal
| | | | - Nuno Germano
- Intensive Care Unit, Curry Cabral Hospital, Lisbon, Portugal
| | - Jody A Rule
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - William M Lee
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Juan G Abraldes
- Liver Unit, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Enric Reverter
- Liver ICU, Liver Unit, Clinic Hospital, Barcelona, Spain
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22
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Zeng Y, Wu Z, Chen G, Liu G, Zhang B, Zhou Y, Chen M, Yao R, Shi Y. Peripheral Injection of hUC-MSCs in the Treatment of Acute Liver Failure: A Pre-Clinical Cohort Study in Rhesus Monkeys. Stem Cells Int 2024; 2024:4654912. [PMID: 39045027 PMCID: PMC11265939 DOI: 10.1155/2024/4654912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 06/19/2024] [Accepted: 06/27/2024] [Indexed: 07/25/2024] Open
Abstract
Background Using a toxin-induced lethal acute liver failure (ALF) monkey model, we have recently shown that early peripheral infusion of human umbilical cord mesenchymal stem cells (hUC-MSCs) can alleviate liver damage and improve animal survival by suppressing the activation of circulating monocytes and the subsequent cytokine storm. Here, we explored whether the administration of hUC-MSCs could still improve ALF when the cytokine storm is fully developed. Method We treated ALF monkeys with peripheral delivery of hUC-MSCs at 48 hr after toxin challenge. Liver indices, histology, imaging, and animal survival were recorded and analyzed. Results In our cohort study, we conducted and demonstrated that the infusion of hUC-MSCs significantly improved liver histology, effectively controlled inflammatory cytokine storms, and increased survival rates. Additionally, the administration of a higher dose of hUC-MSCs (2 × 107/monkey) yielded superior outcomes compared to a lower dose (1 × 107/monkey). Conclusion Treatment of hUC-MSCs can significantly improve the pathological and survival outcomes of ALF even when the cytokine storm has been fully developed, indicating a promising clinical solution for ALF.
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Affiliation(s)
- Yuting Zeng
- Liver Transplant CenterTransplant Center and Key Laboratory of Transplant Engineering and ImmunologyNHCWest China HospitalSichuan University, Chengdu, China
- Institute of clinical PathologyWest China HospitalSichuan University, Chengdu, China
| | - Zhenru Wu
- Liver Transplant CenterTransplant Center and Key Laboratory of Transplant Engineering and ImmunologyNHCWest China HospitalSichuan University, Chengdu, China
- Institute of clinical PathologyWest China HospitalSichuan University, Chengdu, China
| | - Gen Chen
- Development and Application of Human Major Disease Monkey Model Key Laboratory of SichuanSichuan Yibin Horizontal and Vertical Biotechnology Co., Ltd., Yibin 644601, China
| | - Guoqiang Liu
- Development and Application of Human Major Disease Monkey Model Key Laboratory of SichuanSichuan Yibin Horizontal and Vertical Biotechnology Co., Ltd., Yibin 644601, China
| | - Bo Zhang
- Sichuan Stem Cell Bank and Sichuan Neo-Life Stem Cell Biotech Inc., Chengdu 610037, China
| | - Yongjie Zhou
- Laboratory of Liver TransplantationWest China HospitalSichuan University, Chengdu 610041, China
| | - Menglin Chen
- Liver Transplant CenterTransplant Center and Key Laboratory of Transplant Engineering and ImmunologyNHCWest China HospitalSichuan University, Chengdu, China
- Institute of clinical PathologyWest China HospitalSichuan University, Chengdu, China
| | - Rong Yao
- Department of Emergency MedicineEmergency Medical LaboratoryWest China HospitalSichuan University, Chengdu, Sichuan, China
| | - Yujun Shi
- Liver Transplant CenterTransplant Center and Key Laboratory of Transplant Engineering and ImmunologyNHCWest China HospitalSichuan University, Chengdu, China
- Institute of clinical PathologyWest China HospitalSichuan University, Chengdu, China
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23
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Wang K, Zhu Y, Li M, Yang Y, Zuo D, Sheng J, Zhang X, Wang W, Zhou P, Feng M. Genetically Modified Hepatocytes Targeting Bilirubin and Ammonia Metabolism for the Construction of Bioartificial Liver System. Biomater Res 2024; 28:0043. [PMID: 39011520 PMCID: PMC11246981 DOI: 10.34133/bmr.0043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 05/08/2024] [Indexed: 07/17/2024] Open
Abstract
Acute liver failure (ALF) is a complex syndrome that impairs the liver's function to detoxify bilirubin, ammonia, and other toxic metabolites. Bioartificial liver (BAL) aims to help ALF patients to pass through the urgent period by temporarily undertaking the liver's detoxification functions and promoting the recovery of the injured liver. We genetically modified the hepatocellular cell line HepG2 by stably overexpressing genes encoding UGT1A1, OATP1B1, OTC, ARG1, and CPS1. The resulting SynHeps-II cell line, encapsulated by Cytopore microcarriers, dramatically reduced the serum levels of bilirubin and ammonia, as demonstrated both in vitro using patient plasma and in vivo using ALF animal models. More importantly, we have also completed the 3-dimensional (3D) culturing of cells to meet the demands for industrialized rapid and mass production, and subsequently assembled the plasma-cell contacting BAL (PCC-BAL) system to fulfill the requirements of preclinical experiments. Extracorporeal blood purification of ALF rabbits with SynHeps-II-embedded PCC-BAL saved more than 80% of the animals from rapid death. Mechanistically, SynHeps-II therapy ameliorated liver and brain inflammation caused by high levels of bilirubin and ammonia and promoted liver regeneration by modulating the nuclear factor κB (NF-κB) and signal transducer and activator of transcription 3 (STAT3) pathways. Also, SynHeps-II treatment reduced cerebral infiltration of neutrophils, reduced reactive oxygen species (ROS) levels, and mitigated hepatic encephalopathy. Taken together, SynHeps-II cell-based BAL was promising for the treatment of ALF patients and warrants clinical trials.
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Affiliation(s)
- Ke Wang
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Yuankui Zhu
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Mengqing Li
- School of Basic Medicine, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei 430030, China
| | - Yaxi Yang
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Dianbao Zuo
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Junfeng Sheng
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Xinhai Zhang
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
| | - Wei Wang
- Wuhan TOGO Medical Technology Co. Ltd., Wuhan, Hubei 430205, China
| | - Ping Zhou
- Wuhan TOGO Medical Technology Co. Ltd., Wuhan, Hubei 430205, China
| | - Mingqian Feng
- College of Biomedicine and Health, College of Life Science and Technology, Huazhong Agricultural University, Wuhan, Hubei 430070, China
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24
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Alexander V, Chellaiya GK, Gnanadeepam S, David VG, James E, Kandasamy S, Abhilash KPP, Varughese S, Nair SC, Kumar S, Bharadwaj PK, Akilesh S, Kumar SE, Daniel D, Jayaraman S, Zachariah U, Eapen CE, Goel A. On-treatment decline in MELD score predicts one-month transplant-free survival in rodenticidal hepatotoxicity patients treated with low-volume plasma exchange. Indian J Gastroenterol 2024:10.1007/s12664-024-01585-3. [PMID: 39001974 DOI: 10.1007/s12664-024-01585-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 04/03/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND AND AIM Plasma exchange (PLEX) improves survival in patients with rodenticidal hepatotoxicity. However, predictors of treatment response are unknown. We aimed at assessing predictors of response to PLEX treatment in these patients. METHODS Patients with rodenticidal hepatotoxicity from 2014 to 2023 managed in our department were included in this study. Kochi criteria (model for end-stage liver disease [MELD] score ≥ 36 or international normalized ratio [INR] ≥ 6 with hepatic encephalopathy [HE]) derived specifically for rodenticidal hepatotoxicity (PubMed IDentifier [PMID]: 26310868) were used to assess need for liver transplantation. We analyzed predictors of survival at one month. ∆Bilirubin, ∆MELD score and ∆INR were calculated as percentage change of the parameter after third PLEX session (or after last PLEX if < 3 PLEX sessions done) from baseline pre-PLEX value. RESULTS Of 200 patients with rodenticidal hepatotoxicity, 114 patients were treated with low-volume PLEX (PLEX-LV). No patient had liver transplantation. Of 78 patients who fulfilled Kochi criteria, 32 patients were PLEX-LV eligible and underwent PLEX-LV (M: 10; age: 20.5, 7-70 years; median, range; acute liver failure: 24). Twenty-two (69%; acute liver failure: 14) of the 32 patients were alive at one month. Presence of HE (p = 0.03) and ∆MELD (p < 0.001) were significant predictors on univariate analysis, while ∆MELD (aOR = 0.88, 95% CI: 0.79-0.98, p = 0.01) was the only significant independent predictor of one-month transplant-free survival. Area under receiver operating characteristic (ROC) for ∆MELD was 0.93 (95% CI:0.85-1.00) and a decrease of ≥ 20% in MELD score while on PLEX-LV had 90% sensitivity and 90% specificity in predicting one-month survival. CONCLUSIONS Decline in MELD while on PLEX-LV independently predicted one-month transplant-free survival in rodenticidal hepatotoxicity patients. This may help guide decision on stopping PLEX-LV in patients predicted to respond to treatment and to consider alternate treatment options in non-responders.
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Affiliation(s)
- Vijay Alexander
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - S Gnanadeepam
- Nursing Services, Christian Medical College, Vellore, 632 004, India
| | - Vinoi George David
- Department of Nephrology, Christian Medical College, Vellore, 632 004, India
| | - Ebor James
- Pediatric Intensive Care Unit, Christian Medical College, Vellore, 632 004, India
| | - Subramani Kandasamy
- Division of Critical Care, Christian Medical College, Vellore, 632 004, India
| | | | - Santosh Varughese
- Department of Nephrology, Christian Medical College, Vellore, 632 004, India
| | - Sukesh Chandran Nair
- Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, 632 004, India
| | - Sandeep Kumar
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | - P Krishna Bharadwaj
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | - S Akilesh
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | - Santhosh E Kumar
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | - Dolly Daniel
- Transfusion Medicine and Immunohematology, Christian Medical College, Vellore, 632 004, India
| | - Sumathy Jayaraman
- Nursing Services, Christian Medical College, Vellore, 632 004, India
| | - Uday Zachariah
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India
| | | | - Ashish Goel
- Department of Hepatology, Christian Medical College, Vellore, 632 004, India.
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25
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Mishra A, Gupta J, Alam A, Verma SK. Acute liver failure with a massive upper GI bleed meeting the criteria of MIS-C. BMJ Case Rep 2024; 17:e256643. [PMID: 38964873 DOI: 10.1136/bcr-2023-256643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a known complication of COVID-19. There is still limited knowledge about this condition. Here, we report the case of a previously healthy toddler boy, who presented with acute liver failure and duodenal lesions resulting in severe haematemesis and haemorrhagic shock, requiring intensive care unit care. The patient had persistent transaminitis, a deranged coagulation profile, inflammatory markers were elevated, and laboratory tests were negative for common infectious hepatitis aetiologies as well as COVID-19 Reverse transcription polymerase chain reaction. His COVID-19 antibody was reactive. Upper gastrointestinal endoscopy revealed a Forrest grade III duodenal ulcer. Looking into the constellation of symptoms and laboratory findings a confirmed diagnosis of acute viral hepatitis caused by MIS-C was made. Hence, he was given intravenous methylprednisolone along with intravenous immunoglobulins, after which he improved clinically and transaminitis resolved. The patient was discharged on clinical improvement and was doing fine on follow-up up to 6 months.
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Affiliation(s)
- Anshika Mishra
- Pediatrics, King George's Medical University, Lucknow, India
| | - Jaya Gupta
- Pediatrics, King George's Medical University, Lucknow, India
| | - Areesha Alam
- Pediatrics, King George's Medical University, Lucknow, India
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26
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Hernández-Évole H, López Del Campo R, Bassegoda O. A Worrisome Liver Doppelgänger. Gastroenterology 2024; 167:e1-e4. [PMID: 38199590 DOI: 10.1053/j.gastro.2023.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 12/09/2023] [Accepted: 12/12/2023] [Indexed: 01/12/2024]
Affiliation(s)
| | | | - Octavi Bassegoda
- Liver Unit, Hospital Clinic Barcelona, Barcelona, Spain; Liver Intensive Care Unit, Hospital Clinic Barcelona, Barcelona, Spain.
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Campana V, Inizan C, Pommier JD, Menudier LY, Vincent M, Lecuit M, Lamballerie XD, Dupont-Rouzeyrol M, Murgue B, Cabié A. Liver involvement in dengue: A systematic review. Rev Med Virol 2024; 34:e2564. [PMID: 38923215 DOI: 10.1002/rmv.2564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 05/29/2024] [Accepted: 06/11/2024] [Indexed: 06/28/2024]
Abstract
Liver involvement is an unusual yet frequently overlooked dengue complication. Pivotal for an efficient clinical management, the early diagnosis of dengue-associated liver involvement relies on an accurate description of its clinical and biological characteristics, its prognosis factors, its association with severe dengue and its clinical management. We conducted a systematic review by searching PubMed and Web of Science databases for original case reports, cohort and cross-sectional studies reporting the clinical and/or biological features of dengue-associated liver involvement. The study was registered in PROSPERO (CRD42021262657). Of the 2552 articles identified, 167 were included. Dengue-associated liver involvement was characterised by clinical features including abdominal pain, hepatomegaly, jaundice, nausea/vomiting, and an echogenic liver exhibiting hepatocellular necrosis and minimal inflammation. Elevated Aspartate Aminotransferase and Alanine Aminotransferase but also elevated bilirubin, Alkaline Phosphatase, gamma-glutamyl transferase, increased International Normalised Ratio, creatinine and creatine kinase, lower albumin and prolonged prothrombin and activated partial thromboplastin time were prevalent in dengue-associated liver involvement. Cardiovascular and haematological systems were frequently affected, translating in a strong association with severe dengue. Liver involvement was more common in males and older adults. It was associated with dengue virus serotype-2 and secondary infections. Early paracetamol intake increased the risk of liver involvement, which clinical management was mostly conservative. In conclusion, this systematic review demonstrates that early monitoring of transaminases, clinical assessment, and ultrasound examination allow an efficient diagnosis of dengue-associated liver involvement, enabling the early identification and management of severe dengue.
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Affiliation(s)
- Valentine Campana
- CIC Antilles Guyane, INSERM CIC1424, Fort-de-France, France
- PCCEI, Université de Montpellier, INSERM, Etablissement Français du Sang, Université des Antilles, Montpellier, France
| | - Catherine Inizan
- Unité Dengue et Arboviroses, Institut Pasteur de Nouvelle-Calédonie, Pasteur Network, 110, Boulevard Joseph Wamytan, Dumbéa-sur-Mer, Noumea, New Caledonia
| | - Jean-David Pommier
- Intensive Care Unit, Guadeloupe Teaching Hospital, Antilles - Guyane University, Chemin de Chauvel, Les Abymes, France
| | | | | | - Marc Lecuit
- Institut Pasteur, Université Paris Cité, Inserm U1117, Biology of Infection Unit, Paris, France
- Necker-Enfants Malades University Hospital, Department of Infectious Diseases and Tropical Medicine, APHP, Paris, France
| | - Xavier De Lamballerie
- Unité des Virus Emergents (UVE: Aix-Marseille Université - IRD 190 - Inserm 1207), Marseille, France
| | - Myrielle Dupont-Rouzeyrol
- Unité Dengue et Arboviroses, Institut Pasteur de Nouvelle-Calédonie, Pasteur Network, 110, Boulevard Joseph Wamytan, Dumbéa-sur-Mer, Noumea, New Caledonia
| | - Bernadette Murgue
- Unité des Virus Emergents (UVE: Aix-Marseille Université - IRD 190 - Inserm 1207), Marseille, France
| | - André Cabié
- CIC Antilles Guyane, INSERM CIC1424, Fort-de-France, France
- PCCEI, Université de Montpellier, INSERM, Etablissement Français du Sang, Université des Antilles, Montpellier, France
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Orban C, Agapie M, Bratu A, Jafal M, Duțu M, Popescu M. No Significant Beneficial Effects of Intravenous N-Acetylcysteine on Patient Outcome in Non-Paracetamol Acute Liver Failure: A Meta-Analysis of Randomized Controlled Trials. Biomedicines 2024; 12:1462. [PMID: 39062036 PMCID: PMC11274394 DOI: 10.3390/biomedicines12071462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/22/2024] [Accepted: 06/28/2024] [Indexed: 07/28/2024] Open
Abstract
Acute liver failure is a life-threatening organ dysfunction with systemic organ involvement and is associated with significant mortality and morbidity unless specific management is undertaken. This meta-analysis aimed to assess the effects of intravenous N-acetylcysteine (NAC) on mortality and the length of hospital stay in patients with non-acetaminophen acute liver failure. Two hundred sixty-six studies from four databases were screened, and four randomized control trials were included in the final analysis. Our results could not demonstrate increased overall survival (OR 0.70, 95% CI [0.34, 1.44], p = 0.33) or transplant-free survival (OR 0.90, 95% CI [0.25, 3.28], p = 0.87) in patients treated with intravenous NAC. We observed an increased overall survival in adult patients treated with NAC (OR 0.59, 95% CI [0.35, 0.99], p = 0.05) compared to pediatric patients, but whether this is attributed to the age group or higher intravenous dose administered remains unclear. We did not observe a decreased length of stay in NAC-treated patients (OR -5.70, 95% CI [-12.44, 1.05], p = 0.10). In conclusion, our meta-analysis could not demonstrate any significant benefits on overall and transplant-free patient survival in non-acetaminophen ALF. Future research should also focus on specific etiologies of ALF that may benefit most from the use of NAC.
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Affiliation(s)
- Carmen Orban
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mihaela Agapie
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Angelica Bratu
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mugurel Jafal
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
| | - Mădălina Duțu
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesiology and Intensive Care, “Dr. Carol Davila” University Emergency Central Military Hospital, 134 Calea Plevnei, 010242 Bucharest, Romania
| | - Mihai Popescu
- Department of Anesthesia and Intensive Care, “Carol Davila” University of Medicine and Pharmacy, 37 Dionisie Lupu Street, 020021 Bucharest, Romania; (C.O.); (M.J.); (M.D.); (M.P.)
- Department of Anesthesia and Intensive Care, Bucharest University Emergency Hospital, 169 Independentei Street, 050098 Bucharest, Romania;
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Grover M, Gupta E, Samal J, Prasad M, Prabhakar T, Chhabra R, Agarwal R, Raghuvanshi BB, Sharma MK, Alam S. Rising trend of symptomatic infections due to Hepatitis A virus infection in adolescent and adult age group: An observational study from a tertiary care liver institute in India. Indian J Med Microbiol 2024; 50:100653. [PMID: 38906330 DOI: 10.1016/j.ijmmb.2024.100653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Revised: 05/27/2024] [Accepted: 06/19/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND Hepatitis A Virus (HAV) is the most common cause of Acute Viral Hepatitis (AVH) in children. It causes self-limiting illness and rarely acute liver failure. The shifting pattern in HAV endemicity is rendering adolescents and adults vulnerable to infection. METHODS In this retrospective study, samples received from 14,807 patients with acute onset icteric illness from January 2014-December 2022 were analyzed. HAV infection was detected by anti-HAV IgM positivity. The cases were divided into 3 age groups, pediatric, adolescents and adults, and clinical presentations were compared. RESULTS Overall, 7.72%(1144) were positive for anti-HAV IgM. Of these, 60%(690) were finally included in the study. The positive cases were divided into adults, ≥18 years (44%, 304); pediatric, <12 years (31%, 212) and adolescents (25%,174) age groups. Overall males were predominant [72.4%(500)], with a median age of 16 (IQR:9-21) years. Cases were characterised into AVH (68.1%, 470/690), Acute Liver Failure (ALF) (31.4%, 217/690) and Acute-on-Chronic Liver Failure (0.43%, 3/690). AVH in the pediatric age group was 69%(146/212), adolescents was 67%(117/174), and adults was 68%(207/304). ALF cases among the 3 groups were 30%(65/212), 33%(57/174), and 31%(95/304) respectively. Overall mortality was seen in 6.52%(45/690), maximum in adolescents with ALF presentation [10.3%(18/174)]. On molecular characterization of infection, viremia was seen in 28.9%(200/690) and all the isolates were Genotype IIIA. CONCLUSIONS The number of adults experiencing symptomatic HAV infection was seen to increase over the years in the present study. Infection in adolescents was associated with higher mortality and ALF as the clinical presentation.
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Affiliation(s)
- Malika Grover
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Ekta Gupta
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Jasmine Samal
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Manya Prasad
- Department of Epidemiology and Clinical Research, Institute of Liver & Biliary Sciences, New Delhi, India.
| | - Tushar Prabhakar
- Department of Epidemiology and Clinical Research, Institute of Liver & Biliary Sciences, New Delhi, India.
| | - Ruchita Chhabra
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Reshu Agarwal
- Department of Clinical Virology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | | | - Manoj Kumar Sharma
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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Singh K, Lamba M, Kumar V, Ahuja P, Gupta KK, Reddy H, Patwa A, Rungta S, Verma S. A Comparative Study of Novel Fibrosis Index and Other Non-invasive Serum Indices for Predicting Fibrosis in Patients of Chronic Liver Disease. Cureus 2024; 16:e63658. [PMID: 39092367 PMCID: PMC11293017 DOI: 10.7759/cureus.63658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2024] [Indexed: 08/04/2024] Open
Abstract
Introduction Chronic liver disease progression leads to liver fibrosis/cirrhosis. Transient Elastography is used for staging liver fibrosis but ascites, obesity, and operator experience limit its applicability. In this study, we compared various non-invasive serum indices in predicting fibrosis in chronic liver disease patients. Materials and methods A total of 142 cases of confirmed Chronic Liver Disease were included. Quantitative determination of liver stiffness by Transient Elastography and relevant blood investigations was done. We compared the liver stiffness measurement by Transient Elastography and fibrosis indices, i.e., Aspartate Transaminase (AST) to Alanine Transaminase (ALT) Ratio (AAR), AST to Platelet Ratio Index (APRI), Fibrosis Index (FI), Fibrosis-4 (FIB-4) Index, Age-Platelet Index (API), Pohl score, and Fibrosis Cirrhosis Index (FCI) with Novel Fibrosis Index (NFI), to predict liver fibrosis stages. Results The optimum cutoff of NFI for the F4 stage was ≥ 6670 with a sensitivity of 75.8% and specificity of 81.8%, for the F3 stage was ≥ 2112 with a sensitivity of 63.6% and specificity of 72.7%, and for the F2 stage was ≥ 1334 with a sensitivity of 100% and specificity of 56.3%. The NFI had the maximum area under the curve compared to other indices in predicting fibrosis stages. Conclusion The Novel Fibrosis Index was the best in predicting fibrosis stages in Chronic Liver Disease patients, with good performance in predicting the F4 stage.
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Affiliation(s)
- Kaustubh Singh
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Mahak Lamba
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Vivek Kumar
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Pahul Ahuja
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - K K Gupta
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Himanshu Reddy
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Ajay Patwa
- Internal Medicine, King George's Medical University, Lucknow, IND
| | - Sumit Rungta
- Gastroenterology, King George's Medical University, Lucknow, IND
| | - Sudhir Verma
- Internal Medicine, King George's Medical University, Lucknow, IND
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31
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Cheyne I, Boryszewski B, Chang W, Mikaszewska-Sokolewicz M. A DNA Polymerase Subunit Gamma (POLG) Mutation Imposing a Difficult Differential Diagnosis of Hepatic Encephalopathy in a Newborn: A Case Report. Cureus 2024; 16:e65239. [PMID: 39184802 PMCID: PMC11342063 DOI: 10.7759/cureus.65239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/24/2024] [Indexed: 08/27/2024] Open
Abstract
Hepatic encephalopathy (HE) is a condition connected with neuropsychiatric alteration during hepatic failure. The differential diagnosis of HE is challenging due to overlapping symptoms with other conditions. Polymerase subunit gamma (POLG) is a mitochondrial gene, and an infant POLG mutation can manifest with severe and progressive hepatic failure and encephalopathy, imposing a difficult differential diagnosis due to similarities to other conditions. The lack of curative treatment leads to a poor prognosis. An 11-month-old boy was admitted to the intensive care unit (ICU) due to altered consciousness and increasing edema due to acute hepatic failure of unknown etiology. After extensive multidisciplinary discussions and a lack of response to treatment for more than three weeks, a mitochondrial disease was suspected, and a genetic test was taken. The patient's condition continued to deteriorate. The patient died on the 25th day of hospitalization in the ICU. After death, a genetic test confirmed a rare POLG mutation NM_002693.3(POLG):c.3104+2T>A (Variation ID: 422378 Accession: VCV000422378.8). We suggest that a screen test for POLG mutations be considered early in the diagnostic process and that clinicians consider mitochondrial genetic mutations, such as POLG mutations, more often. This article is the first to describe a patient with this specific mutation.
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Affiliation(s)
- Ithamar Cheyne
- Anesthesiology and Critical Care Scientific Circle English Division (ANKONA ED), Medical University of Warsaw, Warsaw, POL
| | - Bartosz Boryszewski
- Anesthesiology and Critical Care Scientific Circle English Division (ANKONA ED), Medical University of Warsaw, Warsaw, POL
| | - Wyven Chang
- Anesthesiology and Critical Care Scientific Circle English Division (ANKONA ED), Medical University of Warsaw, Warsaw, POL
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Zhang Y, He X, Gu L, Li S, Tang J, Ma R, Yang H, Peng Z. Mefunidone ameliorates acute liver failure in mice by inhibiting MKK4-JNK pathway. Biochem Pharmacol 2024; 225:116267. [PMID: 38723721 DOI: 10.1016/j.bcp.2024.116267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 03/23/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
Acute liver failure (ALF) is a critical condition that can lead to substantial liver dysfunction. It is characterized by complex clinical manifestations and rapid progression, presenting significant challenges in diagnosis and treatment. We investigated the protective effect of mefunidone (MFD), a novel antifibrosis pyridone agent, on ALF in mice, and explored its potential mechanism of action. MFD pretreatment can alleviate lipopolysaccharide (LPS) and d-galactosamine (D-GalN)-induced ALF, reduce hepatocyte apoptosis, and reduce inflammation and oxidative stress. Additionally, MFD alleviated LPS/D-GalN-stimulated reactive oxygen species (ROS) production and cell death in AML12 cells. RNA sequencing enrichment analysis showed that MFD significantly affected the Mitogen-Activated Protein Kinase (MAPK) pathway. In vivo and in vitro experiments showed that MFD inhibited MKK4 and JNK phosphorylation. JNK activation caused by MKK4 and JNK activators could eliminate the therapeutic effect of MFD on AML12. In addition, MFD pretreatment alleviated ConA-induced ALF, reduced inflammation and oxidative stress in mice, and reduced mouse mortality. These results suggest that MFD can potentially protect against ALF, partially by inhibiting the MKK4-JNK pathway, and is a promising new therapeutic drug for ALF.
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Affiliation(s)
- Yanqiu Zhang
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Xin He
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Lei Gu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Shenglan Li
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Jie Tang
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Ruixue Ma
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China
| | - Huixiang Yang
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China.
| | - Zhangzhe Peng
- Department of Nephrology, Xiangya Hospital, Central South University, Changsha 410008, China; Hunan Key Lab of Organ Fibrosis, Changsha 410008, China; National International Collaborative Research Center for Medical Metabolomics, Xiangya Hospital, Central South University, Changsha 410008, China.
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Martínez-Martínez LM, Rosales-Sotomayor G, Jasso-Baltazar EA, Torres-Díaz JA, Aguirre-Villarreal D, Hurtado-Díaz de León I, Páez-Zayas VM, Sánchez-Cedillo A, Martínez-Vázquez SE, Tadeo-Espinoza HN, Guerrero-Cabrera JP, García-Alanis M, García-Juárez I. Acute liver failure: Management update and prognosis. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:404-417. [PMID: 39033039 DOI: 10.1016/j.rgmxen.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 05/30/2024] [Indexed: 07/23/2024]
Abstract
Acute liver failure is a rare but serious syndrome, with an incidence of approximately 2,000 to 3,000 cases per year in North America. Its pathophysiology and clinical course vary, depending on the cause of the primary liver injury, and can lead to high morbidity and mortality or the need for liver transplantation, despite available therapies. This syndrome involves excessive activation of the immune system, with damage in other organs, contributing to its high mortality rate. The most accepted definition includes liver injury with hepatic encephalopathy and coagulopathy within the past 26 weeks in a patient with no previous liver disease. The main causes are paracetamol poisoning, viral hepatitis, and drug-induced liver injury, among others. Identifying the cause is crucial, given that it influences prognosis and treatment. Survival has improved with supportive measures, intensive therapy, complication prevention, and the use of medications, such as N-acetylcysteine. Liver transplantation is a curative option for nonresponders to medical treatment, but adequate evaluation of transplantation timing is vital for improving results. Factors such as patient age, underlying cause, and severity of organ failure influence the post-transplant outcomes and survival.
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Affiliation(s)
- L M Martínez-Martínez
- Departamento de Medicina Interna, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potosí, Mexico
| | - G Rosales-Sotomayor
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - E A Jasso-Baltazar
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J A Torres-Díaz
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - D Aguirre-Villarreal
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I Hurtado-Díaz de León
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - V M Páez-Zayas
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - A Sánchez-Cedillo
- Departamento de Trasplante de Órganos, Hospital General de México Dr. Eduardo Liceaga, Mexico City, Mexico
| | - S E Martínez-Vázquez
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - H N Tadeo-Espinoza
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - J P Guerrero-Cabrera
- Departamento de Gastroenterología, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - M García-Alanis
- Departamento de Neurología y Psiquiatría, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - I García-Juárez
- Departamento de Gastroenterología, Clínica de Hígado y Trasplante Hepático, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico.
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34
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Alsabbagh Alchirazi K, Bhavsar-Burke I, Syed H, Alkhayyat M, Bass S, Kapoor A, Lindenmeyer CC. Molecular Adsorbent Recirculating System in Acute Liver Failure. ACG Case Rep J 2024; 11:e01389. [PMID: 38988717 PMCID: PMC11236392 DOI: 10.14309/crj.0000000000001389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 05/07/2024] [Indexed: 07/12/2024] Open
Abstract
Acetaminophen (APAP) overdose is the most common cause of acute liver failure (ALF) in the United States. Liver transplantation (LT) is potentially lifesaving for patients with ALF, but its feasibility in clinical practice is limited. Liver assist devices, such as the Molecular Adsorbent Recirculating System (MARS), are used in some centers as a "bridge" to liver transplantation or as a means of liver recovery, but their role in the treatment of ALF is not well-defined. We present the case of a 44-year-old man with APAP-associated ALF who experienced hepatic recovery after treatment with MARS.
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Affiliation(s)
| | - Indira Bhavsar-Burke
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH
| | - Hareem Syed
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, OH
| | - Motasem Alkhayyat
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH
| | | | - Aanchal Kapoor
- Department of Critical Care, Cleveland Clinic Foundation, Cleveland, OH
| | - Christina C. Lindenmeyer
- Department of Gastroenterology, Hepatology and Nutrition, Cleveland Clinic Foundation, Cleveland, OH
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35
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Tao Y, Wang Y, Wang M, Tang H, Chen E. Mesenchymal Stem Cells Alleviate Acute Liver Failure through Regulating Hepatocyte Apoptosis and Macrophage Polarization. J Clin Transl Hepatol 2024; 12:571-580. [PMID: 38974955 PMCID: PMC11224903 DOI: 10.14218/jcth.2023.00557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/06/2024] [Accepted: 03/18/2024] [Indexed: 07/09/2024] Open
Abstract
Background and Aims Acute liver failure (ALF) is a life-threatening clinical problem with limited treatment options. Administration of human umbilical cord mesenchymal stem cells (hUC-MSCs) may be a promising approach for ALF. This study aimed to explore the role of hUC-MSCs in the treatment of ALF and the underlying mechanisms. Methods A mouse model of ALF was induced by lipopolysaccharide and d-galactosamine administration. The therapeutic effects of hUC-MSCs were evaluated by assessing serum enzyme activity, histological appearance, and cell apoptosis in liver tissues. The apoptosis rate was analyzed in AML12 cells. The levels of inflammatory cytokines and the phenotype of RAW264.7 cells co-cultured with hUC-MSCs were detected. The C-Jun N-terminal kinase/nuclear factor-kappa B signaling pathway was studied. Results The hUC-MSCs treatment decreased the levels of serum alanine aminotransferase and aspartate aminotransferase, reduced pathological damage, alleviated hepatocyte apoptosis, and reduced mortality in vivo. The hUC-MSCs co-culture reduced the apoptosis rate of AML12 cells in vitro. Moreover, lipopolysaccharide-stimulated RAW264.7 cells had higher levels of tumor necrosis factor-α, interleukin-6, and interleukin-1β and showed more CD86-positive cells, whereas the hUC-MSCs co-culture reduced the levels of the three inflammatory cytokines and increased the ratio of CD206-positive cells. The hUC-MSCs treatment inhibited the activation of phosphorylated (p)-C-Jun N-terminal kinase and p-nuclear factor-kappa B not only in liver tissues but also in AML12 and RAW264.7 cells co-cultured with hUC-MSCs. Conclusions hUC-MSCs could alleviate ALF by regulating hepatocyte apoptosis and macrophage polarization, thus hUC-MSC-based cell therapy may be an alternative option for patients with ALF.
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Affiliation(s)
- Yachao Tao
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, China
| | - Yonghong Wang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, China
| | - Menglan Wang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, China
| | - Enqiang Chen
- Center of Infectious Diseases, West China Hospital, Sichuan University, Chengdu, Sichuan, China
- Division of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, Sichuan, China
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Ferrarese A, Cazzagon N, Burra P. Liver transplantation for Wilson disease: Current knowledge and future perspectives. Liver Transpl 2024:01445473-990000000-00405. [PMID: 38899966 DOI: 10.1097/lvt.0000000000000422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Accepted: 06/06/2024] [Indexed: 06/21/2024]
Abstract
Liver transplantation currently represents a therapeutic option for patients with Wilson disease presenting with end-stage liver disease or acute liver failure. Indeed, it has been associated with excellent postoperative survival curves in view of young age at transplant and absence of recurrence. Attention has shifted over the past decades to a wise expansion of indications for liver transplantation. Evidence has emerged supporting the transplantation of carefully selected patients with primarily neuropsychiatric symptoms and compensated cirrhosis. The rationale behind this approach is the potential for surgery to improve copper homeostasis and consequently ameliorate neuropsychiatric symptoms. However, several questions remain unanswered, such as how to establish thresholds for assessing pretransplant neuropsychiatric impairment, how to standardize preoperative neurological assessments, and how to define postoperative outcomes for patients meeting these specific criteria. Furthermore, a disease-specific approach will be proposed both for the liver transplant evaluation of candidates with Wilson disease and for patient care during the transplant waiting period, highlighting the peculiarities of this systemic disease.
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Affiliation(s)
- Alberto Ferrarese
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Nora Cazzagon
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
- Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, Padua, Italy
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Biolato M, Miele L, Marrone G, Tarli C, Liguori A, Calia R, Addolorato G, Agnes S, Gasbarrini A, Pompili M, Grieco A. Frequency of and reasons behind non-listing in adult patients referred for liver transplantation: Results from a retrospective study. World J Transplant 2024; 14:92376. [PMID: 38947971 PMCID: PMC11212587 DOI: 10.5500/wjt.v14.i2.92376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 04/12/2024] [Accepted: 04/26/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Few studies have evaluated the frequency of and the reasons behind the refusal of listing liver transplantation candidates. AIM To assess the ineligibility rate for liver transplantation and its motivations. METHODS A single-center retrospective study was conducted on adult patients which entailed a formal multidisciplinary assessment for liver transplantation eligibility. The predictors for listing were evaluated using multivariable logistic regression. RESULTS In our center, 314 patients underwent multidisciplinary work-up before liver transplantation enlisting over a three-year period. The most frequent reasons for transplant evaluation were decompensated cirrhosis (51.6%) and hepatocellular carcinoma (35.7%). The non-listing rate was 53.8% and the transplant rate was 34.4% for the whole cohort. Two hundred and five motivations for ineligibility were collected. The most common contraindications were psychological (9.3%), cardiovascular (6.8%), and surgical (5.9%). Inappropriate or premature referral accounted for 76 (37.1%) cases. On multivariable analysis, a referral from another hospital (OR: 2.113; 95%CI: 1.259-3.548) served as an independent predictor of non-listing. CONCLUSION A non-listing decision occurred in half of our cohort and was based on an inappropriate or premature referral in one case out of three. The referral from another hospital was taken as a strong predictor of non-listing.
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Affiliation(s)
- Marco Biolato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Luca Miele
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Giuseppe Marrone
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Claudia Tarli
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Liguori
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Rosaria Calia
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Giovanni Addolorato
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Salvatore Agnes
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Maurizio Pompili
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
| | - Antonio Grieco
- Department of Medical and Surgical Sciences, CEMAD, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome 00168, Italy
- Department of Translational Medicine and Surgery, Catholic University of Sacred Heart, Rome 00168, Italy
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Papamichalis P, Oikonomou KG, Xanthoudaki M, Valsamaki A, Skoura AL, Papathanasiou SK, Chovas A. Extracorporeal organ support for critically ill patients: Overcoming the past, achieving the maximum at present, and redefining the future. World J Crit Care Med 2024; 13:92458. [PMID: 38855267 PMCID: PMC11155504 DOI: 10.5492/wjccm.v13.i2.92458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 06/03/2024] Open
Abstract
Extracorporeal organ support (ECOS) has made remarkable progress over the last few years. Renal replacement therapy, introduced a few decades ago, was the first available application of ECOS. The subsequent evolution of ECOS enabled the enhanced support to many other organs, including the heart [veno-arterial extracorporeal membrane oxygenation (ECMO), slow continuous ultrafiltration], the lungs (veno-venous ECMO, extracorporeal carbon dioxide removal), and the liver (blood purification techniques for the detoxification of liver toxins). Moreover, additional indications of these methods, including the suppression of excessive inflammatory response occurring in severe disorders such as sepsis, coronavirus disease 2019, pancreatitis, and trauma (blood purification techniques for the removal of exotoxins, endotoxins, or cytokines), have arisen. Multiple organ support therapy is crucial since a vast majority of critically ill patients present not with a single but with multiple organ failure (MOF), whereas, traditional therapeutic approaches (mechanical ventilation for acute respiratory failure, antibiotics for sepsis, and inotropes for cardiac dysfunction) have reached the maximum efficacy and cannot be improved further. However, several issues remain to be clarified, such as the complexity and cost of ECOS systems, standardization of indications, therapeutic protocols and initiation time, choice of the patients who will benefit most from these interventions, while evidence from randomized controlled trials supporting their use is still limited. Nevertheless, these methods are currently a part of routine clinical practice in intensive care units. This editorial presents the past, present, and future considerations, as well as perspectives regarding these therapies. Our better understanding of these methods, the pathophysiology of MOF, the crosstalk between native organs resulting in MOF, and the crosstalk between native organs and artificial organ support systems when applied sequentially or simultaneously, will lead to the multiplication of their effects and the minimization of complications arising from their use.
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Affiliation(s)
| | | | - Maria Xanthoudaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | - Asimina Valsamaki
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
| | | | | | - Achilleas Chovas
- Intensive Care Unit, General Hospital of Larissa, Larissa 41221, Greece
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Catanzaro R, Marotta F, Yazdani A, Sciuto M. Inflammatory Bowel Disease Therapies and Acute Liver Injury. TOXICS 2024; 12:421. [PMID: 38922101 PMCID: PMC11209202 DOI: 10.3390/toxics12060421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 06/03/2024] [Accepted: 06/06/2024] [Indexed: 06/27/2024]
Abstract
Drug-induced liver disease (DILI) represents one of the main problems in the therapeutic field. There are several non-modifiable risk factors, such as age and sex, and all drugs can cause hepatotoxicity of varying degrees, including those for the treatment of inflammatory bowel diseases (IBD). The aim of this review is to illustrate the adverse effects on the liver of the various drugs used in the treatment of IBD, highlighting which drugs are safest to use based on current knowledge. The mechanism by which drugs cause hepatotoxicity is not fully understood. A possible cause is represented by the formation of toxic metabolites, which in some patients may be increased due to alterations in the enzymatic apparatus involved in drug metabolism. Various studies have shown that the drugs that can most frequently cause hepatotoxicity are immunosuppressants, while mesalazine and biological drugs are, for the most part, less associated with such complications. Therefore, it is possible to assume that in the future, biological therapies could become the first line for the treatment of IBD.
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Affiliation(s)
- Roberto Catanzaro
- Department of Clinical and Experimental Medicine, Gastroenterology Section, “Gaspare Rodolico” Policlinico Hospital, University of Catania, 95100 Catania, Italy
| | - Francesco Marotta
- ReGenera R&D International for Aging Intervention, 20144 Milan, Italy;
| | - Azam Yazdani
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA 02116, USA;
| | - Morena Sciuto
- Specialization School in Digestive System Diseases, University of Palermo, 90133 Palermo, Italy;
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Felgendreff P, Hosseiniasl SM, Minshew A, Amiot BP, Wilken S, Ahmadzada B, Huebert RC, Sakrikar NJ, Engles NG, Halsten P, Mariakis K, Barry J, Riesgraf S, Fecteau C, Ross JJ, Nyberg SL. First Application of a Mixed Porcine-Human Repopulated Bioengineered Liver in a Preclinical Model of Post-Resection Liver Failure. Biomedicines 2024; 12:1272. [PMID: 38927479 PMCID: PMC11201206 DOI: 10.3390/biomedicines12061272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/15/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
In this study, a mixed porcine-human bioengineered liver (MPH-BEL) was used in a preclinical setup of extracorporeal liver support devices as a treatment for a model of post-resection liver failure (PRLF). The potential for human clinical application is further illustrated by comparing the functional capacity of MPH-BEL grafts as assessed using this porcine PRLF model with fully human (FH-BEL) grafts which were perfused and assessed in vitro. BEL grafts were produced by reseeding liver scaffolds with HUVEC and primary porcine hepatocytes (MPH-BEL) or primary human hepatocytes (FH-BEL). PRLF was induced by performing an 85% liver resection in domestic white pigs and randomized into the following three groups 24 h after resection: standard medical therapy (SMT) alone, SMT + extracorporeal circuit (ECC), and SMT + MPH-BEL. The detoxification and metabolic functions of the MPH-BEL grafts were compared to FH-BEL grafts which were perfused in vitro. During the 24 h treatment interval, INR values normalized within 18 h in the MPH-BEL therapy group and urea synthesis increased as compared to the SMT and SMT + ECC control groups. The MPH-BEL treatment was associated with more rapid decline in hematocrit and platelet count compared to both control groups. Histological analysis demonstrated platelet sequestration in the MPH-BEL grafts, possibly related to immune activation. Significantly higher rates of ammonia clearance and metabolic function were observed in the FH-BEL grafts perfused in vitro than in the MPH-BEL grafts. The MPH-BEL treatment was associated with improved markers of liver function in PRLF. Further improvement in liver function in the BEL grafts was observed by seeding the biomatrix with human hepatocytes. Methods to reduce platelet sequestration within BEL grafts is an area of ongoing research.
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Affiliation(s)
- Philipp Felgendreff
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
- Department of General, Visceral and Transplantation Surgery, Hannover Medical School, 30625 Hannover, Germany
| | - Seyed Mohammad Hosseiniasl
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
| | - Anna Minshew
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
| | - Bruce P. Amiot
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
| | - Silvana Wilken
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
| | - Boyukkhanim Ahmadzada
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
| | - Robert C. Huebert
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, USA; (R.C.H.); (N.J.S.); (N.G.E.)
| | - Nidhi Jalan Sakrikar
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, USA; (R.C.H.); (N.J.S.); (N.G.E.)
| | - Noah G. Engles
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN 55902, USA; (R.C.H.); (N.J.S.); (N.G.E.)
| | - Peggy Halsten
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - Kendra Mariakis
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - John Barry
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - Shawn Riesgraf
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - Chris Fecteau
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - Jeffrey J. Ross
- Miromatrix Medical Inc., Eden Prairie, MN 55344, USA; (P.H.); (K.M.); (J.B.); (S.R.); (C.F.); (J.J.R.)
| | - Scott L. Nyberg
- Department of Surgery, Mayo Clinic, Rochester, MN 55902, USA; (S.M.H.); (A.M.); (B.P.A.); (S.W.); (B.A.); (S.L.N.)
- William J. von Liebig Center for Transplantation and Clinical Regeneration, Mayo Clinic, Rochester, MN 55902, USA
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Dong V, Robinson AM, Dionne JC, Cardoso FS, Rewa OG, Karvellas CJ. Continuous renal replacement therapy and survival in acute liver failure: A systematic review and meta-analysis. J Crit Care 2024; 81:154513. [PMID: 38194760 DOI: 10.1016/j.jcrc.2023.154513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Revised: 12/05/2023] [Accepted: 12/26/2023] [Indexed: 01/11/2024]
Abstract
OBJECTIVE Acute liver failure (ALF) is a rare syndrome leading to significant morbidity and mortality. An important cause of mortality is cerebral edema due to hyperammonemia. Different therapies for hyperammonemia have been assessed including continuous renal replacement therapy (CRRT). We conducted a systematic review and meta-analysis to determine the efficacy of CRRT in ALF patients. MATERIALS AND METHODS We searched MEDLINE, EMBASE, Cochrane Library, and Web of Science. Inclusion criteria included adult patients admitted to an ICU with ALF. Intervention was the use of CRRT for one or more indications with the comparator being standard care without the use of CRRT. Outcomes of interest were overall survival, transplant-free survival (TFS), mortality and changes in serum ammonia levels. RESULTS In total, 305 patients underwent CRRT while 1137 patients did not receive CRRT. CRRT was associated with improved overall survival [risk ratio (RR) 0.83, 95% confidence interval (CI) 0.70-0.99, p-value 0.04, I2 = 50%] and improved TFS (RR 0.65, 95% CI 0.49-0.85, p-value 0.002, I2 = 25%). There was a trend towards higher mortality with no CRRT (RR 1.24, 95% CI 0.84-1.81, p-value 0.28, I2 = 37%). Ammonia clearance data was unable to be pooled and was not analyzable. CONCLUSION Use of CRRT in ALF patients is associated with improved overall and transplant-free survival compared to no CRRT.
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Affiliation(s)
- Victor Dong
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, Alberta T2N 2T9, Canada.
| | - Andrea M Robinson
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Joanna C Dionne
- Department of Medicine, Division of Critical Care, McMaster University, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada.
| | - Filipe S Cardoso
- Intensive Care Unit and Transplant Unit, Nova University, R. da Beneficência 8, Lisbon 1050-099, Portugal.
| | - Oleksa G Rewa
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada.
| | - Constantine J Karvellas
- Department of Critical Care Medicine, University of Alberta, 2-124 Clinical Sciences Building, Edmonton, Alberta T6G 2G3, Canada; Department of Medicine, Division of Gastroenterology, University of Alberta, 8540 112 St NW, Edmonton, Alberta T6G 2P8, Canada.
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Biswas T, Lal BB, Sood V, Ashritha A, Maheshwari A, Bajpai M, Kumar G, Khanna R, Alam S. Therapeutic plasma exchange provides native liver survival benefit in children with acute liver failure: A propensity score-matched analysis. J Clin Apher 2024; 39:e22130. [PMID: 38873972 DOI: 10.1002/jca.22130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/06/2024] [Accepted: 05/14/2024] [Indexed: 06/15/2024]
Abstract
OBJECTIVES This study aimed to evaluate the safety and efficacy of therapeutic plasma exchange (TPE) in pediatric acute liver failure (PALF). METHODS All children aged 2-18 years with PALF were included. The intervention cohort included a subset of PALF patients undergoing complete three sessions of TPE, whereas the matching controls were derived by propensity score matching from the patient cohort who did not receive any TPE. Propensity matching was performed based on the international normalized ratio (INR), grade of hepatic encephalopathy (HE), age, bilirubin, and ammonia levels. The primary outcome measure was native liver survival (NLS) in the two arms on day 28. RESULTS Of the total cohort of 403 patients with PALF, 65 patients who received TPE and 65 propensity-matched controls were included in analysis. The 2 groups were well balanced with comparable baseline parameters. On day 4, patients in the TPE group had significantly lower INR (P = 0.001), lower bilirubin (P = 0.008), and higher mean arterial pressure (MAP) (P = 0.033) than controls. The NLS was 46.15% in the TPE arm and 26.15% in the control arm. The overall survival (OS) was 50.8% in the TPE arm and 35.4% in the control arm. Kaplan-Meier survival analysis showed a significantly higher NLS in patients receiving TPE than controls (P = 0.001). On subgroup analysis, NLS benefit was predominantly seen in hepatitis A-related and indeterminate PALF. CONCLUSION TPE improved NLS and OS in a propensity-matched cohort of patients with PALF. Patients receiving TPE had lower INR and bilirubin levels and higher MAP on day 4.
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Affiliation(s)
- Tamoghna Biswas
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Bikrant Bihari Lal
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vikrant Sood
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Avalareddy Ashritha
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Ashish Maheshwari
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Meenu Bajpai
- Department of Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajeev Khanna
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Seema Alam
- Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Capece GE, Luyendyk JP, Poole LG. Fibrinolysis-Mediated Pathways in Acute Liver Injury. Semin Thromb Hemost 2024; 50:638-647. [PMID: 38395065 PMCID: PMC11397073 DOI: 10.1055/s-0044-1779738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2024]
Abstract
Acute liver injury (ALI), that is, the development of reduced liver function in patients without preexisting liver disease, can result from a wide range of causes, such as viral or bacterial infection, autoimmune disease, or adverse reaction to prescription and over-the-counter medications. ALI patients present with a complex coagulopathy, characterized by both hypercoagulable and hypocoagulable features. Similarly, ALI patients display a profound dysregulation of the fibrinolytic system with the vast majority of patients presenting with a hypofibrinolytic phenotype. Decades of research in experimental acute liver injury in mice suggest that fibrinolytic proteins, including plasmin(ogen), plasminogen activators, fibrinolysis inhibitors, and fibrin(ogen), can contribute to initial hepatotoxicity and/or stimulate liver repair. This review summarizes major experimental findings regarding the role of fibrinolytic factors in ALI from the last approximately 30 years and identifies unanswered questions, as well as highlighting areas for future research.
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Affiliation(s)
- Gina E Capece
- Department of Pharmacology, Rutgers University Robert Wood Johnson Medical School, Piscataway, New Jersey
| | - James P Luyendyk
- Department of Pathobiology and Diagnostic Investigation, Michigan State University, East Lansing, Michigan
| | - Lauren G Poole
- Department of Pharmacology, Rutgers University Robert Wood Johnson Medical School, Piscataway, New Jersey
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44
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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] [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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45
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Needham E, Webb G. Hepatic encephalopathy: a neurologist's perspective. Pract Neurol 2024; 24:200-206. [PMID: 38453473 DOI: 10.1136/pn-2023-003802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2024] [Indexed: 03/09/2024]
Abstract
Liver disease is increasingly common, estimated to affect over 25% of the world's population. Failure of the liver to maintain a normal metabolic milieu leads to impaired brain function (hepatic encephalopathy), and conditions that cause liver disease can themselves predispose to neurological disease. As neurologists' involvement with the acute take increases, it is important that we are familiar with the neurological complications of liver disease, their investigation and management, and to know which other neurological diseases occur in this patient population. In this article, we review the causes, presentation and treatment of hepatic encephalopathy, and discuss important differential diagnoses in patients with liver disease who present with neurological disturbance.
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Affiliation(s)
- Edward Needham
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Neurology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Gwilym Webb
- Department of Hepatology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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46
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Hohlstein P, Salvarcioglu C, Pollmanns MR, Adams JK, Abu Jhaisha S, Kabak E, Eisert A, Hamesch K, Weiskirchen R, Koch A, Wirtz TH. Diagnostic and Prognostic Value of Serum Leptin in Critically Ill Patients with Acute versus Acute-on-Chronic Liver Failure. Biomedicines 2024; 12:1170. [PMID: 38927377 PMCID: PMC11200812 DOI: 10.3390/biomedicines12061170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/28/2024] Open
Abstract
Differentiation between acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) can be challenging in patients with de novo liver disease but is important to indicate the referral to a transplant center and urgency of organ allocation. Leptin, an adipocyte-derived cytokine that regulates energy storage and satiety, has multiple regulatory functions in the liver. We enrolled 160 critically ill patients with liver disease and 20 healthy individuals to measure serum leptin concentrations as a potential biomarker for diagnostic and prognostic purposes. Notably, patients with ALF had higher concentrations of serum leptin compared to patients with decompensated advanced chronic liver disease (dACLD) or ACLF (110 vs. 50 vs. 29 pg/mL, p < 0.001). Levels of serum leptin below 56 pg/mL excluded ALF in patients with acute hepatic disease, with a negative predictive value (NPV) of 98.8% in our cohort. Lastly, serum leptin did not show any dynamic changes within the first 48 h of ICU treatment, especially not in comparison with patients with ALF vs. ACLF or survivors vs. non-survivors. In conclusion, serum leptin may represent a helpful biomarker to exclude ALF in critically ill patients who present with acute liver dysfunction.
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Affiliation(s)
- Philipp Hohlstein
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Can Salvarcioglu
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Maike R. Pollmanns
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Jule K. Adams
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Samira Abu Jhaisha
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Elena Kabak
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Albrecht Eisert
- Hospital Pharmacy, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
- Institute of Clinical Pharmacology, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Karim Hamesch
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Ralf Weiskirchen
- Institute of Molecular Pathobiochemistry, Experimental Gene Therapy and Clinical Chemistry (IFMPEGKC), RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany;
| | - Alexander Koch
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
| | - Theresa H. Wirtz
- Department for Gastroenterology, Metabolic Disorders and Intensive Care Medicine, RWTH-University Hospital Aachen, Pauwelsstraße 30, 52074 Aachen, Germany; (P.H.); (C.S.); (M.R.P.); (J.K.A.); (S.A.J.); (E.K.); (K.H.); (T.H.W.)
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47
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Gurakar A, Conde Amiel I, Ozturk NB, Artru F, Selzner N, Psoter KJ, Dionne JC, Karvellas C, Rajakumar A, Saner F, Subramanian RM, Sun LY, Dhawan A, Coilly A. An international, multicenter, survey-based analysis of practice and management of acute liver failure. Liver Transpl 2024:01445473-990000000-00387. [PMID: 38775498 DOI: 10.1097/lvt.0000000000000402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 05/02/2024] [Indexed: 06/30/2024]
Abstract
Acute liver failure (ALF) is an acute liver dysfunction with coagulopathy and HE in a patient with no known liver disease. As ALF is rare and large clinical trials are lacking, the level of evidence regarding its management is low-moderate, favoring heterogeneous clinical practice. In this international multicenter survey study, we aimed to investigate the current practice and management of patients with ALF. An online survey targeting physicians who care for patients with ALF was developed by the International Liver Transplantation Society ALF Special-Interest Group. The survey focused on the management and liver transplantation (LT) practices of ALF. Survey questions were summarized overall and by geographic region. A total of 267 physicians completed the survey, with a survey response rate of 21.36%. Centers from all continents were represented. More than 90% of physicians specialized in either transplant hepatology/surgery or anesthesiology/critical care. Two hundred fifty-two (94.4%) respondents' institutions offered LT. A total of 76.8% of respondents' centers had a dedicated liver-intensive or transplant-intensive care unit ( p < 0.001). The median time to LT was within 48 hours in 12.7% of respondents' centers, 72 hours in 35.6%, 1 week in 37.6%, and more than 1 week in 9.6% ( p < 0.001). Deceased donor liver graft (49.6%) was the most common type of graft offered. For consideration of LT, 84.8% of physicians used King's College Criteria, and 41.6% used Clichy Criteria. Significant differences were observed between Asia, Europe, and North America for offering LT, number of LTs performed, volume of patients with ALF, admission to a dedicated intensive care unit, median time to LT, type of liver graft, monitoring HE and intracranial pressure, management of coagulopathy, and utilization of different criteria for LT. In our study, we observed significant geographic differences in the practice and management of ALF. As ALF is rare, multicenter studies are valuable for identifying global practice.
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Affiliation(s)
- Ahmet Gurakar
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Isabel Conde Amiel
- Department of Medicine, Hepatology and Liver Transplantation Unit, Hospital Universitario y Politécnico La Fe, IIS La Fe, Valencia, Spain
- Ciberehd, Instituto de Salud Carlos III, Madrid, Spain
| | - N Begum Ozturk
- Department of Internal Medicine, Beaumont Hospital, Royal Oak, Michigan, USA
| | - Florent Artru
- Liver Department, Rennes University Hospital, University of Rennes, Inserm U1241 NuMeCan, Rennes, France
| | - Nazia Selzner
- Multi-Organ Transplant Program, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kevin J Psoter
- Department of Pediatrics, Division of General Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Joanna C Dionne
- Department of Medicine, Department of Health Research Medicine, Evidence and Impact, Divisions of Gastroenterology/Critical Care Medicine, Farncombe Family Digestive Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Constantine Karvellas
- Divisions of Hepatology and Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Akila Rajakumar
- The Institute of Liver Disease & Transplantation, Dr. Rela Institute & Medical Centre, Bharath Institute of Higher Education & Research, Chennai, Tamil Nadu, India
| | - Fuat Saner
- Organ Transplant Center of Excellence, King Faisal Specialized Hospital & Research Center, Riyadh, Saudi Arabia
- Department of General, Visceral and Transplantation Surgery, University of Duisburg-Essen, Essen, Germany
| | - Ram M Subramanian
- Liver Transplantation & Liver Critical Care Services, Emory University, Atlanta, Georgia, USA
| | - Li-Ying Sun
- Critical Liver Diseases & Liver Transplantation Center, National Clinical Research Center for Digestive Diseases, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Anil Dhawan
- Department of Pediatrics and Pediatric Liver GI and Nutrition Center and Mowat Labs, King's College Hospital, London, UK
| | - Audrey Coilly
- Paul-Brousse Hospital, Public Hospitals of Paris, FHU Hépatinov, Villejuif, France
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48
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Colak M, Ocak I. Management of pediatric liver failure with therapeutic plasma exchange and continuous renal replacement therapy: A retrospective observational study. Medicine (Baltimore) 2024; 103:e38093. [PMID: 38728496 PMCID: PMC11081591 DOI: 10.1097/md.0000000000038093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/11/2024] [Indexed: 05/12/2024] Open
Abstract
Liver failure represents a critical medical condition, marked by the rapid decline of hepatic functions. Emerging therapies, notably therapeutic plasma exchange (TPE) and continuous venovenous hemodiafiltration (CVVHDF), have demonstrated potential in mitigating these conditions through their roles in detoxification and hepatic support. The utility of these treatments, whether applied individually or in tandem, constitutes a significant area of research concerning the management of liver failure in pediatric patients. This study aims to evaluate the role and efficacy of TPE or TPE combined with CVVHDF in the treatment of liver failure among children. This retrospective study was conducted in a LTICU by reviewing the medical history of pediatric patients aged 1 month to 18 years. Patients were admitted between January 1, 2021 and December 1, 2023 due to acute liver failure or acute-chronic liver failure. The study evaluated those who received TPE or continuous renal replacement therapy combined with TPE. In statistical analyses, a P-value of <.05 was considered statistically significant. The study involved 24 patients with liver failure, comprising 13 males and 11 females. Sixteen patients (66.6%) received only TPE, while 8 patients (33.4%) were treated with TPE and CVVHDF. For patients treated only with TPE, the median INR reduced from 3.1 to 1.26, alanine aminotransferase from 1255 to 148, and aspartate aminotransferase from 2189 to 62. Similar significant reductions were observed in the TPE and CVVHDF group: INR from 3.9 to 1.26, alanine aminotransferase from 1749 to 1148, and aspartate aminotransferase from 1489 to 62. These changes were statistically significant with P-values of .01 for each parameter in both groups. Overall, 14 patients survived without requiring a liver transplant, while 4 patients underwent liver transplantation. Our study on pediatric liver failure treatment shows that both standalone TPE and its combination with CVVHDF are effective, especially as a bridge to transplantation. With 58% transplant-free survival, these therapies demonstrate significant clinical improvements. Future multicentric studies are needed for broader validation of these findings in liver failure management.
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Affiliation(s)
- Mustafa Colak
- Department of Liver Transplantation Intensive Care Unit, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
| | - Ilhan Ocak
- Department of Liver Transplantation Intensive Care Unit, Basaksehir Cam and Sakura City Hospital, Istanbul, Turkey
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49
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Tejedor M, Neria F, De La Rosa G, Almohalla Álvarez C, Padilla M, Boscà Robledo A, Fundora Suárez Y, Sánchez-Bueno F, Gómez-Bravo MA, Berenguer M. Women Are Also Disadvantaged in Accessing Transplant Outside the United States: Analysis of the Spanish Liver Transplantation Registry. Transpl Int 2024; 37:12732. [PMID: 38773987 PMCID: PMC11106452 DOI: 10.3389/ti.2024.12732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/16/2024] [Indexed: 05/24/2024]
Abstract
Sex inequities in liver transplantation (LT) have been documented in several, mostly US-based, studies. Our aim was to describe sex-related differences in access to LT in a system with short waiting times. All adult patients registered in the RETH-Spanish Liver Transplant Registry (2000-2022) for LT were included. Baseline demographics, presence of hepatocellular carcinoma, cause and severity of liver disease, time on the waiting list (WL), access to transplantation, and reasons for removal from the WL were assessed. 14,385 patients were analysed (77% men, 56.2 ± 8.7 years). Model for end-stage liver disease (MELD) score was reported for 5,475 patients (mean value: 16.6 ± 5.7). Women were less likely to receive a transplant than men (OR 0.78, 95% CI 0.63, 0.97) with a trend to a higher risk of exclusion for deterioration (HR 1.17, 95% CI 0.99, 1.38), despite similar disease severity. Women waited longer on the WL (198.6 ± 338.9 vs. 173.3 ± 285.5 days, p < 0.001). Recently, women's risk of dropout has reduced, concomitantly with shorter WL times. Even in countries with short waiting times, women are disadvantaged in LT. Policies directed at optimizing the whole LT network should be encouraged to guarantee a fair and equal access of all patients to this life saving resource.
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Affiliation(s)
| | - Fernando Neria
- Universidad Francisco de Vitoria, Pozuelo de Alarcón, Spain
| | | | | | | | | | | | | | | | - Marina Berenguer
- Hepatology—Liver Transplantation Unit, IIS La Fe and CIBER-EHD, Hospital Universitari i Politècnic La Fe, Valencia, Spain
- Department of Medicine, Universitat de València, Valencia, Spain
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50
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Xu X, Gong K, Hong L, Yu X, Tu H, Lan Y, Yao J, Ye S, Weng H, Li Z, Shi Y, Sheng J. The burden and predictors of 30-day unplanned readmission in patients with acute liver failure: a national representative database study. BMC Gastroenterol 2024; 24:153. [PMID: 38702642 PMCID: PMC11067096 DOI: 10.1186/s12876-024-03249-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/29/2024] [Indexed: 05/06/2024] Open
Abstract
BACKGROUND Liver diseases were significant source of early readmission burden. This study aimed to evaluate the 30-day unplanned readmission rates, causes of readmissions, readmission costs, and predictors of readmission in patients with acute liver failure (ALF). METHODS Patients admitted for ALF from 2019 National Readmission Database were enrolled. Weighted multivariable logistic regression models were applied and based on Directed Acyclic Graphs. Incidence, causes, cost, and predictors of 30-day unplanned readmissions were identified. RESULTS A total of 3,281 patients with ALF were enrolled, of whom 600 (18.3%) were readmitted within 30 days. The mean time from discharge to early readmission was 12.6 days. The average hospital cost and charge of readmission were $19,629 and $86,228, respectively. The readmissions were mainly due to liver-related events (26.6%), followed by infection (20.9%). The predictive factors independently associated with readmissions were age, male sex (OR 1.227, 95% CI 1.023-1.472; P = 0.028), renal failure (OR 1.401, 95% CI 1.139-1.723; P = 0.001), diabetes with chronic complications (OR 1.327, 95% CI 1.053-1.672; P = 0.017), complicated hypertension (OR 1.436, 95% CI 1.111-1.857; P = 0.006), peritoneal drainage (OR 1.600, 95% CI 1.092-2.345; P = 0.016), etc. CONCLUSIONS: Patients with ALF are at relatively high risk of early readmission, which imposes a heavy medical and economic burden on society. We need to increase the emphasis placed on early readmission of patients with ALF and establish clinical strategies for their management.
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Affiliation(s)
- Xianbin Xu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Kai Gong
- Department of Infectious Diseases, The Fourth Affiliated Hospital, Zhejiang University School of Medicine, Yiwu, 322000, Zhejiang, China
| | - Liang Hong
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Xia Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Huilan Tu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Yan Lan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Junjie Yao
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Shaoheng Ye
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Haoda Weng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Zhiwei Li
- Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China
| | - Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China.
| | - Jifang Sheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, 310000, Zhejiang, China.
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