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Beran A, Mohamed MFH, Shaear M, Nayfeh T, Mhanna M, Srour O, Nawras M, Mentrose JA, Assaly R, Kubal CA, Ghabril MS, Hernaez R, Patidar KR. Plasma exchange for acute and acute-on-chronic liver failure: A systematic review and meta-analysis. Liver Transpl 2024; 30:127-141. [PMID: 37530812 DOI: 10.1097/lvt.0000000000000231] [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: 03/31/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023]
Abstract
Plasma exchange (PE) is a promising therapeutic option in patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). However, the impact of PE on patient survival in these syndromes is unclear. We aimed to systematically investigate the use of PE in patients with ALF and ACLF compared with standard medical therapy (SMT). We searched PubMed/Embase/Cochrane databases to include all studies comparing PE versus SMT for patients ≥ 18 years of age with ALF and ACLF. Pooled risk ratios (RR) with corresponding 95% CIs were calculated by the Mantel-Haenszel method within a random-effect model. The primary outcome was 30-day survival for ACLF and ALF. Secondary outcomes were overall and 90-day survival for ALF and ACLF, respectively. Five studies, including 343 ALF patients (n = 174 PE vs. n = 169 SMT), and 20 studies, including 5,705 ACLF patients (n = 2,856 PE vs. n = 2,849 SMT), were analyzed. Compared with SMT, PE was significantly associated with higher 30-day (RR 1.41, 95% CI 1.06-1.87, p = 0.02) and overall (RR 1.35, 95% CI 1.12-1.63, p = 0.002) survival in ALF patients. In ACLF, PE was also significantly associated with higher 30-day (RR 1.36, 95% CI 1.22-1.52, p < 0.001) and 90-day (RR 1.21, 95% CI 1.10-1.34, p < 0.001) survival. On subgroup analysis of randomized controlled trials, results remained unchanged in ALF, but no differences in survival were found between PE and SMT in ACLF. In conclusion, PE is associated with improved survival in ALF and could improve survival in ACLF. PE may be considered in managing ALF and ACLF patients who are not liver transplant (LT) candidates or as a bridge to LT in otherwise eligible patients. Further randomized controlled trials are needed to confirm the survival benefit of PE in ACLF.
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Affiliation(s)
- Azizullah Beran
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Mouhand F H Mohamed
- Department of Internal Medicine, Warren Alpert Medical School Brown University, Providence, Rhode Island, USA
| | - Mohammad Shaear
- Department of General Surgery, College of Medicine, Central Michigan University, Saginaw, Michigan, USA
| | - Tarek Nayfeh
- Evidence-based practice research program, Mayo Clinic, Rochester, USA
| | - Mohammed Mhanna
- Department of Cardiology, University of Iowa, Iowa City, Iowa, USA
| | - Omar Srour
- Department of Critical Care and Pulmonary Medicine, Henry Ford Health System, Detroit, Michigan, USA
| | - Mohamad Nawras
- College of Medicine and Life Sciences, University of Toledo, Toledo, Ohio, USA
| | - Jonathan A Mentrose
- Department of Internal Medicine, Indiana University, Indianapolis, Indiana, USA
| | - Ragheb Assaly
- Divison of Critical Care and Pulmonary Medicine, University of Toledo, Toledo, Ohio, USA
| | - Chandrashekhar A Kubal
- Division of Transplantation, Department of Surgery, Indiana University, Indianapolis, Indiana, USA
| | - Marwan S Ghabril
- Division of Gastroenterology and Hepatology, Indiana University, Indianapolis, Indiana, USA
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Kavish R Patidar
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, Texas, USA
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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2
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Kumar R, Anand U, Priyadarshi RN. Liver transplantation in acute liver failure: Dilemmas and challenges. World J Transplant 2021; 11:187-202. [PMID: 34164294 PMCID: PMC8218344 DOI: 10.5500/wjt.v11.i6.187] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/17/2021] [Accepted: 05/24/2021] [Indexed: 02/06/2023] Open
Abstract
Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage
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Affiliation(s)
- Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Utpal Anand
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Patna 801507, Bihar, India
| | - Rajeev Nayan Priyadarshi
- Department of Radiodiagnosis, All India Institute of Medical Sciences, Patna 801507, Bihar, India
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3
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Patale D, Bajpai M, Maiwall R, Kumar G. Hemodynamic stability in liver failure patients undergoing therapeutic plasma exchange. J Clin Apher 2019; 35:86-93. [DOI: 10.1002/jca.21761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 10/19/2019] [Accepted: 10/29/2019] [Indexed: 12/23/2022]
Affiliation(s)
- Dnyaneshwar Patale
- Department of Transfusion MedicineInstitute of Liver and Biliary Sciences New Delhi India
| | - Meenu Bajpai
- Department of Transfusion MedicineInstitute of Liver and Biliary Sciences New Delhi India
| | - Rakhi Maiwall
- Department of HepatologyInstitute of Liver and Biliary Sciences New Delhi India
| | - Guresh Kumar
- Department of ResearchInstitute of Liver and Biliary Sciences New Delhi India
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Chamuleau RAFM, Hoekstra R. End-stage liver failure: filling the treatment gap at the intensive care unit. J Artif Organs 2019; 23:113-123. [PMID: 31535298 PMCID: PMC7228976 DOI: 10.1007/s10047-019-01133-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 09/09/2019] [Indexed: 12/14/2022]
Abstract
End-stage liver failure is a condition of collapsing liver function with mortality rates up to 80. Liver transplantation is the only lifesaving therapy. There is an unmet need for therapy to extend the waiting time for liver transplantation or regeneration of the native liver. Here we review the state-of-the-art of non-cell based and cell-based artificial liver support systems, cell transplantation and plasma exchange, with the first therapy relying on detoxification, while the others aim to correct also other failing liver functions and/or modulate the immune response. Meta-analyses on the effect of non-cell based systems show contradictory outcomes for different types of albumin purification devices. For bioartificial livers proof of concept has been shown in animals with liver failure. However, large clinical trials with two different systems did not show a survival benefit. Two clinical trials with plasma exchange and one with transplantation of mesenchymal stem cells showed positive outcomes on survival. Detoxification therapies lack adequacy for most patients. Correction of additional liver functions, and also modulation of the immune system hold promise for future therapy of liver failure.
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Affiliation(s)
- Robert A F M Chamuleau
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, AG&M, Academic Medical Center, Meibergdreef 69-71, S1-176, 1105 BK, Amsterdam, The Netherlands.
| | - Ruurdtje Hoekstra
- Amsterdam UMC, University of Amsterdam, Tytgat Institute for Liver and Intestinal Research, AG&M, Academic Medical Center, Meibergdreef 69-71, S1-176, 1105 BK, Amsterdam, The Netherlands
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5
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Xue R, Zhu Y, Liu H, Meng Q. The clinical parameters for the diagnosis of hepatitis B virus related acute-on-chronic liver failure with sepsis. Sci Rep 2019; 9:2558. [PMID: 30796255 PMCID: PMC6385344 DOI: 10.1038/s41598-019-38866-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 01/09/2019] [Indexed: 12/30/2022] Open
Abstract
It is still unknown that whether sepsis with hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF) fit into the conventional diagnostic criteria of sepsis. Our aim was to investigate the potential clinical parameters for the diagnosis of HBV-ACLF with sepsis. A retrospective study was conducted in 43 patients with HBV-ACLF and sepsis who underwent orthotopic liver transplantation. All patients were divided into three groups according to the pathological results and laboratory test results. Immunohistochemistry (IHC) staining, hematoxylin-eosin (HE) staining and Gordon Sweet’s reticulin staining were performed in this study. Alanine aminotransferase (ALT), aspartale aminotransferase (AST), total bilirubin (TBiL), cholinesterase (CHE), albumin (ALB), prothrombin activity (PTA), blood routine examination were detected. The results being chosen at admission and before transplantation were analyzed. TBiL had a significant increase (563.5 ± 191.8 umol/L vs. 383.9 ± 157.6 umol/L, 438.3 ± 154.7 umol/L, P = 0.031) and ALT significantly decreased (81.6 ± 66.4 U/L, 754.5 ± 1084.7 U/L, 120.6 ± 102.5 U/L, P = 0.005) in sepsis group before liver transplantation. When sepsis appeared in patients with HBV-ACLF, the ratio of PLT to WBC count before liver transplantation was much lower than it at admission (4.6 ± 2.0 vs. 16.1 ± 7.2, P = 0.000). In conclusion, the clinical parameters of sepsis in patients with HBV-ACLF should be reset. The ratio of PLT/WBC and (WBCBLT/WBCAA)/ (PLTBLT/PLTAA) could remind us the occurring of sepsis in patients with HBV-ACLF.
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Affiliation(s)
- Ran Xue
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Yueke Zhu
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Hui Liu
- Clinical-Pathology Center, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China
| | - Qinghua Meng
- Department of Critical Care Medicine of Liver Disease, Beijing You-An Hospital, Capital Medical University, Beijing, 100069, China.
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Mücke MM, Rumyantseva T, Mücke VT, Schwarzkopf K, Joshi S, Kempf VAJ, Welsch C, Zeuzem S, Lange CM. Bacterial infection-triggered acute-on-chronic liver failure is associated with increased mortality. Liver Int 2018; 38:645-653. [PMID: 28853199 DOI: 10.1111/liv.13568] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Accepted: 08/23/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterized by an acute deterioration of liver function in patients with cirrhosis in combination with recently defined organ failures. Our aim was to independently validate the prognostic value of the recently established EASL-CLIF-Consortium definition of ACLF and to identify new predictors of short-term mortality. METHODS Patients with cirrhosis and the International Classification of Diseases, Tenth Revision diagnosis of (sub)acute liver failure were retrospectively categorized according to the EASL-CLIF-Consortium definition. Logistic regression analyses were performed to identify clinical and epidemiological predictors of 30- and 90-day mortality. RESULTS From 2008 to 2015, 257 patients were included. Overall, 173 (67%) patients met the EASL criteria for ACLF (grade 1: n = 43 [25%], grade 2: n = 52 [30%], grade 3: n = 79 [45%]). Mortality within 30 days in patients without ACLF was 3.6%, and 18.6%, 37.3% and 62.0% in patients with ACLF grades 1, 2 and 3 respectively. Outcome of patients with bacterial infection-triggered ACLF was distinct from non-infection-triggered ACLF (71.6% vs 33.8% 30-day survival, P < .001), and infection-triggered ACLF was independently associated with increased mortality (odds ratio [OR] = 4.28, P < .001). Pneumonia was a particularly frequent infection and burdened with high mortality. In addition, infections with multidrug-resistant organisms were frequent and independently associated with mortality (P = .030, OR = 4.41), as was glycopeptide antibiotic therapy as initial empirical antibiotic therapy (P = .005). CONCLUSIONS This study confirmed the EASL-CLIF-Consortium definition of ACLF as strong predictor of mortality in patients with acute decompensation of cirrhosis. However, we have observed a remarkably higher mortality in infection-triggered ACLF compared to other precipitating events.
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Affiliation(s)
- Marcus M Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Tatiana Rumyantseva
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Victoria T Mücke
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Katharina Schwarzkopf
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Sabrina Joshi
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Volkhard A J Kempf
- University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany.,Institute of Medical Microbiology and Infection Control, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christoph Welsch
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Christian M Lange
- Department of Internal Medicine 1, University Hospital Frankfurt, Frankfurt am Main, Germany.,University Center for Infectious Diseases, University Hospital Frankfurt, Frankfurt am Main, Germany
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7
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Chen YS, Wu ZW, He JQ, Yu J, Yang SG, Zhang YM, Du WB, Cao HC, Li LJ. The Curative Effect of ALSS on 1-month Mortality in AoCLF Patients after 72 to 120 Hours. Int J Artif Organs 2018; 30:906-14. [PMID: 17992652 DOI: 10.1177/039139880703001008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Hepatitis B virus (HBV)-related acute-on-chronic liver failure (AoCLF) is associated with a high mortality rate. An artificial liver support system (ALSS) creates a better environment for the self-regeneration of retained hepatocytes. Aim and Patients We investigated the curative effect of ALSS on 1-month mortality at 72–120 h post-ALSS in 289 AoCLF patients. Methods Of the 289 patients, 117 who survived for at least 1 month post-ALSS comprised the survival group; the remaining cases who died within 1 month served as controls. The improvements in laboratory data and clinical syndromes at 72–120 h post-ALSS were compared with those at 24 h. Results Total bilirubin, international normalized ratio, and creatinine levels, and encephalopathy were significantly improved at 24 h post-ALSS in both the groups (p<0.05); however, these variables showed deterioration at 72–120 h; a rebound occurred in the nonsurvivors (p>0.05). The improvements in these variables in the nonsurvivors were considerably smaller than those in the survivors (p<0.05), particularly at 72–120 h. One-month mortality was more accurately predicted by the logistic regression model at 72–120 h than at 24 h. Conclusions The prognosis of AoCLF patients was highly dependent on the improvement in encephalopathy, total bilirubin, international normalized ratio, and creatinine levels at 72–120 h post-ALSS. These variables are useful, therefore, as disease severity indexes to determine organ allocation priorities for liver transplant.
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Affiliation(s)
- Y.-S. Chen
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - Z.-W. Wu
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - J.-Q. He
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - J. Yu
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - S.-G. Yang
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - Y.-M. Zhang
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - W.-B. Du
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - H.-C. Cao
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
| | - L.-J. Li
- State Key Laboratory of Infectious Diseases, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang - China
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8
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Lin S, Chen J, Wang M, Han L, Zhang H, Dong J, Zeng D, Jiang J, Zhu Y. Prognostic nomogram for acute-on-chronic hepatitis B liver failure. Oncotarget 2017; 8:109772-109782. [PMID: 29312647 PMCID: PMC5752560 DOI: 10.18632/oncotarget.21012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 08/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background & Aims To establish an effective prognostic nomogram for acute-on-chronic hepatitis B liver failure (ACHBLF). Materials and Methods The nomogram was based on clinical data of 203 ACHBLF patients who admitted to the First Affiliated Hospital of Fujian Medical University from 2009 to 2014. The area under the receiver-operating characteristic curve (AUC) and calibration curve were carried out to verify the predictive accuracy ability of the nomogram. The result was validated in internal and external validation cohorts. Kaplan-Meier survival curve was used in survival analysis. Results We developed a new prognostic nomogram to predict 3-month mortality based on risk factors selected by multivariate analysis. This nomogram consisted three independent factors: age, liver to abdominal area ratio (LAAR) and model for end-stage liver disease (MELD) score. The AUC of this nomogram for survival prediction was 0.877 (95% CI 0.831–0.923), which was higher than that of MELD score, MELD-Na and Child-Turcotte-Pugh (CTP). Good agreement of calibration plot for the probability of survival at 3-month was shown between the prediction by nomogram and actual observation. These results were supported by internal and external validation studies. Conclusions The ACHBLF nomogram could predict the short-term survival for ACHBLF patients.
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Affiliation(s)
- Su Lin
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Juan Chen
- Digestive System Department, Fujian Provincial Hospital, Fuzhou, Fujian, China
| | - Mingfang Wang
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Lifen Han
- Department of Infectious Disease, Meng Chao Hepatobiliary Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Haoyang Zhang
- Division of Biostatistics, JC School of Public Health and Primary Care, The Chinese University of Hong Kong, Sha Tin, Hongkong, China
| | - Jing Dong
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Dawu Zeng
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Jiaji Jiang
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
| | - Yueyong Zhu
- Liver Research Center, First Affiliated Hospital of Fujian Medical University, Fuzhou, Fujian, China
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9
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Fan Z, EnQiang C, Yao DL, LiBo Y, Hong L, Lang B, Ping F, Hong T. Neutrophil-lymphocyte ratio predicts short term mortality in patients with hepatitis B virus-related acute-on-chronic liver failure treated with an artificial liver support system. PLoS One 2017; 12:e0175332. [PMID: 28426800 PMCID: PMC5398520 DOI: 10.1371/journal.pone.0175332] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Accepted: 03/25/2017] [Indexed: 02/05/2023] Open
Abstract
Aim Hepatitis B virus-related acute-on-chronic liver failure has high short-term mortality. Artificial liver support systems (ALSS) may improve outcome and avoid liver transplantation, but predicting short-term prognosis in such patients is difficult. This study aimed to determine whether the neutrophil–lymphocyte ratio (NLR), an inflammation marker, predicted mortality in patients treated with ALSS. Methods A total of 560 patients with hepatitis B virus-related acute-on-chronic liver failure were enrolled, 338 were treated with ALSS and the others treated with standard of care(SOC). Clinical variables and the NLR were evaluated for prognostic value. Results Thirty-day mortality was 28.4% in ALSS and 55.4% in SOC patients. The NLR was lower in survivors than in ALSS or SOC patients who died. Univariate and multivariate analysis found that NLR and the chronic liver failure sequential organ failure assessment scores(CLIF-SOFA) were independently associated with 30-day mortality. Among patients with NLRs ≤ 3, 3–6, and >6, 30-day mortality was 7.7%,23.1%, and 69.2% in ALSS and 25.5%, 50.0%, and 75.0% in SOC patients. Among patients with NLRs ≤ 3 or 3–6, mortality was lower in ALSS than in SOC patients (P < 0.01). Mortality rates of ALSS and SOC patients with NLRs > 6 did not different (P >0.05). The area under curve of NLR and CLIF-SOFA was 0.82 and 0.88 in ALSS group, 0.78 and 0.86 in SOC group. The results suggest that liver function in most patients with NLRs ≤ 3 recovered with ALSS treatment, and patients with NLRs > 6 needed emergency liver transplantation. Conclusion NLR was an independent predictor of mortality in ALSS patients and may assist physicians in determining treatment options.
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Affiliation(s)
- Zeng Fan
- Centre of Infectious Diseases, West China Hospital, Sichuan University
- Department of intensive care unit, Hospital of the University of Electronic Science, Sichuan Provincial People’s Hospital, Chengdu, Sichuan, China
| | - Chen EnQiang
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Du Ling Yao
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Yan LiBo
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Li Hong
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Bai Lang
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Feng Ping
- Centre of Infectious Diseases, West China Hospital, Sichuan University
| | - Tang Hong
- Centre of Infectious Diseases, West China Hospital, Sichuan University
- * E-mail:
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10
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Wan YM, Li YH, Xu ZY, Yang J, Yang LH, Xu Y, Yang JH. Therapeutic plasma exchange versus double plasma molecular absorption system in hepatitis B virus-infected acute-on-chronic liver failure treated by entercavir: A prospective study. J Clin Apher 2017; 32:453-461. [PMID: 28304106 DOI: 10.1002/jca.21535] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Revised: 02/04/2017] [Accepted: 03/05/2017] [Indexed: 12/12/2022]
Abstract
BACKGROUND Therapeutic plasma exchange (TPE) and double plasma molecular absorption system (DPMAS) were two extracorporeal liver support systems. Few studies compared their efficacy profile. OBJECTIVE This study was to compare the efficacy of TPE and DPMAS on acute-on-chronic liver failure (ACLF) caused by hepatitis B virus (HBV-ACLF). METHODS 60 HBV-ACLF patients were enrolled and prospectively studied. All patients received entecavir therapy, and were assigned to TPE group (n = 33) and DPMAS group (n = 27). Primary end-points were the effects of TPE and DPMAS on liver function and serum inflammatory markers. RESULTS Serum procalcitonin, interleukin (IL)-6, and high sensitive C-reactive protein (hsCRP) were significantly elevated in patients with HBV-ACLF. TPE achieved significantly higher removal rates of total bilirubin (TBIL, P = .002), direct bilirubin (DBIL, P = .006), and hsCRP (P = .010) than DPMAS, but DPMAS displayed lower loss rate of albumin (P = .000). TPE and DPMAS resulted in similarly increased serum IL-6 levels and comparable 12-week survivals (P > .05). Multivariate analysis showed that hospital stay (Relative Risk [RR]: 1.062, 95% Confidence Interval [CI]: 1.011-1.115, P = .016), prothrombin time (RR: 1.346, 95% CI: 1.077-1.726, P = .010), and international normalized ratio (RR: 0.013, 95% CI: 0.006-0.788, P = .041) were independent predictors for 12-week survival. Both TPE and DPMAS treatments were well-tolerated. CONCLUSION Compared to DPMAS, TPE was more efficient in eliminating TBIL, DBIL, and hsCRP, but it was associated with higher loss rate of albumin. TPE and DPMAS were similar in improving 12-week survivals in HBV-ACLF.
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Affiliation(s)
- Yue-Meng Wan
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China.,Graduate Department of Kunming Medical University, Kunming City, 650500, Yunnan Province, China
| | - Yu-Hua Li
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
| | - Zhi-Yuan Xu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
| | - Jing Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
| | - Li-Hong Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
| | - Ying Xu
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
| | - Jin-Hui Yang
- Gastroenterology Department II or Hepatology Center, The Second Affiliated Hospital of Kunming Medical University, Kunming City, 650101, Yunnan Province, China
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Hernaez R, Solà E, Moreau R, Ginès P. Acute-on-chronic liver failure: an update. Gut 2017; 66:541-553. [PMID: 28053053 PMCID: PMC5534763 DOI: 10.1136/gutjnl-2016-312670] [Citation(s) in RCA: 397] [Impact Index Per Article: 56.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 10/10/2016] [Accepted: 10/13/2016] [Indexed: 02/06/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome characterised by acute decompensation of chronic liver disease associated with organ failures and high short-term mortality. Alcohol and chronic viral hepatitis are the most common underlying liver diseases. Up to 40%-50% of the cases of ACLF have no identifiable trigger; in the remaining patients, sepsis, active alcoholism and relapse of chronic viral hepatitis are the most common reported precipitating factors. An excessive systemic inflammatory response seems to play a crucial role in the development of ACLF. Using a liver-adapted sequential organ assessment failure score, it is possible to triage and prognosticate the outcome of patients with ACLF. The course of ACLF is dynamic and changes over the course of hospital admission. Most of the patients will have a clear prognosis between day 3 and 7 of hospital admission and clinical decisions such as evaluation for liver transplant or discussion over goals of care could be tailored using clinical scores. Bioartificial liver support systems, granulocyte-colony stimulating factors or stem-cell transplant are in the horizon of medical care of this patient population; however, data are too premature to implement them as standard of care.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Centro d'Investigaciones Biomedicas en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Richard Moreau
- Inserm, U1149, Centre de Recerche sur l'inflammation (CRI), Paris, France,Faculté de Médicine, Université Paris Diderot, Paris, France,Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France,Laboratoire d'Excellence (Labex) Inflamex, CUE Sorbonne Paris Cité, Paris, France,European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain,Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain,Centro d'Investigaciones Biomedicas en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain
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12
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Wu DB, Chen EQ, Bai L, Tang H. Propylthiouracil-induced liver failure and artificial liver support systems: a case report and review of the literature. Ther Clin Risk Manag 2017; 13:65-68. [PMID: 28138249 PMCID: PMC5238756 DOI: 10.2147/tcrm.s122611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Antithyroid drugs carry a potential risk of hepatotoxicity. Propylthiouracil (PTU) is commonly prescribed for patients with hyperthyroidism. PTU, however, can induce liver injury, ranging from mild asymptomatic elevation of aminotransferases to acute liver failure (ALF). CASE PRESENTATION This case reports on a 16-year-old Chinese girl with hyperthyroidism, who was admitted to our hospital for jaundice, nausea, and fatigue associated with severe hyperbilirubinemia and coagulopathy. She had been prescribed PTU 5 months earlier. There was no history of hypersensitivity to drugs, viral liver diseases, blood transfusion, or surgery. On the basis of her symptoms and the clinical data, she was diagnosed with PTU-induced ALF. Due to the limited number of available donor organs for liver transplantation, she was started on treatment with artificial liver support system (ALSS). After four sessions of ALSS, her clinical signs and symptoms were found to be markedly improved, and she was discharged 25 days after admission. Four months later, her liver function normalized. CONCLUSION Although PTU-induced liver failure is rare in clinical practice, liver function should be appropriately monitored during treatment with PTU. PTU-induced ALF in this patient was successfully managed with an ALSS, suggesting that the latter may be an alternative to liver transplantation.
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Affiliation(s)
- Dong-Bo Wu
- Center of Infectious Diseases, West China Hospital of Sichuan University; Division of Molecular Biology of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, People's Republic of China
| | - En-Qiang Chen
- Center of Infectious Diseases, West China Hospital of Sichuan University; Division of Molecular Biology of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, People's Republic of China
| | - Lang Bai
- Center of Infectious Diseases, West China Hospital of Sichuan University; Division of Molecular Biology of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, People's Republic of China
| | - Hong Tang
- Center of Infectious Diseases, West China Hospital of Sichuan University; Division of Molecular Biology of Infectious Diseases, State Key Laboratory of Biotherapy, Sichuan University, Chengdu, People's Republic of China
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13
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Zhang ML, Xu J, Zhang W, Liu XY, Zhang M, Wang WL, Zheng SS. Microbial epidemiology and risk factors of infections in recipients after DCD liver transplantation. Int J Clin Pract 2016; 70 Suppl 185:17-21. [PMID: 27198000 DOI: 10.1111/ijcp.12812] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
AIM Infection is a major cause of increased mortality after a liver transplant (LT). This study sought to identify the incidence, prevalence and risk factors of microbial infection for recipients who underwent LT using grafts from donors after cardiac death (DCD). METHODS We retrospectively analysed the frequency and characteristics of post-transplantation infections in 236 recipients who underwent DCD LT between 1 January 2010 and 31 December 2014 in our centre and evaluated the risk factors of post-transplantation infection. RESULTS Overall, 162 recipients acquired at least one type of infection during hospitalisation after LT, and the morbidity rate was 68.6%. Moreover, 19 of the 236 recipients died, with an overall mortality rate of 8.1%. In total, 752 pathogens were isolated. Gram-positive bacteria, Gram-negative bacteria and fungi accounted for 26.1% (196), 58.2% (438) and 15.7% (118) of the pathogens, respectively. Kaplan-Meier curves of 1-year survival showed that recipients with infection had a significantly lower cumulative survival rate compared with those without infection (83.2% vs. 90.6%, p < 0.05). Multivariate analysis revealed that age > 60 years (p = 0.010) and severe hepatitis (p = 0.036) were independent risk factors for infection during hospitalisation after LT. CONCLUSION Infection is a common complication after a DCD-LT that could impair 1-year survival. We suggest physicians pay more attention to the infection of recipients post-LT, especially those recipients greater than 60 years of age and those who suffered from severe hepatitis.
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Affiliation(s)
- M-L Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - J Xu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - W Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - X-Y Liu
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - M Zhang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - W-L Wang
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
| | - S-S Zheng
- Department of Hepatobiliary and Pancreatic Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Key Laboratory of Combined Multi-organ Transplantation, Ministry of Public Health, Hangzhou, China
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14
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Kim TY, Song DS, Kim HY, Sinn DH, Yoon EL, Kim CW, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Kim JH, Choe WH, Yim HJ, Kim SE, Baik SK, Lee BS, Jang JY, Suh JI, Kim HS, Nam SW, Kwon HC, Kim YS, Kim SG, Chae HB, Yang JM, Sohn JH, Lee HJ, Park SH, Han BH, Choi EH, Kim CH, Kim DJ. Characteristics and Discrepancies in Acute-on-Chronic Liver Failure: Need for a Unified Definition. PLoS One 2016; 11:e0146745. [PMID: 26789409 PMCID: PMC4720429 DOI: 10.1371/journal.pone.0146745] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/20/2015] [Indexed: 02/07/2023] Open
Abstract
Background & Aim To investigate the prevalence, mortalities, and patient characteristics of Acute-on-chronic liver failure (ACLF) according to the AARC (Asian Pacific Association for the Study of the Liver ACLF Research Consortium) and European Association for the Study of the Liver CLIF-C (Chronic Liver Failure Consortium) definitions. Methods We collected retrospective data for 1470 hospitalized patients with chronic liver disease (CLD) and acute deterioration between January 2013 and December 2013 from 21 university hospitals in Korea. Results Of the patients assessed, the prevalence of ACLF based on the AARC and CLIF-C definitions was 9.5% and 18.6%, respectively. The 28-day and 90-day mortality rates were higher in patients with ACLF than in those without ACLF. Patients who only met the CLIF-C definition had significantly lower 28-day and 90-day survival rates than those who only met the AARC definition (68.0% vs. 93.9%, P<0.001; 55.1% vs. 92.4%, P<0.001). Among the patients who had non-cirrhotic CLD, the 90-day mortality of the patients with ACLF was higher than of those without ACLF, although not significant (33.3% vs. 6.0%, P = 0.192). Patients with previous acute decompensation (AD) within 1- year had a lower 90-day survival rate than those with AD more than 1 year prior or without previous AD (81.0% vs. 91.9% or 89.4%, respectively, all P<0.001). Patients who had extra-hepatic organ failure without liver failure had a similar 90-day survival rate to those who had liver failure as a prerequisite (57.0% vs. 60.6%, P = 0.391). Conclusions The two ACLF definitions result in differences in mortality and patient characteristics among ACLF patients. We suggest that non-cirrhotic CLD, previous AD within 1 year, and extra-hepatic organ failure should be included in the ACLF diagnostic criteria. In addition, further studies are necessary to develop a universal definition of ACLF.
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Affiliation(s)
- Tae Yeob Kim
- Institute of Medical Science, Hanyang University, Seoul, Republic of Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Eileen L. Yoon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Chang Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University, School of Medicine, Daejeon, Republic of Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jeong Ill Suh
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongju, Republic of Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Seong Woo Nam
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Hyeok Choon Kwon
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Hee Bok Chae
- Department of Internal medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Heon Ju Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Seung Ha Park
- Department of Internal Medicine, Inje University Haeundae Paik-Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byung Hoon Han
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Republic of Korea
| | - Eun Hee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Chang H. Kim
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, United States of America
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
- * E-mail:
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Model for End-Stage Liver Disease (MELD) score does not predict outcomes of hepatitis B-induced acute-on-chronic liver failure in transplant recipients. Transplant Proc 2015; 46:3502-6. [PMID: 25498080 DOI: 10.1016/j.transproceed.2014.07.075] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Revised: 07/05/2014] [Accepted: 07/15/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical entity and liver transplantation is the only definitive therapy to salvage these patients. However, the timing of liver transplant for these patients remains unclear. METHODS Seventy-eight patients undergoing liver transplantation because of hepatitis B ACLF were retrospectively analyzed from June 2004 to December 2010. The areas under the receiver operating characteristic curve (AUC) of Model for End-Stage Liver Disease (MELD) score and Child-Turcotte-Pugh (CTP) score for the post-transplantation outcomes were calculated. RESULTS The median age was 44 years (range, 25-64 years), serum bilirubin 418.53 μmol/L (range, 112.90-971.40 μmol/L), INR 3.177 (range, 1.470-9.850), and creatinine 70.84 μmol/L (range, 12.39-844.1 μmol/L); the median MELD score was 32 (range, 21-53) and CTP score 12 (8-15). The AUCs of MELD and CTP scores for 3-month mortality were 0.581 (95% confidence interval [CI], 0.421-0.742; sensitivity, 87.5%; specificity, 32.8%) and 0.547 (95% CI, 0.401-0.693; sensitivity, 75%; specificity, 41%), respectively. Meanwhile, there were no significant differences in hospital mortality (P = .252) or morbidity (P = .338) between the patients with MELD score ≥30 and those <30. CONCLUSIONS MELD score had no predictive ability for the outcomes of patients with hepatitis B ACLF after orthotopic liver transplantation.
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16
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Zhou PQ, Zheng SP, Yu M, He SS, Weng ZH. Prognosis of acute-on-chronic liver failure patients treated with artificial liver support system. World J Gastroenterol 2015; 21:9614-9622. [PMID: 26327769 PMCID: PMC4548122 DOI: 10.3748/wjg.v21.i32.9614] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Revised: 05/21/2015] [Accepted: 07/08/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To establish a new model for predicting survival in acute-on-chronic liver failure (ACLF) patients treated with an artificial liver support system.
METHODS: One hundred and eighty-one ACLF patients who were admitted to the hospital from January 1, 2012 to December 31, 2014 and were treated with an artificial liver support system were enrolled in this retrospective study, including a derivation cohort (n = 113) and a validation cohort (n = 68). Laboratory parameters at baseline were analyzed and correlated with clinical outcome. In addition to standard medical therapy, ACLF patients underwent plasma exchange (PE) or plasma bilirubin adsorption (PBA) combined with plasma exchange. For the derivation cohort, Kaplan-Meier methods were used to estimate survival curves, and Cox regression was used in survival analysis to generate a prognostic model. The performance of the new model was tested in the validation cohort using a receiver-operator curve.
RESULTS: The mean overall survival for the derivation cohort was 441 d (95%CI: 379-504 d), and the 90- and 270-d survival probabilities were 70.3% and 58.3%, respectively. The mean survival times of patients treated with PBA plus PE and patients treated with PE were 531 d (95%CI: 455-605 d) and 343 d (95%CI: 254-432 d), respectively, which were significantly different (P = 0.012). When variables with bivariate significance were selected for inclusion into the multivariate Cox regression model, number of complications, age, scores of the model for end-stage liver disease (MELD) and type of artificial liver support system were defined as independent risk factors for survival in ACLF patients. This new prognostic model could accurately discriminate the outcome of patients with different scores in this cohort (P < 0.001). The model also had the ability to assign a predicted survival probability for individual patients. In the validation cohort, the new model remained better than the MELD.
CONCLUSION: A novel model was constructed to predict prognosis and accurately discriminate survival in ACLF patients treated with an artificial liver support system.
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Pattern and profile of chronic liver disease in acute on chronic liver failure. Hepatol Int 2015; 9:366-72. [PMID: 26016461 DOI: 10.1007/s12072-015-9627-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/30/2015] [Indexed: 12/19/2022]
Abstract
The etiology of the chronic liver disease (CLD) in patients with acute on chronic liver failure (ACLF) may vary from region to region. The major cause of underlying CLD is viral (hepatitis B and C) in the East, while it is alcohol related in the West and in some parts of the Indian subcontinent. Autoimmune liver disease and Wilson's disease are the major underlying etiologies in the pediatric age group. The patients with CLD without cirrhosis should be included when defining ACLF. Non-alcoholic fatty liver disease related chronic liver insult in patients with known risk factors for progressive disease should be taken as a chronic liver disease in the setting of ACLF, whereas fatty liver with normal aminotransferases in low risk patients should not. The patients with CLD and previous decompensation should be excluded. Diagnosis of chronic liver disease in the setting of ACLF is made by history, physical examination and previously available or recent laboratory, endoscopic or radiological investigations. A liver biopsy through the transjugular route may help in cases where the presence of underlying CLD or its cause is not clear. The need of liver biopsy in ACLF should, however, be individualized. Standardization of liver biopsy assessment is essential for a uniform approach to the diagnosis and treatment of CLD and acute insult. Tools to measure liver stiffness may aid in identifying patients with advanced fibrosis. Studies are needed to validate the performance of these tests in the setting of ACLF.
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Qin G, Shao JG, Wang B, Shen Y, Zheng J, Liu XJ, Zhang YY, Liu YM, Qin Y, Wang LJ. Artificial liver support system improves short- and long-term outcomes of patients with HBV-associated acute-on-chronic liver failure: a single-center experience. Medicine (Baltimore) 2014; 93:e338. [PMID: 25526495 PMCID: PMC4603116 DOI: 10.1097/md.0000000000000338] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
For patients with acute-on-chronic liver failure (ACLF), artificial liver support system (ALSS) may help prolong lifespan and function as a bridge to liver transplantation (LT), but data on its long-term benefit are lacking. We conducted this prospective, controlled study to determine the efficacy of ALSS and the predictors of mortality in patients with hepatitis B virus (HBV)-associated ACLF.From January 2003 to December 2007, a total of 234 patients with HBV-associated ACLF not eligible for LT were enrolled in our study. They were allocated to receive either plasma exchange centered ALSS plus standard medical therapy (SMT) (ALSS group, n=104) or SMT alone (control group, n=130). All the patients were followed-up for at least 5 years, or until death.At 90 days, the survival rate of ALSS group was higher than that of the control group (62/104 [60%] vs 61/130 [47%], respectively; P<0.05). Median survival was 879 days in the ALSS group (43% survival at 5 years) and 649 days in the control group (31% survival at 5 years, log-rank P<0.05). ALSS was found to be associated with favorable outcome of these patients by both univariate and multivariate analysis. Multivariate Cox regression analysis also revealed that lower serum sodium levels, higher grades of encephalopathy, presence of cirrhosis, hepatorenal syndrome, and higher model for end-stage liver disease scores were independent predictors for both 90-day and 5-year mortality due to ACLF.Our findings suggest that ALSS is safe and may improve the short- and long-term prognosis of patients with HBV-associated ACLF.
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Affiliation(s)
- Gang Qin
- From the Center for Liver Diseases (GQ, J-GS, BW, X-JL, Y-YZ, L-JW), Nantong Third People's Hospital, Nantong University; Department of Biostatistics (YS, Y-ML), School of Public Health, Nantong University, Jiangsu, China; Department of Paediatrics and Adolescent Medicine (JZ), Faculty of Medicine, The University of Hong Kong, Hong Kong; and Department of Internal Medicine (YQ), Singapore General Hospital, Singapore
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Liu X, Zhang Y, Xu X, Du W, Su K, Zhu C, Chen Y, Lei S, Zheng S, Jiang J, Yang S, Guo J, Shao L, Yang Q, Chen J, Li L. Evaluation of plasma exchange and continuous veno-venous hemofiltration for the treatment of severe avian influenza A (H7N9): a cohort study. Ther Apher Dial 2014; 19:178-84. [PMID: 25363618 DOI: 10.1111/1744-9987.12240] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Avian influenza A (H7N9) is a severe disease with high mortality. Hypercytokinemia is thought to play an important role in the pathogenesis. This study was to investigate the efficiency of plasma exchange (PE) + continuous veno-venous hemofiltration (CVVH) on the removal of inflammatory mediators and their benefits in the management of fluid overload and metabolic disturbance. In total, 40 H7N9-infected patients were admitted to our hospital. Sixteen critically ill H7N9-infected patients received combination of PE and CVVH. Data from these 16 patients were collected and analyzed. The effects of PE + CVVH on plasma cytokine/chemokine levels and clinical outcomes were examined. H7N9-infected patients had increased plasma levels compared to healthy controls. After 3 h of PE + CVVH treatment, the cytokine/chemokine levels descended remarkably to lower levels and were maintained thereafter. PE + CVVH also benefited the management of fluid, cardiovascular dysfunction and metabolic disturbance. Of the 16 critically ill patients who received PE + CVVH, 10 patients survived. PE + CVVH decreased the plasma cytokine/chemokine levels significantly. PE + CVVH were also beneficial to the management of severe avian influenza A (H7N9).
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Affiliation(s)
- Xiaoli Liu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
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Chen LG, Guleng B, Ren JL, Chen JM, Wang L. Artificial liver support system in treatment of liver failure after acute poisoning. World J Emerg Med 2014; 2:283-6. [PMID: 25215024 DOI: 10.5847/wjem.j.1920-8642.2011.04.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Accepted: 10/08/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute poisoning (AP) may cause failure of the liver and kidney, and even death. This study aimed to investigate the efficacy of artificial liver support system (ALSS) on the treatment of liver failure after acute poisoning. METHODS A total of 31 patients with liver failure caused by AP were admitted to emergency ICU, central ICU, and Department of Gastroenterology from 2005 to 2009 in Zhongshan Hospital Affiliated to Xiamen University, China. Among them, 13 patients served as a treatment group, and used ALSS in addition to detoxification treatment and protective treatment of liver function, and the other 18 patients served as a control group receiving detoxification treatment and protective treatment of liver function. RESULTS In the treatment group, 10 patients (76.9%) were cured or improved, 2 died, and 1 was discharged against advice. In the 18 patients in the control group, 7 (38.9%) were cured or improved, 3 died, and 8 were discharged against advice. There was a significant difference in the rates of improvement between the two groups (P<0.05). CONCLUSION ALSS is a safe and effective clinical method for the treatment of acute toxic liver failure.
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Affiliation(s)
- Li-Gang Chen
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen 361004, China
| | - Bayasi Guleng
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen 361004, China
| | - Jian-Lin Ren
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen 361004, China
| | - Jian-Min Chen
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen 361004, China
| | - Lin Wang
- Department of Gastroenterology, Zhongshan Hospital Affiliated to Xiamen University, Xiamen 361004, China
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Wu FL, Shi KQ, Chen YP, Braddock M, Zou H, Zheng MH. Scoring systems predict the prognosis of acute-on-chronic hepatitis B liver failure: an evidence-based review. Expert Rev Gastroenterol Hepatol 2014; 8:623-32. [PMID: 24762209 DOI: 10.1586/17474124.2014.906899] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Acute-on-chronic hepatitis B liver failure is a devastating condition that is associated with mortality rates of over 50% and is consequent to acute exacerbation of chronic hepatitis B in patients with previously diagnosed or undiagnosed chronic liver disease. Liver transplantation is the definitive treatment to lower mortality rate, but there is a great imbalance between donation and potential recipients. An early and accurate prognostic system based on the integration of laboratory indicators, clinical events and some mathematic logistic equations is needed to optimize treatment for patients. As parts of the scoring systems, the MELD was the most common and the donor-MELD was the most innovative for patients on the waiting list for liver transplantation. This review aims to highlight the various features and prognostic capabilities of these scoring systems.
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Affiliation(s)
- Fa-Ling Wu
- Department of Infection and Liver Diseases, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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A single-center experience of non-bioartificial liver support systems among Chinese patients with liver failure. Int J Artif Organs 2014; 37:442-54. [PMID: 25008954 DOI: 10.5301/ijao.5000341] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/12/2014] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Liver failure is one of the most deadly, prevalent, and costly diseases worldwide. Non-bioartificial liver support systems (NBALs) have been shown to be effective in improving the clinical symptoms and laboratory parameters of patients with liver failure. The main aim of this large case series analysis was to investigate the status of NBALs and their effectiveness in improving survival in liver-failure patients. METHODS In this retrospective study, 460 patients with liver failure who received NBAL treatment in addition to conventional medications were compared with 422 patients who were treated with conventional medications alone. Kaplan-Meier and life table analyses were used to estimate survival rates. RESULTS Clinical outcomes were improved after NBAL treatment. The 30-day survival rates of subacute liver failure (SALF) patients were 63% among those who received NBALs and 21% among those who did not receive NBALs (p < 0.01). Similarly, the 30-day survival rate of acute-on-chronic liver failure (ACLF) patients who received NBALs was 47%, significantly higher than that of the non-NBAL patients (p < 0.05). The survival rates of ACLF patients with low Model for End-Stage Liver Disease (MELD) scores (MELD ≤ 20) were 64% and 40% among whom received NBALs and those who did not, respectively (p < 0.01). CONCLUSIONS NBAL treatment is helpful to improve the survival of patients with ALF, SALF or ACLF. ACLF patients with lower MELD scores showed improved outcomes relative to those with higher MELD scores.
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Yu CB, Chen JJ, Du WB, Chen P, Huang JR, Chen YM, Cao HC, Li LJ. Effects of plasma exchange combined with continuous renal replacement therapy on acute fatty liver of pregnancy. Hepatobiliary Pancreat Dis Int 2014; 13:179-83. [PMID: 24686545 DOI: 10.1016/s1499-3872(14)60028-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Acute fatty liver of pregnancy (AFLP) in the third trimester or early postpartum period can lead to fatal liver damage. Its traditional therapy is not very effective in facilitating hepatic recovery. The safety and effect of plasma exchange (PE) in combination with continuous renal replacement therapy (CRRT) (PE+CRRT) for AFLP still needs evaluation. METHODS Five AFLP patients with hepatic encephalopathy and renal failure were subjected to PE+CRRT in our department from 2007 to 2012. Their symptoms, physical signs and results were observed, and all relevant laboratory tests were compared before and after PE+CRRT. RESULTS All the 5 patients were well tolerated to the therapy. Four of them responded to the treatment and showed improvement in clinical symptoms/signs and laboratory results, and they were cured and discharged home after the treatment. One patient succeeded in bridging to transplantation for slowing down hepatic failure and its complications process after 2 treatment sessions. Intensive care unit stay and hospital stay were 9.4 (range 5-18) and 25.0 days (range 11-42), respectively. CONCLUSION PE+CRRT is safe and effective and should be used immediately at the onset of hepatic encephalopathy and/or renal failure in patients with AFLP.
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Affiliation(s)
- Cheng-Bo Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, the First Affiliated Hospital, Zhejiang University School of Medicine; Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou 310003, China.
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Administration of Lactobacillus salivarius LI01 or Pediococcus pentosaceus LI05 improves acute liver injury induced by D-galactosamine in rats. Appl Microbiol Biotechnol 2014; 98:5619-32. [PMID: 24639205 DOI: 10.1007/s00253-014-5638-2] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 02/18/2014] [Accepted: 02/22/2014] [Indexed: 12/19/2022]
Abstract
This work investigated the effect of the intragastric administration of five lactic acid bacteria from healthy people on acute liver failure in rats. Sprague-Dawley rats were given intragastric supplements of Lactobacillus salivarius LI01, Lactobacillus salivarius LI02, Lactobacillus paracasei LI03, Lactobacillus plantarum LI04, or Pediococcus pentosaceus LI05 for 8 days. Acute liver injury was induced on the eighth day by intraperitoneal injection of 1.1 g/kg body weight D-galactosamine (D-GalN). After 24 h, samples were collected to determine the level of liver enzymes, liver function, histology of the terminal ileum and liver, serum levels of inflammatory cytokines, bacterial translocation, and composition of the gut microbiome. The results indicated that pretreatment with L. salivarius LI01 or P. pentosaceus LI05 significantly reduced elevated alanine aminotransferase and aspartate aminotransferase levels, prevented the increase in total bilirubin, reduced the histological abnormalities of both the liver and the terminal ileum, decreased bacterial translocation, increased the serum level of interleukin 10 and/or interferon-γ, and resulted in a cecal microbiome that differed from that of the liver injury control. Pretreatment with L. plantarum LI04 or L. salivarius LI02 demonstrated no significant effects during this process, and pretreatment with L. paracasei LI03 aggravated liver injury. To the best of our knowledge, the effects of the three species-L. paracasei, L. salivarius, and P. pentosaceus-on D-GalN-induced liver injury have not been previously studied. The excellent characteristics of L. salivarius LI01 and P. pentosaceus LI05 enable them to serve as potential probiotics in the prevention or treatment of acute liver failure.
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Prognostic factors in acute-on-chronic liver failure: a prospective study from western India. Indian J Gastroenterol 2014; 33:119-24. [PMID: 24122317 DOI: 10.1007/s12664-013-0409-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 09/08/2013] [Indexed: 02/06/2023]
Abstract
The profile of acute-on-chronic liver failure (ACLF) has not been reported from western India. This study was undertaken to analyze the etiology and clinical profile of patients with ACLF and correlate these with outcome. Fifty-four consecutive cases of ACLF were investigated for underlying chronic liver disease (CLD) and acute insult and followed up for 6 months. Mortality, Child–Pugh score, and model for end-stage liver disease (MELD) score were recorded. The most common etiologies of CLD were hepatitis B (29.6 %) and cryptogenic (27.7 %). Prognosis was worse in patients with hepatitis B or alcohol as cause of CLD (mortality 79 %). Acute viral hepatitis A or E was the commonest cause of acute insult (33.3 %) and with statistically better outcome (60 % survival) as compared to sepsis, gastrointestinal bleed, or flare of HBV (survival 5 %, p < 0.05). On univariate analysis age, past history of decompensation, leukocytosis, serum bilirubin and creatinine, international normalized ratio, presence of spontaneous bacterial peritonitis, Child–Pugh score and hepatorenal syndrome were significant predictors of mortality. Multivariate analysis revealed a MELD score of >27 and presence of encephalopathy as independent predictors of mortality. Patients with ACLF had high mortality especially when they had underlying chronic hepatitis B or alcoholic liver disease. Presence of encephalopathy and MELD score were independent baseline predictors of mortality. Child–Pugh score was helpful for prognostication.
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Chen HM, Liu HL, Yang YC, Cheng XL, Wang YF, Xing FF, Zhao YR. Serum IL-21 levels associated with chronic hepatitis B and hepatitis B-related liver failure. Exp Ther Med 2014; 7:1013-1019. [PMID: 24669269 PMCID: PMC3964921 DOI: 10.3892/etm.2014.1533] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2013] [Accepted: 01/27/2014] [Indexed: 12/14/2022] Open
Abstract
The aim of the present study was to investigate the role of interleukin (IL)-21 in chronic hepatitis B virus (HBV) infection. IL-21 stimulates T and B cell responses and plays a role in the control of chronic viral infections. Serum IL-21 levels were measured by enzyme immunoassay in 109 patients with chronic HBV infection at various clinical stages, as well as in 19 healthy controls (HCs). The proportion of T cells producing IL-21 in the peripheral blood was assessed by intracellular cytokine staining and flow cytometry. Mean serum IL-21 levels in patients with chronic hepatitis B (CHB) and the HCs were 303.54±152.77 pg/ml and 68.24±9.06 pg/ml, respectively (P=0.003). In addition, the mean serum IL-21 level in patients with hepatitis B-related acute-on-chronic liver failure (HB-ACLF) was 455.38±412.38 pg/ml, which exhibited a statistically significant difference when compared with the HCs (P=0.000). Serum IL-21 levels were highest in the patients with HB-ACLF (455.38±412.38 pg/ml) and exhibited a significant difference when compared with the CHB patients (P=0.04). The mean serum IL-21 levels in patients with cirrhosis also increased, but there was no statistically significant difference when compared with the HCs (P=0.82). The frequency of IL-21+CD4+ cells also increased compared with the HCs and correlated with the number and percentage of lymphocytes in the peripheral blood. Serum IL-21 levels increased in CHB and HB-ACLF patients. Relatively low serum IL-21 levels in CHB may have a causal role in the persistence of HBV infection. Higher serum levels in HB-ACLF may activate T and B cells to eliminate the virus or injure the liver via the release of inflammatory cytokines.
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Affiliation(s)
- Hong-Mei Chen
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Hong-Li Liu
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yu-Cong Yang
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Xiao-Li Cheng
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Yue-Fei Wang
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Fan-Fan Xing
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
| | - Ying-Ren Zhao
- Department of Infectious Diseases, First Affiliated Hospital of Medical College, Xi'an Jiaotong University, Xi'an, Shaanxi 710061, P.R. China
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Zhang A, Wan Z, You S, Liu H, Zhu B, Chen J, Rong Y, Zang H, Li C, Wang H, Xin S. Association of Hepatitis B Virus Mutations of A1846T and C1913A/G With Acute-on-Chronic Liver Failure Development From Different Underlying Chronic Liver Diseases. HEPATITIS MONTHLY 2013; 13:e12445. [PMID: 24282424 PMCID: PMC3830524 DOI: 10.5812/hepatmon.12445] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 07/23/2013] [Accepted: 08/12/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND As most HBV-related acute-on-chronic liver failure (ACLF) have concurrent cirrhosis, it is important to clarify the association of viral factors with ACLF with or without cirrhosis. OBJECTIVES The aim of this study was to analyze the association of HBV genotypes and mutations with ACLF development underlying different chronic liver diseases. PATIENTS AND METHODS Eighty-seven ACLF patients including 29 patients with chronic hepatitis (ACLF-CHB) and 58 patients with liver cirrhosis (ACLF-LC) were enrolled. Age and sex matched patients with chronic hepatitis (CHB) and liver cirrhosis (LC) were enrolled as controls. The genotypes and mutations at HBV basic core promoter (BCP), precore (PC), and partial C regions were determined by nested PCR and direct sequencing. RESULTS Our results revealed significantly higher incidences (P < 0.05) of genotype B with C1913A/G or A1846T in patients with ACLF-CHB than those with CHB; genotype C with C1913A/G or A1846T in patients with ACLF-CHB and ACLF-LC than those with CHB and LC, respectively. Multivariable analysis indicated that A1846T and C1913A/G mutations were independent factors for ACLF (OR = 2.86 and 5.93, respectively), suggesting an association between the mutations and development of ACLF. In addition, there were no significant differences in mutations at T1753V, A1762T, G1764A, G1896A, and G1899A which were found between either CHB and ACLF-CHB or LC and ACLF-LC patients, suggesting no associations of these mutations with ACLF development. CONCLUSIONS Our findings suggest that CHB or LC patients infected with HBV A1846T and C1913A/G mutants are more susceptible to develop ACLF.
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Affiliation(s)
- Aimin Zhang
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Zhihong Wan
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Shaoli You
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Hongling Liu
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Bing Zhu
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Jing Chen
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Yihui Rong
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Hong Zang
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Chen Li
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
| | - Huifen Wang
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
- Corresponding authors: Huifen Wang, Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China. Tel: +86-1066933433; Fax: +86-1066933434, E-mail: ; Shaojie Xin, Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China. Tel: +86-1066933433; Fax: +86-1066933434, E-mail:
| | - Shaojie Xin
- Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China
- Corresponding authors: Huifen Wang, Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China. Tel: +86-1066933433; Fax: +86-1066933434, E-mail: ; Shaojie Xin, Liver Failure Treatment and Research Center, Beijing 302 Hospital, Beijing, China. Tel: +86-1066933433; Fax: +86-1066933434, E-mail:
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Niu YH, Yin DL, Liu HL, Yi RT, Yang YC, Xue HA, Chen TY, Zhang SL, Lin SM, Zhao YR. Restoring the Treg cell to Th17 cell ratio may alleviate HBV-related acute-on-chronic liver failure. World J Gastroenterol 2013; 19:4146-4154. [PMID: 23864777 PMCID: PMC3710416 DOI: 10.3748/wjg.v19.i26.4146] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2013] [Accepted: 06/04/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the role of T helper 17 cells (Th17) and regulatory T cells (Treg) in hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).
METHODS: We enrolled 79 patients with HBV infection into the study, 50 patients with HBV-related ACLF and 29 patients with chronic hepatitis B (CHB), from the First Affiliated Hospital of Medical College from January 2009 to June 2012. The ACLF patients were diagnosed according to the criteria recommended by The 19th Conference of the Asian Pacific Association for the Study of the Liver in 2009. Twenty healthy individuals with a similar gender and age structures to the two patient groups were also included as the normal controls (NC). Of the 50 ACLF patients, 28 were subsequently classified as non-survivors: 19 patients died from multi-organ failure, 3 underwent liver transplantation, and 6 discontinued therapy during follow-up because of financial reasons. The remaining 22 ACLF patients whose liver and anticoagulation function recovered to nearly normal levels within the next 6 mo were classified as survivors. The number of circulating Treg and Th17 cells was determined upon diagnosis and during the 8th week of follow-up through flow cytometry.
RESULTS: The percentage of circulating Treg cells in the ACLF group was significantly higher than that in the CHB group (5.50% ± 1.15% vs 3.30% ± 1.13%, P < 0.01). The percentages of circulating Th17 cells in the ACLF and the CHB groups were significantly higher than that in the NC group (6.32% ± 2.22% vs 1.56% ± 0.44%, P < 0.01; 3.53% ± 1.65% vs 1.56% ± 0.44%, P < 0.01). No significant difference in Treg cell to Th17 cell ratio was observed between the ACLF group and the CHB group (0.98 ± 0.44 vs 1.12 ± 0.64, P = 0.991), whereas those in the two HBV infection groups were significantly lower than that in the NC group (1.85 ± 1.22; both P < 0.01). The percentage of Treg cells in the survivors during the 8th week of follow-up was significantly lower than that during peak ACLF severity [total bilirubin (TBIL) peak] (3.45% ± 0.97% vs 5.18% ± 1.02%, P < 0.01). The percentage of Th17 cells in survivors during the 8th week of follow-up was significantly lower than that during the peak TBIL (2.89% ± 0.60% vs 5.24% ± 1.46%; P < 0.01). The Treg cell to Th17 cell ratio during the 8th week of follow-up was significantly higher than that during the TBIL peak (1.22 ± 0.36 vs 1.10 ± 0.54; P < 0.05).
CONCLUSION: Restoring the Treg cell to Th17 cell ratio during the follow-up phase of ACLF could maintain the immune system at a steady state, which favours good prognosis.
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MESH Headings
- Adult
- Antiviral Agents/therapeutic use
- Case-Control Studies
- Cells, Cultured
- End Stage Liver Disease/diagnosis
- End Stage Liver Disease/immunology
- End Stage Liver Disease/mortality
- End Stage Liver Disease/therapy
- End Stage Liver Disease/virology
- Female
- Hepatitis B, Chronic/complications
- Hepatitis B, Chronic/diagnosis
- Hepatitis B, Chronic/immunology
- Hepatitis B, Chronic/mortality
- Hepatitis B, Chronic/therapy
- Humans
- Liver Failure, Acute/diagnosis
- Liver Failure, Acute/immunology
- Liver Failure, Acute/mortality
- Liver Failure, Acute/therapy
- Liver Failure, Acute/virology
- Liver Transplantation
- Male
- Middle Aged
- Multiple Organ Failure/immunology
- Multiple Organ Failure/mortality
- Multiple Organ Failure/virology
- T-Lymphocytes, Regulatory/immunology
- T-Lymphocytes, Regulatory/virology
- Th17 Cells/immunology
- Th17 Cells/virology
- Time Factors
- Treatment Outcome
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Acute on chronic liver failure: From pathophysiology to clinical management. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2013. [DOI: 10.1016/j.tacc.2013.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Comparison of Plasmapheresis and Molecular Adsorbent Recirculating System Efficacy in Graft Failure After Living Donor Liver Transplantation. Transplant Proc 2013; 45:971-3. [DOI: 10.1016/j.transproceed.2013.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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Duan BW, Lu SC, Wang ML, Liu JN, Chi P, Lai W, Wu JS, Guo QL, Lin DD, Liu Y, Zeng DB, Li CY, Meng QH, Ding HG, Chen XY, Liao HY, Ma LQ, Chen Y, Zhang J, Xiang HP, Duan ZP, Li N. Liver transplantation in acute-on-chronic liver failure patients with high model for end-stage liver disease (MELD) scores: a single center experience of 100 consecutive cases. J Surg Res 2013; 183:936-43. [PMID: 23558257 DOI: 10.1016/j.jss.2013.03.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2013] [Revised: 02/19/2013] [Accepted: 03/01/2013] [Indexed: 02/06/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. However, there are little published data on risk factors and outcomes of LT for ACLF. METHODS The objective of this study was to analyze preoperative, intraoperative, postoperative, and overall survival data on 100 consecutive cases with ACLF in order to try to determine for which patients LT are futile. RESULTS One hundred consecutive patients with pathology-confirmed ACLF who underwent LT from June 2004 to September 2012 were enrolled. The preoperative data showed that all patients were in a serious condition with a median high model for end-stage liver disease (MELD) score of 32, total bilirubin of 440.20 umol/L, international normalized ratio (INR) of 3.012, and at least one organ dysfunction as assessed by a Sequential Organ Failure Assessment (SOFA) score of ≥9. The patients had either deceased or a living donor LT with an overall mortality of 20%. The 1-, 3-, and 5-year cumulative survival rates were 76.8%, 75.6%, and 74.1%, respectively, and graft 1-, 3-, and 5-y accumulative survival rates were 73.3%, 72.1%, and 70.6%, respectively. However, the area under receiver operating characteristic of SOFA score, MELD score, as well as Child-Pugh score were 0.552, 0.547, and 0.547, respectively. CONCLUSIONS Both deceased and living donor LT are effective therapeutic options for patients with ACLF and the short- and long-term survival rates are encouraging. It is important to conduct more prospective and multi-center studies to define preoperatively which patients would benefit from LT.
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Affiliation(s)
- Bin-Wei Duan
- Department of Hepatobiliary Surgery and You-An Liver Transplant Center, Beijing You-An Hospital, Capital Medical University, Beijing, China
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Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is the most effective therapy for liver failure. However, OLT is severely limited by the shortage of liver donors. Bioartificial liver (BAL) shows great potential as an alternative therapy for liver failure. In recent years, progress has been made in BAL regarding genetically engineered cell lines, immortalized human hepatocytes, methods for preserving the phenotype of primary human hepatocytes, and other functional hepatocytes derived from stem cells. DATA SOURCES A systematic search of PubMed and ISI Web of Science was performed to identify relevant studies in English language literature using the key words such as liver failure, bioartificial liver, hepatocyte, stem cells, differentiation, and immortalization. More than 200 articles related to the cell sources of hepatocyte in BAL were systematically reviewed. RESULTS Methods for preserving the phenotype of primary human hepatocytes have been successfully developed. Many genetically engineered cell lines and immortalized human hepatocytes have also been established. Among these cell lines, the incorporation of BAL with GS-HepG2 cells or alginate-encapsulated HepG2 cells could prolong the survival time and improve pathophysiological parameters in an animal model of liver failure. The cBAL111 cells were evaluated using the AMC-BAL bioreactor, which could eliminate ammonia and lidocaine, and produce albumin. Importantly, BAL loading with HepLi-4 cells could significantly improve the blood biochemical parameters, and prolong the survival time in pigs with liver failure. Other functional hepatocytes differentiated from stem cells, such as human liver progenitor cells, have been successfully achieved. CONCLUSIONS Aside from genetically modified liver cell lines and immortalized human hepatocytes, other functional hepatocytes derived from stem cells show great potential as cell sources for BAL. BAL with safe and effective liver cells may be achieved for clinical liver failure in the near future.
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Affiliation(s)
- Xiao-Ping Pan
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310003, China
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Zhao LF, Pan XP, Li LJ. Key challenges to the development of extracorporeal bioartificial liver support systems. Hepatobiliary Pancreat Dis Int 2012; 11:243-9. [PMID: 22672816 DOI: 10.1016/s1499-3872(12)60155-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND For nearly three decades, extracorporeal bioartificial liver (BAL) support systems have been anticipated as promising tools for the treatment of liver failure. However, these systems are still far from clinical application. This review aimed to analyze the key challenges to the development of BALs. DATA SOURCE We carried out a PubMed search of English-language articles relevant to extracorporeal BAL support systems and liver failure. RESULTS Extracorporeal BALs face a series of challenges. First, an appropriate cell source for BAL is not readily available. Second, existing bioreactors do not provide in vivo-like oxygenation and bile secretion. Third, emergency needs cannot be met by current BALs. Finally, the effectiveness of BALs, either in animals or in patients, has been difficult to document. CONCLUSIONS Extracorporeal BAL support systems are mainly challenged by incompetent cell sources and flawed bioreactors. To advance this technology, future research is needed to provide more insights into interpreting the conditions for hepatocyte differentiation and liver microstructure formation.
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Affiliation(s)
- Li-Fu Zhao
- Zhejiang University School of Medicine, Hangzhou, China
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34
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Ling Q, Xu X, Wei Q, Liu X, Guo H, Zhuang L, Chen J, Xia Q, Xie H, Wu J, Zheng S, Li L. Downgrading MELD improves the outcomes after liver transplantation in patients with acute-on-chronic hepatitis B liver failure. PLoS One 2012; 7:e30322. [PMID: 22291934 PMCID: PMC3265473 DOI: 10.1371/journal.pone.0030322] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Accepted: 12/19/2011] [Indexed: 12/23/2022] Open
Abstract
Background High score of model for end-stage liver diseases (MELD) before liver transplantation (LT) indicates poor prognosis. Artificial liver support system (ALSS) has been proved to effectively improve liver and kidney functions, and thus reduce the MELD score. We aim to evaluate whether downgrading MELD score could improve patient survival after LT. Methodology/Principal Findings One hundred and twenty-six LT candidates with acute-on-chronic hepatitis B liver failure and MELD score ≥30 were included in this prospective study. Of the 126 patients, 42 received emergency LT within 72 h (ELT group) and the other 84 were given ALSS as salvage treatment. Of the 84 patients, 33 were found to have reduced MELD score (<30) on the day of LT (DGM group), 51 underwent LT with persistent high MELD score (N-DGM group). The median waiting time for a donor was 10 for DGM group and 9.5 days for N-DGM group. In N-DGM group there is a significantly higher overall mortality (43.1%) than that in ELT group (16.7%) and DGM group (15.2%). N-DGM (vs. ECT and DGM) was the only independent risk factor of overall mortality (P = 0.003). Age >40 years and the interval from last ALSS to LT >48 h were independent negative influence factors of downgrading MELD. Conclusions/Significance Downgrading MELD for liver transplant candidates with MELD score ≥30 was effective in improving patient prognosis. An appropriate ALSS treatment within 48 h prior to LT is potentially beneficial.
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Affiliation(s)
- Qi Ling
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiao Xu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qiang Wei
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Xiaoli Liu
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haijun Guo
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Li Zhuang
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jiajia Chen
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Qi Xia
- State Key Lab for Diagnosis and Treatment of Infectious Diseases, Department of Infectious Diseases, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Haiyang Xie
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Wu
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Shusen Zheng
- Key Lab of Combined Multi-Organ Transplantation, Ministry of Public Health, Division of Hepatobiliary and Pancreatic Surgery, Department of Surgery, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
- * E-mail: (LL) (LL); (SZ) (SZ)
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Hu X, Ma S, Huang X, Jiang X, Zhu X, Gao H, Xu M, Sun J, Abbott WGH, Hou J. Interleukin-21 is upregulated in hepatitis B-related acute-on-chronic liver failure and associated with severity of liver disease. J Viral Hepat 2011; 18:458-67. [PMID: 21692955 DOI: 10.1111/j.1365-2893.2011.01475.x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The immune mechanism(s) that lead to hepatitis B-related acute-on-chronic liver failure (HB-ACLF) are poorly understood. Interleukin-21 is a newly discovered cytokine that is involved in autoimmune and inflammatory diseases. Its potential role in HB-ACLF remains unknown. The serum levels of 12 immune cytokines measured by cytometric bead arrays and the frequency of IL-21-secreting CD4+ T cells in peripheral blood mononuclear cells (PBMC) measured by intracellular cytokine staining were compared in moderate chronic hepatitis B (M-CHB, n = 20), severe chronic hepatitis B (S-CHB, n = 20), HB-ACLF (n = 39) and healthy controls (n = 10). PBMC from M-CHB patients or healthy subjects were stimulated with rhIL-21 in vitro, and cytokines in supernatants were measured by FlowCytomix. The frequencies of IL-21-secreting CD4+ T cells were higher in HB-ACLF (both P < 0.001) and S-CHB (P = 0.002 and 0.001) as compared to M-CHB patients and controls. Serum IL-21 levels were highest (P < 0.001) in HB-ACLF and positively associated with high MELD score (P = 0.001) and mortality (P = 0.038). Recovery from HB-ACLF was associated with reduced serum IL-21 levels (P = 0.003) and lower CD4+ IL-21(+) T-cell frequency (P = 0.006). The secretions of IL-1β (P < 0.001), IL-6 (P < 0.001), IL-10 (P < 0.001), IFN-γ (P = 0.001) and TNF-α (P = 0.042) from PBMC were significantly increased with rhIL-21 stimulation. In summary, IL-21 has a causal role in the development of severe liver inflammation, which is upregulated in HB-ACLF and associated with severity of liver disease.
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Affiliation(s)
- X Hu
- Hepatology Unit and Key Lab for Organ Failure Research, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Changes in Peripheral CD4+CD25high Regulatory T Cells in the Acute-on-Chronic Liver Failure Patients with Plasma Exchange Treatment. Inflammation 2011; 35:436-44. [DOI: 10.1007/s10753-011-9333-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Stutchfield BM, Simpson K, Wigmore SJ. Systematic review and meta-analysis of survival following extracorporeal liver support. Br J Surg 2011; 98:623-31. [DOI: 10.1002/bjs.7418] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2010] [Indexed: 12/22/2022]
Abstract
Abstract
Background
Extracorporeal liver support (ELS) systems offer the potential to prolong survival in acute and acute-on-chronic liver failure. However, the literature has been unclear on their specific role and influence on mortality. This meta-analysis aimed to test the hypothesis that ELS improves survival in acute and acute-on-chronic liver failure.
Methods
Clinical trials citing MeSH terms ‘liver failure’ and ‘liver, artificial’ were identified by searching MEDLINE, Embase and the Cochrane registry of randomized controlled trials (RCTs) between January 1995 and January 2010. Only RCTs comparing ELS with standard medical therapy in acute or acute-on-chronic liver failure were included. A predefined data collection pro forma was used and study quality assessed according to Consolidated Standards of Reporting Trials (CONSORT) criteria. Risk ratio was used as the effect size measure according to a random-effects model.
Results
The search strategy revealed 74 clinical studies including 17 RCTs, five case–control studies and 52 cohort studies. Eight RCTs were suitable for inclusion, three addressing acute liver failure (198 participants) and five acute-on-chronic liver failure (157 participants). The mean CONSORT score was 14 (range 11–20). Overall ELS therapy significantly improved survival in acute liver failure (risk ratio 0·70; P = 0·05). The number needed to treat to prevent one death in acute liver failure was eight. No significant survival benefit was demonstrated in acute-on-chronic liver failure (risk ratio 0·87; P = 0·37).
Conclusion
ELS systems appear to improve survival in acute liver failure. There is, however, no evidence that they improve survival in acute-on-chronic liver failure.
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Affiliation(s)
- B M Stutchfield
- Department of Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - K Simpson
- Department of Hepatology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
| | - S J Wigmore
- Department of Surgery, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SA, UK
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Prediction value of model for end-stage liver disease scoring system on prognosis in the acute on chronic liver failure patients with plasma exchange treatment. ASAIO J 2011; 56:475-8. [PMID: 20613491 DOI: 10.1097/mat.0b013e3181e6bf13] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Hepatitis B virus-related acute-on-chronic liver failure (AoCLF) is associated with a high mortality rate. Plasma exchange (PE) is useful to bridge patients with AoCLF to liver transplantation or recovery. The aim of this study was to analyze the impact of the model for end-stage liver disease (MELD) score on 30-day survival in patients with AoCLF treated with PE or conventional medications and to evaluate the therapeutic effectiveness of PE. In this study, 62 enrolled patients with AoCLF who received PE treatment were compared with 131 patients treated with conventional medications. The MELD scores were calculated according to the original formula, and the 30-day survival in patients was recorded. The 30-day survival rate of the patients who received PE versus controls was 41.9% versus 25.2% (p < 0.05). The 30-day survival rate of patients in the PE group (50.0%) with a MELD score from 20 to 30 was higher than that of the control group (31.7%, p < 0.05); for MELD scores more than 30, there was no significant difference in two groups (8.3% vs. 0%, p > 0.05). PE seems to be efficacious and safe for the treatment of patients with AoCLF and significantly increased the survival rates of patients with a MELD score of 20-30.
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39
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Dual Grafts Live Donor Liver Transplantation for Acute-on-Chronic Hepatitis B Liver Failure. Transplant Proc 2010; 42:4552-4. [DOI: 10.1016/j.transproceed.2010.09.172] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 02/10/2010] [Accepted: 09/16/2010] [Indexed: 12/30/2022]
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Sarin SK, Kumar A, Almeida JA, Chawla YK, Fan ST, Garg H, de Silva HJ, Hamid SS, Jalan R, Komolmit P, Lau GK, Liu Q, Madan K, Mohamed R, Ning Q, Rahman S, Rastogi A, Riordan SM, Sakhuja P, Samuel D, Shah S, Sharma BC, Sharma P, Takikawa Y, Thapa BR, Wai CT, Yuen MF. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2009; 3:269-82. [PMID: 19669378 PMCID: PMC2712314 DOI: 10.1007/s12072-008-9106-x] [Citation(s) in RCA: 610] [Impact Index Per Article: 40.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2008] [Accepted: 09/26/2008] [Indexed: 02/06/2023]
Abstract
The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on acute-on-chronic liver failure (ACLF) in 2004, with a mandate to develop consensus guidelines on various aspects of ACLF relevant to disease patterns and clinical practice in the Asia-Pacific region. Experts predominantly from the Asia-Pacific region constituted this working party and were requested to identify different issues of ACLF and develop the consensus guidelines. A 2-day meeting of the working party was held on January 22-23, 2008, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and subsequently presented at the Annual Conference of the APASL at Seoul, Korea, in March 2008. The consensus statements along with relevant background information are presented in this review.
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Affiliation(s)
- Shiv Kumar Sarin
- Department of Gastroenterology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002 India
| | - Ashish Kumar
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi, 110 070 India
| | - John A. Almeida
- Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Barker Street, Randwick 2031, New South Wales, Australia
| | - Yogesh Kumar Chawla
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sheung Tat Fan
- Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China
| | - Hitendra Garg
- Department of Gastroenterology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002 India
| | - H. Janaka de Silva
- Department of Medicine, Faculty of Medicine, University of Kelaniya, P.O. Box 6, Thalagolla Road, Ragama, Sri Lanka
| | - Saeed Sadiq Hamid
- Section of Gastroenterology, Department of Medicine, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi , 74800 Pakistan
| | - Rajiv Jalan
- The University College London (UCL) Institute of Hepatology, Division of Medicine, University College London, 69-75 Chenies Mews, London, WC1E 6HX UK
| | - Piyawat Komolmit
- Department of Medicine, Faculty and Medicine, Chulalongkorn University, Bangkok , 10330 Thailand
| | - George K. Lau
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China
| | - Qing Liu
- Beijing Youan Hospital, Capital University of Medical Sciences, Beijing, China
| | - Kaushal Madan
- Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi, 110 070 India
| | - Rosmawati Mohamed
- Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603 Malaysia
| | - Qin Ning
- Laboratory of Infectious Immunology, Department of Infectious Disease, Institute of Immunology, Huazhong University of Science and Technology, Wuhan, China
| | - Salimur Rahman
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Archana Rastogi
- Department of Pathology, Institute of Liver & Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi, 110 070 India
| | - Stephen M. Riordan
- Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Barker Street, Randwick 2031, New South Wales, Australia
| | - Puja Sakhuja
- Department of Pathology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002 India
| | - Didier Samuel
- INSERM Unité 785, AP-HP Hôpital Paul Brousse, Villejuif, 94800 France
| | - Samir Shah
- Department of Gastroenterology, Jaslok Hospital and Research Center, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 400 026 India
| | - Barjesh Chander Sharma
- Department of Gastroenterology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002 India
| | - Praveen Sharma
- Department of Gastroenterology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002 India
| | - Yasuhiro Takikawa
- Department of Gastroenterology and Hepatology, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505 Japan
| | - Babu Ram Thapa
- Division of Pediatric Gastroenterology, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Chun-Tao Wai
- Asian Center for Liver Diseases and Transplantation, Gleneagles Hospital, Annexe Block #02-37, 6A Gleneagles Hospital, Singapore, 258500 Singapore
| | - Man-Fung Yuen
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China
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Yu JW, Sun LJ, Zhao YH, Li SC. Prediction value of model for end-stage liver disease scoring system on prognosis in patients with acute-on-chronic hepatitis B liver failure after plasma exchange and lamivudine treatment. J Gastroenterol Hepatol 2008; 23:1242-9. [PMID: 18637053 DOI: 10.1111/j.1440-1746.2008.05484.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIM We used the model for end-stage liver disease (MELD) scoring system to predict the 3-month prognosis of patients with acute-on-chronic liver failure (ACLF) after plasma exchange (PE) and lamivudine treatment, and studied the predictive factors on the prognosis of patients. METHODS A total of 280 patients treated with lamivudine were randomly divided into PE and control groups. The relationship between mortality and influential factors of patients was studied by univariate and multivariate analysis. RESULTS The mortality (49.4%) of patients in the PE group with a MELD score from 30 to 40 was lower than that (86.1%) of the control group (chi(2) = 24.546, P < 0.01). The total bilirubin (TBIL) rebound rate of the dead group was significantly higher than that of the survival group (P < 0.01). Univariate analysis showed that mortality was significantly related to age (P = 0.003), treatment method (P = 0.000), TBIL (P = 0.010), MELD score (P = 0.001), international normalised ratio (P = 0.014), pretreatment HBV-DNA load (P = 0.000), decline of hepatitis B virus (HBV)-DNA load during therapy (P = 0.013), encephalopathy (P = 0.019), and hepatorenal syndrome (P = 0.026). In multivariate analysis, MELD scores of 30-40, treatment method (P = 0.003), pretreatment HBV-DNA load (P = 0.009), decline of HBV-DNA load during therapy (P = 0.016), and encephalopathy (P = 0.015) were independent predictors of mortality; for MELD scores above 40, only the MELD score (P = 0.012) was an independent predictive. CONCLUSIONS PE significantly decreased the mortality of patients with a MELD score of 30-40. For ACLF patients with a MELD score of 30-40, a low viral load pretreatment and quick decline of HBV-DNA load are good predictors for the survival with PE and lamivudine treatment.
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Affiliation(s)
- Jian-Wu Yu
- Department of Infectious Diseases, Second Affiliated Hospital, Harbin Medical University, Harbin, China
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Abstract
PURPOSE OF REVIEW Liver support devices are used either as a bridge to liver transplantation or liver recovery in patients with acute or acute-on-chronic liver failure. The review analyzes the recent literature and asks if the current enthusiasm for these devices is justified. RECENT FINDINGS Many liver support devices exist and are discussed. Clinical data on artificial devices are rapidly emerging, especially on the molecular adsorbents recirculating system, and fractionated plasma separation and adsorption (Prometheus). While hepatic encephalopathy is improved by the molecular adsorbents recirculating system and probably Prometheus too, neither system has been shown to improve survival. Less clinical data exist for bioartificial support devices. These may use human hepatocytes, such as the extracorporeal liver assist device, although most devices use porcine hepatocytes, such as HepatAssist. SUMMARY Enthusiasm in liver support devices is justified as many nonrandomized studies have suggested some biochemical and clinical benefits. The results of several ongoing multicenter randomized controlled trials are anxiously awaited. Meanwhile, because mortality without liver transplantation remains high despite the use of liver support devices, these devices should only be used in the research setting or by experts proficient in their use and as a bridge to liver transplantation rather than liver recovery.
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Affiliation(s)
- Jason Phua
- Division of Respiratory and Critical Care Medicine, Department of Medicine, National University Hospital, Singapore
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Wang ZX, Yan LN, Wang WT, Xu MQ, Yang JY. Impact of Pretransplant MELD Score on Posttransplant Outcome in Orthotopic Liver Transplantation for Patients with Acute-on-Chronic Hepatitis B Liver Failure. Transplant Proc 2007; 39:1501-4. [PMID: 17580172 DOI: 10.1016/j.transproceed.2007.02.070] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2006] [Revised: 12/12/2006] [Accepted: 02/05/2007] [Indexed: 12/28/2022]
Abstract
UNLABELLED This study was performed to evaluate the usefulness of the model for end-stage liver disease (MELD) score in comparison with the Child-Turcotte-Pugh (CTP) score to predict short-term postoperative survival and 3-month morbidity among patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation. METHODS We retrospectively analyzed data from all patients undergoing orthotopic liver transplantation in our unit from December 1999 to November 2005, on the admission day MELD and CTP scores were calculated for each patient according to the original formula. We evaluated the accuracy of MELD and CTP to predict postoperative short-term survival and 3-month morbidity using receiver operating characteristic (ROC) analysis and Kaplan-Meier analysis, respectively. RESULTS Seven of 42 patients died within 3-months follow-up. The MELD scores for nonsurvivors (32.97 +/- 7.11) were significantly higher than those for survivors (24.90 +/- 4.96; P < .05), CTP scores were significantly higher, too (12.57 +/- 0.98, 11.51 +/- 1.17; P < .05). ROC analysis identified the MELD best cut-off point to be 25.67 to predict postoperative morbidity (area under the curve [AUC] = 0.841; sensitivity = 85.7%; specificity = 60.0%), and the CTP best cut-off point was 11.5 (AUC = 0.747; sensitivity = 85.7%; specificity = 54.3%). MELD score was superior to CTP score to predict postoperative short-term survival and 3-month morbidity among patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation. CONCLUSION MELD score was an objective predictive system and more efficient than CTP score to evaluate the risk of 3-month morbidity and short-term prognosis in patients with acute-on-chronic hepatitis B liver failure undergoing orthotopic liver transplantation.
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Affiliation(s)
- Z-X Wang
- Liver Transplantation Division, Department of Surgery, West China Hospital, Sichuan University Medical School, Chengdu 610041, Sichuan, China
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44
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Abstract
The Model for End-stage Liver Disease (MELD) was initially created to predict survival in patients with complications of portal hypertension undergoing elective placement of transjugular intrahepatic portosystemic shunts. The MELD which uses only objective variables was validated subsequently as an accurate predictor of survival among different populations of patients with advanced liver disease. The major use of the MELD score has been in allocation of organs for liver transplantation. However, the MELD score has also been shown to predict survival in patients with cirrhosis who have infections, variceal bleeding, as well as in patients with fulminant hepatic failure and alcoholic hepatitis. MELD may be used in selection of patients for surgery other than liver transplantation and in determining optimal treatment for patients with hepatocellular carcinoma who are not candidates for liver transplantation. Despite the many advantages of the MELD score, there are approximately 15%-20% of patients whose survival cannot be accurately predicted by the MELD score. It is possible that the addition of variables that are better determinants of liver and renal function may improve the predictive accuracy of the model. Efforts at further refinement and validation of the MELD score will continue.
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Affiliation(s)
- Patrick S Kamath
- Advanced Liver Disease Study Group, Miles and Shirley Fiterman Center for Digestive Diseases, Mayo Clinic College of Medicine, Rochester, MN 55905, USA.
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Abstract
Acute liver failure (ALF) is an uncommon disorder that leads to jaundice, coagulopathy, and multisystem organ failure. Its definition is based on the timing from onset of jaundice to encephalopathy. In 2005, ALF accounted for 6% of liver-related deaths and 7% of orthotopic liver transplants (OLT) in the United States. Several classification systems have been developed for ALF, with the King's College criteria most widely used for prediction of OLT. Specific diagnostic tests should be implemented to identify the cause of ALF, which will help to determine its treatment and prognosis. Viral hepatitis was previously reported to be the most common cause of ALF in the United States, but acetaminophen overdose and idiosyncratic drug reactions have emerged as the most frequent causes in recent studies. Malignancy is an uncommon cause of ALF, and thus imaging studies may not be useful in this setting, but liver biopsy may be beneficial in selected cases. An overall strategy for ALF should start with identifying the cause, assessing the prognosis, and early transfer to a transplantation center for suitable candidates. OLT has emerged as a life-saving procedure leading to marked improvement in survival rates. Improved surgical techniques, immunosuppression, and comprehensive care have led to an overall survival rate of approximately 65% with OLT. N-acetylcysteine is effective in ALF caused by acetaminophen overdose, with results strongly related to how soon it is given rather than the route of administration. Liver support systems show potential for the treatment of ALF, but their role needs validation in large multicenter randomized trials.
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Affiliation(s)
- Mouen Khashab
- Division of Gastroenterology and Hepatology, Department of Medicine, Indiana University School of Medicine, 675 West Walnut, IB 327, Indianapolis, IN 46202, USA
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Abstract
In the present review, various animal models of acute liver failure are reviewed with respect to their suitability for evaluating liver support systems (LSS) according to envisaged modes of therapy. In order to increase the value of the preclinical testing of LSS, it would be advantageous to include more than one animal model in the evaluation program. It is possible to identify appropriate sets of models, which make a suitable test system for particular clinical applications. A standardization of evaluation methods between testing groups would also be beneficial to the field of liver support.
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Affiliation(s)
- Oleksandr Seleverstov
- Center for Biotechnology and Biomedicine (BBZ), University of Leipzig, Leipzig, Germany.
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