Hepatorenal failure

Mechanisms of Acute Liver Failure

Acute liver failure (ALF) is characterized by the sudden onset of liver failure in a patient without evidence of chronic liver disease. This definition is important, as it differentiates patients with ALF from patients who suffer from liver failure owing to end-stage chronic liver disease [1].

Mechanisms of Acute Liver Failure

Acute liver failure is characterized by the sudden onset of liver failure in a patient without evidence of chronic liver disease. This definition is important, as it differentiates patients with acute liver failure from patients who suffer from liver failure owing to end-stage chronic liver disease.

The clinical course of patients with type 1 hepatorenal syndrome maintained on hemodialysis

GOAL

Report the natural coarse of hepatorenal syndrome in 4 patients who were maintained on chronic hemodialysis.

BACKGROUND

The diagnosis of hepatorenal syndrome carries a grave prognosis with a mortality rate >90% and a median survival time of <2 weeks without orthotopic liver transplantation.

STUDY

We report the clinical course of 4 patients with hepatorenal syndrome who underwent long-term (greater than 3 weeks) hemodialysis in an attempt to bridge them to orthotopic liver transplantation. The etiologies of cirrhosis were: chronic hepatitis C infection (n = 2), alcoholic liver disease (n = 1), and primary sclerosing cholangitis (n = 1).

RESULTS

Mean survival time on hemodialysis was 236 days (range: 31 to 460 days). All patients survived their initial hospitalization and were discharged from the hospital. However, only one patient received orthotopic liver transplantation. Mean number of hospital admissions was 11 (range: 4 to 18) while receiving hemodialysis at an average rate of 2.2 (range: 1.1 to 5) admissions/patient month. Mean number of days spent in hospital while on hemodialysis support was 85 days (range: 15 to 199 days) at an average rate of 11.2 (range: 8.3 to 15) hospital days/patient month. An average of 33% (range: 26% to 48%) of the days of the prolonged survival on hemodialysis was spent in hospital.

CONCLUSION

Although our 4 patients with hepatorenal syndrome demonstrated long-term survival with hemodialysis, their prolonged survival was at the cost of a very heavy burden of morbidity and in-patient stay. The advisability of maintenance hemodialysis in patients with hepatorenal syndrome should be judged on an individual basis.

Liver failure, transplantation, and critical care

The management of patients for end-stage liver disease in the ICU mandates a multidisciplinary approach and intense monitoring. Orthotopic liver transplantation still remains the only definitive therapy. Given the increasing disparity between the number of potential recipients and available cadaver organs, the current challenge is to optimize outcome with the limited resource. In recent years, considerable progress has been made in developing specific and supportive medical measures. Future research should target a better understanding of mechanisms responsible for liver cell death and liver regeneration, as well as developments in xenotransplantation, hepatocyte transplantation, and liver-directed gene therapy.

Perioperative perfusion strategies for optimal fluid management in liver transplant recipients with renal insufficiency

Renal Insufficiency (RI) is a common finding in patients suffering from end-stage liver disease. The causes of RI are reported to be multifactorial and the degree of RI can range from early functional impairment to hepatorenal syndrome (HRS). The process of liver transplantation is highly likely to exacerbate the symptoms and sequelae of renal dysfunction. RI continues to be a cause of morbidity and mortality in the intraoperative and postoperative periods. With careful evaluation and monitoring in addition to appropriate intervention, a uniformly good outcome may be possible even for these most complicated patients. This paper will describe successful perfusion interventions carried out during the three phases of liver transplantation: pre-anhepatic, anhepatic and reperfusion at our institution for a three-year period. Intraoperative plasmapheresis (n = 3), continuous veno-venous hemofiltration (CVVH) (n = 7), intraoperative dialysis (n = 8), and intraoperative dialysis with fluid removal (n = 3) techniques will be presented for review.