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Orozco G, Gupta M, Ancheta A, Shah MB, Warriner Z, Marti F, Mei X, Desai S, Bernard A, Gedaly R. Liver transplantation for severe hepatic trauma: A multicenter analysis from the UNOS data set. J Trauma Acute Care Surg 2024; 96:763-768. [PMID: 37994467 DOI: 10.1097/ta.0000000000004220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2023]
Abstract
BACKGROUND Orthotopic liver transplantation (OLT) is rarely indicated after hepatic trauma but it can be the only therapeutic option in some patients. There are scarce data analyzing the surgical outcomes of OLT after trauma. METHODS We used the UNOS data set to identify patients who underwent OLT for trauma from 1987 to 2022 and compared them to a cohort of patients transplanted for other indications. Cox proportional hazard and multivariable logistic regression analyses were performed to assess predictors of graft and patient survival. RESULTS Seventy-two patients underwent OLT for trauma during the study period. Patients with trauma were more frequently on mechanical ventilation at the time of transplantation (26.4% vs. 7.6%, p < 0.001) and had a greater incidence of pretransplant portal vein thrombosis (12.5% vs. 4%, p = 0.002). Our 4:1 matched analysis showed that trauma patients had significantly shorter wait times, higher incidence of pretransplant portal vein thrombosis and prolonged length of stay. Trauma was associated with decreased overall graft survival (hazards ratio, 1.42; 95% confidence interval, 1.01-1.98), and increased length of stay ( p = 0.048). There were no significant differences in long-term patient survival. CONCLUSION Unique physiological and vascular challenges after severe hepatic trauma might be associated with decreased graft survival in patients requiring liver transplantation. LEVEL OF EVIDENCE Prognostic and Epidemiological; Level III.
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Affiliation(s)
- Gabriel Orozco
- From the Division of Transplantation, Department of Surgery (G.O., M.G., A.A., M.B.S., F.M., X.M., S.D., R.G.), and Division of Acute Care Surgery, Trauma & Surgical Critical Care, Department of Surgery (Z.W., A.B.), University of Kentucky, Lexington, Kentucky
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2
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Coelho DRA, da Luz RO, Basto ST, de Sousa CCT, da Silva HP, de Sousa Martins Fernandes E, Brito-Azevedo A. Prolonged Anhepatic State as a Bridge to Retransplantation: A Challenging Case of a 35-Year-Old Male Liver Transplant Patient with a Temporary Portacaval Shunt. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941933. [PMID: 38150414 PMCID: PMC10763644 DOI: 10.12659/ajcr.941933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/24/2023] [Accepted: 11/03/2023] [Indexed: 12/29/2023]
Abstract
BACKGROUND Liver transplantation is a life-saving intervention for patients with a diagnosis of acute liver failure or end-stage liver disease. Despite advances in surgical techniques and immunosuppressive therapies, primary nonfunction remains a concern, often necessitating retransplantation. In these scenarios, the anhepatic state, achieved through total hepatectomy with a temporary portacaval shunt, serves as a bridge to retransplantation. However, the challenge lies in the uncertain survival period and several potential complications associated with this procedure. CASE REPORT We present a case of a 35-year-old male patient with autoimmune hepatitis who underwent liver transplantation from a deceased donor. Seven days later, he experienced acute liver failure, leading to an urgent listing for retransplantation. To prevent the intense systemic inflammatory response, the patient underwent a total hepatectomy with a temporary portacaval shunt while awaiting another graft and endured a 57-h anhepatic state. On day 17 following retransplantation, he had cerebral death due to a hemorrhagic stroke. CONCLUSIONS This case underscores one of the most prolonged periods of anhepatic state as a bridge to retransplantation, highlighting the complexities associated with this technique. The challenges include sepsis, hypotension, coagulopathy, metabolic acidosis, renal failure, electrolyte disturbances, hypoglycemia, and hypothermia. Vigilant monitoring and careful management are crucial to improve patient outcomes. Further research is needed to optimize the duration of the anhepatic state and minimize complications for liver transplantation recipients.
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Affiliation(s)
| | | | - Samanta Teixeira Basto
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
| | | | | | | | - Anderson Brito-Azevedo
- Department of Gastrointestinal and Liver Transplant Surgery, Hospital Adventista Silvestre (HAS), Rio de Janeiro, RJ, Brazil
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3
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Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN, Larson AM, Grant L. Acute Liver Failure Guidelines. Am J Gastroenterol 2023; 118:1128-1153. [PMID: 37377263 DOI: 10.14309/ajg.0000000000002340] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 06/29/2023]
Abstract
Acute liver failure (ALF) is a rare, acute, potentially reversible condition resulting in severe liver impairment and rapid clinical deterioration in patients without preexisting liver disease. Due to the rarity of this condition, published studies are limited by the use of retrospective or prospective cohorts and lack of randomized controlled trials. Current guidelines represent the suggested approach to the identification, treatment, and management of ALF and represent the official practice recommendations of the American College of Gastroenterology. The scientific evidence was reviewed using the Grading of Recommendations, Assessment, Development and Evaluation process to develop recommendations. When no robust evidence was available, expert opinions were summarized using Key Concepts. Considering the variety of clinical presentations of ALF, individualization of care should be applied in specific clinical scenarios.
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Affiliation(s)
- Alexandra Shingina
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Nizar Mukhtar
- Department of Gastroenterology, Kaiser Permanente, San Francisco, California, USA
| | - Jamilé Wakim-Fleming
- Department of Gastroenterology, Hepatology & Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic Foundation, Cleveland Ohio, USA
| | - Saleh Alqahtani
- Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
- Liver Transplantation Unit, King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Robert J Wong
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, Gastroenterology Section, Veterans Affairs Palo Alto Healthcare System, Palo Alto, California, USA
| | | | - Anne M Larson
- Division of Gastroenterology and Hepatology, University of Washington, Seattle, Washington, USA
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas, USA
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4
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Kathawate RG, Ibeabuchi T, Abt PL, Bittermann T. Utilization and outcomes of rescue hepatectomy among U.S. liver retransplant candidates. Clin Transplant 2023; 37:e14890. [PMID: 36544328 PMCID: PMC9911400 DOI: 10.1111/ctr.14890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 10/06/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
INTRODUCTION The frequency and outcomes of anhepatic patients listed for transplantation in the United States have not been studied. The United Network for Organ Sharing (UNOS) records anhepatic status for patients listed as Status 1A for hepatic artery thrombosis (HAT) or primary non-function (PNF). METHODS Using the UNOS database from 2005 to 2020, demographics and waitlist outcomes of anhepatic candidates relisted as Status 1A for HAT or PNF were assessed. RESULTS Among 1364 adult Status 1A patients relisted for PNF or HAT across 120 distinct transplant centres, 75 (5.5%) patients were anhepatic and 1289 (94.5%) were non-anhepatic. A substantial number of centres (n = 51) had experience with ≥1 anhepatic patient relisted for either PNF or HAT, with individual centre rates ranging from 0% to 11.4%. Waitlist mortality was more than twice as high for anhepatic patients: 42.5% versus 17.0% non-anhepatic patients (p < .001). The post-transplant outcomes of anhepatic patients were markedly inferior to non-anhepatic patients. For example, 41.9% of anhepatic patients died during the index admission versus 23.4% of the non-anhepatic group (p = .006). Patient survival for the anhepatic and non-anhepatic groups was 48.3% versus 66.2% at 1-year and 29.3% versus 46.2% at 5-years, respectively (log-rank test for overall survival p = .014). CONCLUSIONS Rescue hepatectomy after initial liver transplantation is not only associated with high waitlist mortality, but also markedly worse post-transplant outcomes. With less than half of anhepatic patients surviving to the first year post-LT, further research is warranted to better delineate which patients should be considered for rescue hepatectomy.
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Affiliation(s)
- Ranganath G. Kathawate
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Tobenna Ibeabuchi
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Peter L. Abt
- Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Therese Bittermann
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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5
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Peters S, Bezinover D, Nowak K, Saner FH. Management of an Anhepatic Patient: The Ultimate Challenge for an Intensive Care Physician. J Cardiothorac Vasc Anesth 2022; 36:3187-3192. [PMID: 35393240 DOI: 10.1053/j.jvca.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 02/27/2022] [Accepted: 03/02/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Sonja Peters
- Department of General, Visceral, and Transplant Surgery, Medical Center University Duisburg-Essen, Essen, Germany
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State Hershey Medical Center, Penn State College of Medicine, Hershey, PA
| | - Knut Nowak
- Department of General, Visceral, and Transplant Surgery, Medical Center University Duisburg-Essen, Essen, Germany
| | - Fuat H Saner
- Department of General, Visceral, and Transplant Surgery, Medical Center University Duisburg-Essen, Essen, Germany.
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6
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One Step at a Time: A Pediatric Case of Primary Two Staged Liver Transplantation in a Child with ESLD. TRANSPLANTOLOGY 2022. [DOI: 10.3390/transplantology3020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Toxic liver syndrome is a rare condition with multiorgan failure in end-stage liver disease (ESLD), and a two-stage LT following hepatectomy with a prolonged anhepatic phase is an accepted approach to bridge to transplant. This primary approach has not been described for toxic liver syndrome in children with ESLD. We report a 6-year-old boy who developed toxic liver syndrome with multiorgan failure while awaiting LT for ESLD from biliary atresia and failed Kasai at the age of 2 years. Deemed too sick to transplant, he underwent full hepatectomy and portocaval shunt placement. The child was then transplanted hemodynamically stable after an anhepatic phase of 10 h and 30 min. Although his initial graft showed primary liver dysfunction and he needed re-transplantation after 14 days, he was able to leave the hospital 4 months following 2nd LT and is well with a fully working graft 5 years later. Primary two stage LT is feasible in children in dire situations.
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7
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Abstract
Severe allograft dysfunction, as opposed to the expected immediate function, following liver transplantation is a major complication, and the clinical manifestations of such that lead to either immediate retransplant or death are the catastrophic end of the spectrum. Primary nonfunction (PNF) has declined in incidence over the years, yet the impact on patient and healthcare teams, and the burden on the organ pool in case of the need for retransplant should not be underestimated. There is no universal test to define the diagnosis of PNF, and current criteria are based on various biochemical parameters surrogate of liver function; moreover, a disparity remains within different healthcare systems on selecting candidates eligible for urgent retransplantation. The impact on PNF from traditionally accepted risk factors has changed somewhat, mainly driven by the rising demand for organs, combined with the concerted approach by clinicians on the in-depth understanding of PNF, optimal graft recipient selection, mitigation of the clinical environment in which a marginal graft is reperfused, and postoperative management. Regardless of the mode, available data suggest machine perfusion strategies help reduce the incidence further but do not completely avert the risk of PNF. The mainstay of management relies on identifying severe allograft dysfunction at a very early stage and aggressive management, while excluding other identifiable causes that mimic severe organ dysfunction. This approach may help salvage some grafts by preventing total graft failure and also maintaining a patient in an optimal physiological state if retransplantation is considered the ultimate patient salvage strategy.
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Affiliation(s)
- Hermien Hartog
- The Liver Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
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8
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Salhanick M, MacConmara MP, Pedersen MR, Grant L, Hwang CS, Parekh JR. Two-stage liver transplant for ruptured hepatic adenoma: A case report. World J Hepatol 2019; 11:242-249. [PMID: 30820274 PMCID: PMC6393718 DOI: 10.4254/wjh.v11.i2.242] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 01/03/2019] [Accepted: 01/28/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Only one case of liver transplantation for hepatic adenoma has previously been reported for patients with rupture and uncontrolled hemorrhage. We present the case of a massive ruptured hepatic adenoma with persistent hemorrhagic shock and toxic liver syndrome which resulted in a two-stage liver transplantation. This is the first case of a two-stage liver transplantation performed for a ruptured hepatic adenoma.
CASE SUMMARY A 23 years old African American female with a history of pre-diabetes and oral contraceptive presented to an outside facility complaining of right-sided chest pain and emesis for one day. She was found to be in hemorrhagic shock due to a massive ruptured hepatic hepatic adenoma. She underwent repeated embolizations with interventional radiology with ongoing hemorrhage and the development of renal failure, hepatic failure, and hemodynamic instability, known as toxic liver syndrome. In the setting of uncontrolled hemorrhage and toxic liver syndrome, a hepatectomy with porto-caval anastomosis was performed with liver transplantation 15 h later. She tolerated the anhepatic stage well, and has done well over one year later.
CONCLUSION When toxic liver syndrome is recognized, liver transplantation with or without hepatectomy should be considered before the patient becomes unstable.
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Affiliation(s)
- Marc Salhanick
- Division of Vascular Surgery, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Malcolm P MacConmara
- Division of Surgical Transplantation, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Mark R Pedersen
- Division of Digestive and Liver Diseases, Department of Internal Medicine, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Lafaine Grant
- Division of Digestive and Liver Diseases, Department of Internal Medicine, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Christine S Hwang
- Division of Surgical Transplantation, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
| | - Justin R Parekh
- Division of Surgical Transplantation, Department of Surgery, the University of Texas Southwestern Medical Center, Dallas, TX 75390, United States
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Lauterio A, De Carlis R, Di Sandro S, Ferla F, Buscemi V, De Carlis L. Liver transplantation in the treatment of severe iatrogenic liver injuries. World J Hepatol 2017; 9:1022-1029. [PMID: 28932348 PMCID: PMC5583534 DOI: 10.4254/wjh.v9.i24.1022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/19/2017] [Accepted: 07/17/2017] [Indexed: 02/06/2023] Open
Abstract
The place of liver transplantation in the treatment of severe iatrogenic liver injuries has not yet been widely discussed in the literature. Bile duct injuries during cholecystectomy represent the leading cause of liver transplantation in this setting, while other indications after abdominal surgery are less common. Urgent liver transplantation for the treatment of severe iatrogenic liver injury may-represent a surgical challenge requiring technically difficult and time consuming procedures. A debate is ongoing on the need for centralization of complex surgery in tertiary referral centers. The early referral of patients with severe iatrogenic liver injuries to a tertiary center with experienced hepato-pancreato-biliary and transplant surgery has emerged as the best treatment of care. Despite widespread interest in the use of liver transplantation as a treatment option for severe iatrogenic injuries, reported experiences indicate few liver transplants are performed. This review analyzes the literature on liver transplantation after hepatic injury and discusses our own experience along with surgical advances and future prospects in this uncommon transplant setting.
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Affiliation(s)
- Andrea Lauterio
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Riccardo De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Stefano Di Sandro
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Experimental Medicine, University of Pavia, 27100 Pavia, Italy
| | - Fabio Ferla
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
| | - Vincenzo Buscemi
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- Department of Surgical Sciences, University of Pavia, 27100 Pavia, Italy
| | - Luciano De Carlis
- Division of General Surgery and Abdominal Transplantation, ASST Grande Ospedale Metropolitano Niguarda, 20162 Milan, Italy
- School of Medicine, University of Milan-Bicocca, 20162 Milan, Italy
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10
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Liver transplantation for acute liver failure. Cir Esp 2017; 95:181-189. [PMID: 28433231 DOI: 10.1016/j.ciresp.2017.01.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2016] [Revised: 01/11/2017] [Accepted: 01/19/2017] [Indexed: 12/16/2022]
Abstract
Before liver transplantation became widely applicable as a treatment option, the mortality rate for acute liver failure was as high as 85%. Today, acute liver failure is a relatively common transplant indication in some settings, but the results of liver transplantation in this context appear to be worse than those for chronic forms of liver disease. In this review, we discuss the indications and contraindications for urgent liver transplantation. In particular, we consider the roles of auxiliary, ABO-incompatible, and urgent living donor liver transplantation and address the management of a «status 1» patient with total hepatectomy and portocaval shunt for toxic liver syndrome.
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11
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Irreversible Graft Failure Requiring 3 Repeated Liver Transplantations Combined With a 2-Stage Liver Transplantation: A Case Report. Transplant Proc 2016; 48:242-6. [PMID: 26915875 DOI: 10.1016/j.transproceed.2015.11.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2015] [Revised: 10/31/2015] [Accepted: 11/18/2015] [Indexed: 01/10/2023]
Abstract
INTRODUCTION Although repeated liver transplantation (RLT) for irreversible graft failure is relatively rare, RLT is the only life-saving option available for a patient with failure of a previous liver transplant (LT). In cases in which failure of a previous LT is combined with TLS and exsanguination, waiting for organ allocation is not feasible and 2-stage liver transplantation (TSLT) is required. The aim of our case report was to describe the clinical management, including the criteria informing clinical decisions, for a patient who required 3 RLTs combined with TSLT. CASE A 55-year-old man was admitted with liver cirrhosis associated with hepatitis B and multiple hepatocellular carcinomas. LT was performed using an emergent deceased donor graft of marginal quality. The graft was unsuccessful, with the patient showing hemodynamic deterioration and primary nonfunction of the graft. A total hepatectomy, with temporary portocaval shunt, was performed, with a second transplantation performed 3 days later. The second graft was from a 71-year-old, non-heart-beating donor, which resulted in a second episode of primary nonfunction. A third transplantation was performed 4 days later. The patient progressively recovered with extensive rehabilitation. CONCLUSION We report the successful outcome for a patient requiring 3 RLTs, with TSLT used as a bridge between transplants to reduce the duration of the anhepatic state. In selected cases, the combination of RLT and TSLT can provide a chance of survival from life-threatening liver failure.
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12
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13
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Levesque E, Azoulay D, Feray C, Dhonneur G. Albumin Dialysis as a Bridge From Total Hepatectomy to Liver Transplantation for Fulminant Hepatitis With Toxic Syndrome. Ther Apher Dial 2016; 20:692-693. [PMID: 27629817 DOI: 10.1111/1744-9987.12455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 04/05/2016] [Accepted: 05/16/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Eric Levesque
- Department of Anaesthesia and Surgical Intensive Care - Liver ICU, AP-HP Henri Mondor Hospital, Créteil, France
| | - Daniel Azoulay
- Digestive Surgery and Liver Transplant Unit, AP-HP Henri Mondor Hospital, Créteil, France
| | - Cyrille Feray
- Department of Hepatology, AP-HP Henri Mondor Hospital, Créteil, France
| | - Gilles Dhonneur
- Department of Anaesthesia and Surgical Intensive Care - Liver ICU, AP-HP Henri Mondor Hospital, Créteil, France
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14
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Sanabria Mateos R, Hogan NM, Dorcaratto D, Heneghan H, Udupa V, Maguire D, Geoghegan J, Hoti E. Total hepatectomy and liver transplantation as a two-stage procedure for fulminant hepatic failure: A safe procedure in exceptional circumstances. World J Hepatol 2016; 8:226-230. [PMID: 26855693 PMCID: PMC4733465 DOI: 10.4254/wjh.v8.i4.226] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Revised: 12/17/2015] [Accepted: 01/19/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the outcomes of two-stage liver transplant at a single institution, between 1993 and March 2015.
METHODS: We reviewed our institutional experience with emergency hepatectomy followed by transplantation for fulminant liver failure over a twenty-year period. A retrospective review of a prospectively maintained liver transplant database was undertaken at a national liver transplant centre. Demographic data, clinical presentation, preoperative investigations, cardiocirculatory parameters, operative and postoperative data were recorded.
RESULTS: In the study period, six two-stage liver transplants were undertaken. Indications for transplantation included acute paracetamol poisoning (n = 3), fulminant hepatitis A (n = 1), trauma (n = 1) and exertional heat stroke (n = 1). Anhepatic time ranged from 330 to 2640 min. All patients demonstrated systemic inflammatory response syndrome in the first post-operative week and the incidence of sepsis was high at 50%. There was one mortality, secondary to cardiac arrest 12 h following re-perfusion. Two patients required re-transplantation secondary to arterial thrombosis. At a median follow-up of 112 mo, 5 of 6 patients are alive and without evidence of graft dysfunciton.
CONCLUSION: Two-stage liver transplantation represents a safe and potentially life-saving treatment for carefully selected exceptional cases of fulminant hepatic failure.
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15
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Gray S, Shiekh F, Shiber J. Complex hepatic injury involving a liver transplant recipient: A case report and review of literature. Int J Surg Case Rep 2016; 28:282-284. [PMID: 27769024 PMCID: PMC5072138 DOI: 10.1016/j.ijscr.2016.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/08/2016] [Indexed: 11/28/2022] Open
Abstract
Multidisciplinary approach is required to improve the morbidity and mortality of complex liver injuries AAST grades IV and V. Angioembolization is an essential adjunct in the management of complex liver injuries. Injuries to a transplanted liver warrant special consideration to the early involvement of a transplant surgeon.
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Affiliation(s)
- Sanjiv Gray
- 3rd Floor, Faculty Clinic, 653 West 8th Street, FC12, Jacksonville, FL 32209, United States.
| | - Fariha Shiekh
- 3rd Floor, Faculty Clinic, 653 West 8th Street, FC12, Jacksonville, FL 32209, United States.
| | - Joseph Shiber
- 3rd Floor, Faculty Clinic, 653 West 8th Street, FC12, Jacksonville, FL 32209, United States.
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16
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Gedik E, Bıçakçıoğlu M, Otan E, İlksen Toprak H, Işık B, Aydın C, Kayaalp C, Yılmaz S. The 2-stage liver transplant: 3 clinical scenarios. EXP CLIN TRANSPLANT 2015; 13 Suppl 1:286-9. [PMID: 25894175 DOI: 10.6002/ect.mesot2014.p135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The main goal of 2-stage liver transplant is to provide time to obtain a new liver source. We describe our experience of 3 patients with 3 different clinical conditions. A 57-year-old man was retransplanted successfully with this technique due to hepatic artery thrombosis. However, a 38-year-old woman with fulminant toxic hepatitis and a 5-year-old-boy with abdominal trauma had poor outcome. This technique could serve as a rescue therapy for liver transplant patients who have toxic liver syndrome or abdominal trauma. These patients required intensive support during long anhepatic states. The transplant team should decide early whether to use this technique before irreversible conditions develop.
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Affiliation(s)
- Ender Gedik
- From the Department of Anesthesiology and Reanimation, Baskent University Faculty of Medicine, Ankara, Turkey
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17
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Patrono D, Brunati A, Romagnoli R, Salizzoni M. Liver transplantation after severe hepatic trauma: a sustainable practice. A single-center experience and review of the literature. Clin Transplant 2014; 27:E528-37. [PMID: 23923975 DOI: 10.1111/ctr.12192] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2013] [Indexed: 12/20/2022]
Abstract
Severe hepatic trauma is a rare indication for liver transplantation (LT). We report our single-center experience of LT for hepatic trauma. Four new cases are discussed in light of a literature review in order to depict the pathways leading from hepatic trauma to LT and to assess the outcomes of this practice. LT is generally indicated in case of uncontrollable hemorrhage, acute liver failure, or post-traumatic late sequelae. Hepatic vessels thrombosis, sepsis, major hepatic resections, and a late referral are factors associated with the progression toward irreversible liver failure. Considering all reported cases, early patient and graft survival reached 68% and 62%, respectively, but in the last decade both have improved to 84%. LT after severe hepatic trauma is a sustainable practice considering the current good outcomes and the ineluctable death of these patients without LT.
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Affiliation(s)
- Damiano Patrono
- General Surgery 8 and Liver Transplantation Center, San Giovanni Battista - Molinette University Hospital, A. O. Città della Salute e della Scienza, Turin, Italy
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18
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O'Grady J. Timing and benefit of liver transplantation in acute liver failure. J Hepatol 2014; 60:663-70. [PMID: 24211740 DOI: 10.1016/j.jhep.2013.10.024] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 10/22/2013] [Accepted: 10/25/2013] [Indexed: 12/13/2022]
Abstract
The case for using emergency liver transplantation in acute liver failure was made two decades ago by a series of single centre experiences. The development of models identifying a poor prognosis assisted the selection of patients for liver transplantation but none of these delivers both high sensitivity and specificity for prediction of death. Enhanced sensitivity favours the individual patient while enhanced specificity targets the pool of organs available at those who will derive greatest benefit. The non-transplant survival rates have improved considerably for certain cohorts of patients and these prognostic models have not been adjusted to reflect these changes. The presumption of transplant benefit can no longer be taken as established in paracetamol-related acute liver failure and a policy review is appropriate. In other scenarios, such as seronegative hepatitis and the phenotype of sub-acute liver failure, spontaneous survival rates remain low and the basis for liver transplantation remains sound. Outcomes after liver transplantation are improving but are not yet comparable to elective transplantation. The understanding of factors associated with failure after liver transplantation is improving but accurate definition of futility has not yet been attained.
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Affiliation(s)
- John O'Grady
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK.
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19
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Rajput I, Prasad KR, Bellamy MC, Davies M, Attia MS, Lodge JPA. Subtotal hepatectomy and whole graft auxiliary transplantation for acetaminophen-associated acute liver failure. HPB (Oxford) 2014; 16:220-8. [PMID: 23870048 PMCID: PMC3945847 DOI: 10.1111/hpb.12124] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 03/17/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND An acetominophen overdose (AOD) is the leading cause of acute liver failure (ALF) in the UK and USA. For patients who meet the King's College Hospital criteria, (mortality risk > 85%), an emergency orthotopic liver transplantation (OLT) is conventionally performed with subsequent life-long immunosuppression. A new technique was developed in 1998 for AOD-induced ALF where a subtotal hepatectomy (right hepatic trisectionectomy) and whole graft auxiliary liver transplant (WGALT) was performed with complete withdrawal of immunosupression during the first year post-operatively. RESULTS During 1998-2010, 68 patients were listed for an emergency transplantation for AOD ALF at our institution: 28 died waiting, 16 underwent OLT and 24 a subtotal hepatectomy with WGALT. Eight OLT (50%) and 16 WGALT remain alive (67%); actuarial survival at 5 years OLT 50%, WGALT 63%, P = 0.37. All patients who had successful WGALT are off immunosuppression. Poor prognostic factors in the WGALT group included higher donor age (40.4 versus 53.9, P = 0.043), requirements for a blood transfusion (4.3 versus 7.6, P = 0.0043) and recipient weight (63.1 versus 54 kg, P = 0.036). CONCLUSION Although OLT remains standard practice for AOD-induced ALF, life-long immunosuppression is required. A favourable survival rate using a subtotal hepatectomy and WGALT has been demonstrated, and importantly, all successful patients have undergone complete immunosuppression withdrawal. This technique is advocated for patients who have acetominophen hepatotoxicity requiring liver transplantation.
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Affiliation(s)
- Ibrahim Rajput
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
| | | | - Mark C Bellamy
- Department of Anaesthesia, St. James's University HospitalLeeds, UK
| | - Mervyn Davies
- Department of Hepatology, St. James's University HospitalLeeds, UK
| | - Magdy S Attia
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
| | - J Peter A Lodge
- HPB and Transplant Unit, St. James's University HospitalLeeds, UK
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20
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Abstract
BACKGROUND Liver transplantation (LTX) for severe hepatic trauma and its sequelae is a rare but potentially lifesaving option at the far end of the operative spectrum. METHODS This study analyzes 12 cases with LTX for hepatic trauma and its consequences from two transplant centers. A total of 2,701 consecutive liver transplants unrelated to trauma served as a control group. χ and Mann-Whitney U-tests, Kaplan-Meier analysis with log-rank tests, and Cox regression analysis were applied. Addressed were issues before, during, and after LTX. Major study end points were patient and graft survival. RESULTS The posttrauma transplant recipients are significantly younger (p = 0.014), with a significantly shorter graft survival (p = 0.038), resulting in a significantly higher retransplantation rate (p = 0.043). Of the 12 patients, 11 underwent surgical treatment for hepatic trauma before LTX with 7 of 12 patients experiencing liver necrosis at the time of LTX. Short-term survival and long-term survival are not significantly different between trauma and nontrauma patients. Severity of liver trauma (Moore Score) and concomitant injuries (Injury Severity Score [ISS]) have no significant impact on patient and graft survival. Four patients with hepatic trauma were treated with two-stage LTX with anhepatic phases between 14 hours and 28 hours. Two of those patients reached long-term survival (20-22 years). CONCLUSION LTX for severe liver trauma and its consequences seems justified in extreme cases. The high frequency of liver necrosis at the time of LTX may indicate possible shortcomings in liver packing technique or liver resection for hemorrhage control. Thus, severe hepatic trauma requires treatment by experienced liver surgeons and emergency physicians. LEVEL OF EVIDENCE Therapeutic study, level IV.
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21
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Whitehouse T, Wendon J. Acute liver failure. Best Pract Res Clin Gastroenterol 2013; 27:757-69. [PMID: 24160932 DOI: 10.1016/j.bpg.2013.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Revised: 08/01/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Untreated acute liver failure (ALF) has a poor outcome and so rapid diagnosis and management is vital if the patient is to survive. ALF has such profound and widespread physiological consequences that whenever possible, patients with ALF should be managed in an intensive care unit. Management is to support the physiology and treat the underlying cause. Advice should be sought from a centre capable of performing liver transplantation. Should recovery seem unlikely, liver transplantation is a viable treatment option in some cases.
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Affiliation(s)
- Tony Whitehouse
- University Hospital Birmingham, Edgbaston, Birmingham B15 2WB, UK.
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22
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Dupré A, Gagnière J, Tixier L, Ines DD, Perbet S, Pezet D, Buc E. Massive hepatic necrosis with toxic liver syndrome following portal vein ligation. World J Gastroenterol 2013; 19:2826-2829. [PMID: 23687421 PMCID: PMC3653158 DOI: 10.3748/wjg.v19.i18.2826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Revised: 01/08/2013] [Accepted: 02/06/2013] [Indexed: 02/06/2023] Open
Abstract
Right portal vein ligation (PVL) is a safe and widespread procedure to induce controlateral liver hypertrophy for the treatment of bilobar colorectal liver metastases. We report a case of a 60-year-old man treated by both right PVL and ligation of the glissonian branches of segment 4 for colorectal liver metastases surrounding the right and median hepatic veins. After surgery, the patient developed massive hepatic necrosis with secondary pulmonary and renal insufficiency requiring transfer to the intensive care unit. This so-called toxic liver syndrome finally regressed after hemofiltration and positive oxygen therapy. Diagnosis of acute congestion of the ligated lobe was suspected. The mechanism suspected was an increase in arterial inflow secondary to portal vein ligation concomitant with a decrease in venous outflow due to liver metastases encircling the right and median hepatic vein. This is the first documented case of toxic liver syndrome in a non-cirrhotic patient with favorable issue, and a rare complication of PVL.
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23
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O'Grady J. Liver transplantation for acute liver failure. Best Pract Res Clin Gastroenterol 2012; 26:27-33. [PMID: 22482523 DOI: 10.1016/j.bpg.2012.01.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2011] [Revised: 01/17/2012] [Accepted: 01/19/2012] [Indexed: 01/31/2023]
Abstract
Liver transplantation is now an integral part of the management of acute liver failure. The challenge for clinicians is to select the appropriate candidates with a combination of need and high likelihood of benefiting from the transplant. This is achieved through a combination of prognostic modelling and ongoing clinical evaluation. Although the outcomes after liver transplantation are good the survival rates do not quite match those achieved after elective transplantation.
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Affiliation(s)
- John O'Grady
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London, UK. john.o’
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25
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Mpabanzi L, Jalan R. Neurological complications of acute liver failure: pathophysiological basis of current management and emerging therapies. Neurochem Int 2011; 60:736-42. [PMID: 22100567 DOI: 10.1016/j.neuint.2011.10.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 10/17/2011] [Accepted: 10/26/2011] [Indexed: 12/11/2022]
Abstract
One of the major causes of mortality in patients with acute liver failure (ALF) is the development of hepatic encephalopathy (HE) which is associated with increased intracranial pressure (ICP). High ammonia levels, increased cerebral blood flow and increased inflammatory response have been identified as major contributors to the development of HE and the related brain swelling. The general principles of the management of patients with ALF are straightforward. They include identifying the insult causing hepatic injury, providing organ systems support to optimize the patient's physical condition, anticipation and prevention of development of complications. Increasing insights into the pathophysiological mechanisms of ALF are contributing to better therapies. For instance, the evident role of cerebral hyperemia in the pathogenesis of increased ICP has led to a re-evaluation of established therapies such as hyperventilation, N-acetylcysteine, thiopentone sodium and propofol. The role of systemic inflammatory response in the pathogenesis of increased ICP has also gained importance supporting the concept that antibiotics given prophylactically reduce the risk of developing sepsis during the course of illness. Moderate hypothermia has also been established as a therapy able to reduce ICP in patients with uncontrolled intracranial hypertension and to prevent increases in ICP during orthopic liver transplantation. Ornithine phenylacetate, a new drug in the treatment of liver failure, and liver replacement therapies are still being investigated both experimentally and clinically. Despite many advances in the understanding of the pathophysiological basis and the management of intracranial hypertension in ALF, more clinical trials should be conducted to determine the best therapeutic management for this difficult clinical event.
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Affiliation(s)
- Liliane Mpabanzi
- Department of Surgery, Maastricht University Medical Centre, and NUTRIM School of Nutrition, Toxicology and Metabolism, Maastricht University, PO Box 5800, Maastricht, The Netherlands
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26
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Nguyen JH. Blood-brain barrier in acute liver failure. Neurochem Int 2011; 60:676-83. [PMID: 22100566 DOI: 10.1016/j.neuint.2011.10.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/20/2011] [Accepted: 10/26/2011] [Indexed: 12/16/2022]
Abstract
Brain edema remains a challenging obstacle in the management of acute liver failure (ALF). Cytotoxic mechanisms associated with brain edema have been well recognized, but evidence for vasogenic mechanisms in the pathogenesis of brain edema in ALF has been lacking. Recent reports have not only shown a role of matrix metalloproteinase-9 in the pathogenesis of brain edema in experimental ALF but have also found significant alterations in the tight junction elements including occludin and claudin-5, suggesting a vasogenic injury in the blood-brain barrier (BBB) integrity. This article reviews and explores the role of the paracellular tight junction proteins in the increased selective BBB permeability that leads to brain edema in ALF.
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Affiliation(s)
- Justin H Nguyen
- Division of Transplant Surgery, Department of Transplantation, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States.
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27
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Wright G, Chattree A, Jalan R. Management of hepatic encephalopathy. Int J Hepatol 2011; 2011:841407. [PMID: 21994873 PMCID: PMC3177461 DOI: 10.4061/2011/841407] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Accepted: 06/08/2011] [Indexed: 12/11/2022] Open
Abstract
Hepatic encephalopathy (HE), the neuropsychiatric presentation of liver disease, is associated with high morbidity and mortality. Reduction of plasma ammonia remains the central therapeutic strategy, but there is a need for newer novel therapies. We discuss current evidence supporting the use of interventions for both the general management of chronic HE and that necessary for more acute and advanced disease.
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Affiliation(s)
- G. Wright
- University College London Institute of Hepatology, The Royal Free Hospital, Pond Street, London NW3 2PF, UK
| | - A. Chattree
- Department of Gastroenterology, King Georges Hospital, Barley Lane, Goodmayes, Ilford, Essex IG3 8YB, UK
| | - R. Jalan
- University College London Institute of Hepatology, The Royal Free Hospital, Pond Street, London NW3 2PF, UK
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28
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Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock 2011; 4:114-9. [PMID: 21633579 PMCID: PMC3097559 DOI: 10.4103/0974-2700.76846] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2010] [Accepted: 07/22/2010] [Indexed: 12/21/2022] Open
Abstract
The liver is one of the most commonly injured organs in abdominal trauma. Recent advancements in imaging studies and enhanced critical care monitoring strategies have shifted the paradigm for the management of liver injuries. Nonoperative management of both low- and high-grade injuries can be successful in hemodynamically stable patients. Direct suture ligation of bleeding parenchymal vessels, total vascular isolation with repair of venous injuries, and the advent of damage control surgery have all improved outcomes in the hemodynamically unstable patient population. Anatomical resection of the liver and use of atriocaval shunt are rarely indicated.
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Affiliation(s)
- Nasim Ahmed
- Department of Surgery & Division of Trauma and Surgical Critical Care, Jersey Shore University Medical Center 1945 State Rt. 33, Neptune, US
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29
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Arora H, Thekkekandam J, Tesche L, Sweeting R, Gerber DA, Hayashi PH, Andreoni K, Kozlowski T. Long-term survival after 67 hours of anhepatic state due to primary liver allograft nonfunction. Liver Transpl 2010; 16:1428-33. [PMID: 21117253 DOI: 10.1002/lt.22166] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Primary liver allograft nonfunction immediately after transplantation poses a life-threatening situation for the recipient. Emergency retransplantation may not be immediately possible due to organ unavailability. Total hepatectomy with temporary portacaval shunt has been described as a bridge to retransplantation when the presence of the graft appears to be harming the recipient. Case reports of retransplantation after total hepatectomy with anhepatic times greater than 48 hours routinely describe poor outcomes. We present a case with excellent patient outcome after 95 hours of clinical anhepatic state, including 67 hours of anatomical anhepatic time, because of primary liver allograft nonfunction. This case report documents the longest anhepatic time with subsequent successful transplant to date.
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Affiliation(s)
- Harendra Arora
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7211, USA
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30
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Two-stage liver transplantation with temporary porto-middle hepatic vein shunt. J Transplant 2010; 2010. [PMID: 20847953 PMCID: PMC2935162 DOI: 10.1155/2010/570392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2010] [Accepted: 06/24/2010] [Indexed: 11/24/2022] Open
Abstract
Two-stage liver transplantation (LT) has been reported for cases of fulminant liver failure that can lead to toxic hepatic syndrome, or massive hemorrhages resulting in uncontrollable bleeding. Technically, the first stage of the procedure consists of a total hepatectomy with preservation of the recipient's inferior vena cava (IVC), followed by the creation of a temporary end-to-side porto-caval shunt (TPCS). The second stage consists of removing the TPCS and implanting a liver graft when one becomes available. We report a case of a two-stage total hepatectomy and LT in which a temporary end-to-end anastomosis between the portal vein and the middle hepatic vein (TPMHV) was performed as an alternative to the classic end-to-end TPCS. The creation of a TPMHV proved technically feasible and showed some advantages compared to the standard TPCS. In cases in which a two-stage LT with side-to-side caval reconstruction is utilized, TPMHV can be considered as a safe and effective alternative to standard TPCS.
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31
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Landsman IS, Karsanac CJ. Case report: pediatric liver retransplantation on an extracorporeal membrane oxygenation-dependent child. Anesth Analg 2010; 111:1275-8. [PMID: 20841407 DOI: 10.1213/ane.0b013e3181f334a6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the perioperative management of a venovenous extracorporeal membrane oxygenator-dependent child requiring liver retransplantation after emergent hepatectomy because of an ischemic liver graft. This child required renal replacement and inotropic support as well as treatment for heparin-induced thrombocytopenia (HIT). We describe each step in this child's perioperative management leading to the successful liver retransplantation. This is the first description, to our knowledge, of a pediatric patient undergoing liver transplantation while supported by extracorporeal membrane oxygenation (ECMO).
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Affiliation(s)
- Ira S Landsman
- Department of Anesthesiology, Vanderbilt University Medical Center, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA.
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32
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Ytrebø LM, Klepstad P. [Intensive care of patients with acute liver failure]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2010; 130:1609-13. [PMID: 20805858 DOI: 10.4045/tidsskr.08.0345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Acute liver failure and acute decompensated chronic liver failure are two diseases that demand extensive knowledge of etiology and triggering factors, pathophysiology, diagnosis, prognosis and recommended guidelines for treatment. The article defines the diseases, discusses etiological factors, treatment strategies, indications for referral to the transplantation unit at Rikshospitalet and prognostic factors of importance. MATERIAL AND METHODS The basis for this article is literature identified through a non-systematic search in PubMed and the authors' clinical experience and experimental research within the field. RESULTS In the Western world paracetamol poisoning and toxic reactions to other drugs are the most common triggering factors for acute liver poisoning in adults. Patients can quickly develop multi organ failure requiring advanced intensive care. The most common complications are hepatic encephalopathy, acute renal failure and coagulation disturbances. Acute decompensated chronic liver failure strikes patients with known liver disease and is most often triggered by inflammation, infection, gastrointestinal bleeding, drugs, traumas or disturbances in acid/base/electrolyte balance. Early diagnosing of triggering factors and intensive medical supportive treatment is especially important. Acute renal failure indicates a very bad prognosis. INTERPRETATION Patients diagnosed with acute liver failure or acute decompensated chronic liver failure remain a clinical challenge. Optimal treatment requires extensive knowledge of pathophysiological mechanisms and treatment strategies.
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Affiliation(s)
- Lars Marius Ytrebø
- Critical Care Unit, University College London Hospitals NHS Foundation Trust og Institutt for klinisk medisin, Universitetet i Tromsø, Norway.
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33
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Ford RM, Sakaria SS, Subramanian RM. Critical care management of patients before liver transplantation. Transplant Rev (Orlando) 2010; 24:190-206. [PMID: 20688502 DOI: 10.1016/j.trre.2010.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2010] [Revised: 05/26/2010] [Accepted: 05/28/2010] [Indexed: 02/07/2023]
Abstract
The critical care management of patients before liver transplantation is aimed at optimizing hepatic and extrahepatic organ function before the transplant operation, with a goal to favorably influence perioperative and postoperative graft and patient outcomes. Critical illness in liver disease can present in the context of acute liver failure or acute on chronic liver failure. The differing pathophysiologic processes underlying these 2 types of liver failure necessitate specific approaches to their intensive care management. In their extreme presentations, both types of liver failure present as multiorgan system failure; and therefore, the critical care management of these entities requires a systematic multiorgan system approach to address hepatic and extrahepatic organ dysfunction. This review provides a multiorgan system-based description of critical care management of acute liver failure and acute on chronic liver failure before liver transplantation.
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Affiliation(s)
- Ryan M Ford
- Division of Gastroenterology and Hepatology, Emory University School of Medicine, Atlanta, GA, USA
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34
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McDowell Torres D, Stevens RD, Gurakar A. Acute liver failure: a management challenge for the practicing gastroenterologist. Gastroenterol Hepatol (N Y) 2010; 6:444-50. [PMID: 20827368 PMCID: PMC2933761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Although comprising a minority of the transplant population, acute liver failure (ALF) patients represent some of the most challenging cases in terms of the level and complexity of care required. An ALF patient requires much more than a single skilled intensivist, gastroenterologist, or surgeon. Successful care of the ALF patient begins with early diagnosis and triage to the appropriate level of care where a multitude of specialties are required to work together to maximize the chance of recovery and/or extend the window of opportunity for transplant.
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35
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Montalti R, Busani S, Masetti M, Girardis M, Di Benedetto F, Begliomini B, Rompianesi G, Rinaldi L, Ballarin R, Pasetto A, Gerunda GE. Two-stage liver transplantation: an effective procedure in urgent conditions. Clin Transplant 2010; 24:122-6. [PMID: 19843110 DOI: 10.1111/j.1399-0012.2009.01118.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Temporary portocaval shunt and total hepatectomy is a technique used in the presence of toxic liver syndrome because of fulminant hepatic failure, hepatic trauma, primary non-function (PNF), and eclampsia. We performed this technique on four patients. An indication for anhepatic state was severe hemodynamic instability in three of them. Etiologies of these three patients were as follows: PNF after liver transplantation, ischemic hepatitis after right hepatic artery embolization, and massive reperfusion syndrome during a liver transplantation. In the fourth patient, during the liver transplantation when hepatic artery was ligated, a kidney carcinoma in the donor graft was discovered. We decided to complete the hepatectomy and to construct a temporary portocaval shunt. Mean anhepatic phases were 19 h and 15 min. All patients survived the two-stage liver transplantation procedure without major complications. Our cases demonstrated that temporary portocaval shunt while awaiting urgent liver transplantation could be an effective "bridge" in selected patients who develop toxic liver syndrome; however, a short time between portocaval shunt and transplantation and careful intensive care managements are mandatory.
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Affiliation(s)
- Roberto Montalti
- Liver and Multivisceral Transplant Centre, University of Modena and Reggio Emilia, Modena, Italy
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36
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Lee SH, Yang SH, Kim GS. Two-stage liver transplantation in a surgically complicated liver failure patient after hepatic tumor resection -A case report-. Korean J Anesthesiol 2010; 59:348-52. [PMID: 21179299 PMCID: PMC2998657 DOI: 10.4097/kjae.2010.59.5.348] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2010] [Revised: 03/02/2010] [Accepted: 03/17/2010] [Indexed: 11/10/2022] Open
Affiliation(s)
- Sang Hyun Lee
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Soo Hyun Yang
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Seoul Hospital, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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37
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Abstract
Acute liver failure (ALF) is a syndrome of diverse etiology, in which patients without previously recognized liver disease sustain a liver injury that results in rapid loss of hepatic function. Depending on the etiology and severity of the insult, some patients undergo rapid hepatic regeneration and spontaneously recover. However, nearly 60% of patients with ALF in the US require and undergo orthotopic liver transplantation or die. Management decisions made by clinicians who initially assess individuals with ALF can drastically affect these patients' outcomes. Even with optimal early management, however, many patients with ALF develop a cascade of complications often presaged by the systemic inflammatory response syndrome, which involves failure of nearly every organ system. We highlight advances in the intensive care management of patients with ALF that have contributed to a marked improvement in their overall survival over the past 20 years. These advances include therapies that limit the extent of liver injury and maximize the likelihood of spontaneous recovery and approaches to enable prevention, recognition and early treatment of complications that lead to multi-organ-system failure, the most common cause of death. Finally, we summarize the role of orthotopic liver transplantation in salvage of the most severely affected patients.
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38
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Delis SG, Bakoyiannis A, Selvaggi G, Weppler D, Levi D, Tzakis AG. Liver transplantation for severe hepatic trauma: Experience from a single center. World J Gastroenterol 2009; 15:1641-4. [PMID: 19340909 PMCID: PMC2669949 DOI: 10.3748/wjg.15.1641] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Liver transplantation has been reported in the literature as an extreme intervention in cases of severe and complicated hepatic trauma. The main indications for liver transplant in such cases were uncontrollable bleeding and postoperative hepatic insufficiency. We here describe four cases of orthotopic liver transplantation after penetrating or blunt liver trauma. The indications were liver failure, extended liver necrosis, liver gangrene and multiple episodes of gastrointestinal bleeding related to portal hypertension, respectively. One patient died due to postoperative cerebral edema. The other three patients recovered well and remain on immunosuppression. Liver transplantation should be considered as a saving procedure in severe hepatic trauma, when all other treatment modalities fail.
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39
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Abstract
Iatrogenic porta hepatis transection is a rare but devastating surgical complication. There are no systematic studies examining the best treatment strategy in patients with this injury. We report two cases of transection of all three portal structures, one during an open right adrenalectomy and another during a laparoscopic cholecystectomy, both of which were transferred to our tertiary care center hours postinjury. Diagnostic imaging and exploration revealed nonsalvageable livers, and both patients underwent total hepatectomies and portocaval shunting. Donor livers were available 12 to 20 hours after United Network for Organ Sharing Status 1 listing and both patients survived their postoperative course with 2- and 6-year follow up to date. Two-stage total hepatectomy with portocaval shunting followed by liver transplantation should be considered for patients presenting with porta hepatis transection.
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Affiliation(s)
- Victor Zaydfudim
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - J. Kelly Wright
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - C. Wright Pinson
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, Tennessee
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Ferraz-Neto BH, Moraes-Junior JMA, Hidalgo R, Zurstrassen MPVC, Lima IK, Novais HS, Rezende MB, Meira-Filho SP, Afonso RC. Total hepatectomy and liver transplantation as a two-stage procedure for toxic liver: case reports. Transplant Proc 2008; 40:814-6. [PMID: 18455026 DOI: 10.1016/j.transproceed.2008.02.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Total hepatectomy with temporary portocaval shunt was employed as a bridging procedure before liver transplantation, in the setting of fulminant hepatic failure with "toxic liver syndrome"; acute, severe, and extensive liver necrosis associated with cardiovascular shock and acute renal failure with or without respiratory failure. This procedure sought to improve metabolic acidosis and hemodynamic instability related to advanced liver necrosis. The aim of this study was to report our experience with three patients who underwent total hepatectomy and protocaval shunt, followed by liver transplantation (two-stage procedure).
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Affiliation(s)
- B H Ferraz-Neto
- Liver Transplantation Unit, Albert Einstein Jewish Hospital, São Paulo, Brazil.
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41
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Tucker ON, Marriott P, Rela M, Heaton N. Emergency liver transplantation following severe liver trauma. Liver Transpl 2008; 14:1204-10. [PMID: 18668654 DOI: 10.1002/lt.21555] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Liver trauma is a major cause of mortality after major blunt and penetrating abdominal trauma. The need for life-saving emergency hepatectomy and liver transplantation is extremely rare. We report the management of 2 patients who required urgent liver transplantation for liver trauma. One patient developed hepatic failure following global ischemia after a gunshot injury. The second patient developed a severe postreperfusion injury following removal of a perihepatic pack after blunt abdominal trauma. We highlight the difficulties in the management of severe liver trauma with an emphasis on the clinical features, radiological investigations, and surgical treatment of these complex patients.
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Affiliation(s)
- Olga N Tucker
- Institute of Liver Studies, King's College London School of Medicine, King's College Hospital, London, United Kingdom.
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42
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Ringe B, Xiao G, Sass DA, Karam J, Shang S, Maroney TP, Trebelev AE, Levison S, Fuchs AC, Petrucci R, Ko A, Gonzalez M, Reynolds JC, Meyers WC. Rescue of a living donor with liver transplantation. Am J Transplant 2008; 8:1557-61. [PMID: 18510644 DOI: 10.1111/j.1600-6143.2008.02261.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Postoperative liver failure is a rare complication after living donor liver resection. This is a case report of a 22-year-old healthy donor who was rescued with liver transplantation 11 days after right hemihepatectomy. Nine months later the patient is alive, and has fully recovered from his multiple organ failure. According to a review of the literature, there are four additional living liver donors, who received a liver transplant. Our own patient is the only survivor, so far. This case demonstrates that even in supposedly healthy living donors postoperative complications cannot be completely prevented. Although liver failure is rare in these patients, timely transplantation may need to be considered as the only life-saving treatment.
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Affiliation(s)
- B Ringe
- Department of Surgery, Division of Gastroenterology and Hepatology, Drexel University College of Medicine, Philadelphia, PA, USA.
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43
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Stravitz RT, Kramer AH, Davern T, Shaikh AOS, Caldwell SH, Mehta RL, Blei AT, Fontana RJ, McGuire BM, Rossaro L, Smith AD, Lee WM. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med 2008; 35:2498-508. [PMID: 17901832 DOI: 10.1097/01.ccm.0000287592.94554.5f] [Citation(s) in RCA: 243] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To provide a uniform platform from which to study acute liver failure, the U.S. Acute Liver Failure Study Group has sought to standardize the management of patients with acute liver failure within participating centers. METHODS In areas where consensus could not be reached because of divergent practices and a paucity of studies in acute liver failure patients, additional information was gleaned from the intensive care literature and literature on the management of intracranial hypertension in non-acute liver failure patients. Experts in diverse fields were included in the development of a standard study-wide management protocol. MEASUREMENTS AND MAIN RESULTS Intracranial pressure monitoring is recommended in patients with advanced hepatic encephalopathy who are awaiting orthotopic liver transplantation. At an intracranial pressure of > or =25 mm Hg, osmotic therapy should be instituted with intravenous mannitol boluses. Patients with acute liver failure should be maintained in a mildly hyperosmotic state to minimize cerebral edema. Accordingly, serum sodium should be maintained at least within high normal limits, but hypertonic saline administered to 145-155 mmol/L may be considered in patients with intracranial hypertension refractory to mannitol. Data are insufficient to recommend further therapy in patients who fail osmotherapy, although the induction of moderate hypothermia appears to be promising as a bridge to orthotopic liver transplantation. Empirical broad-spectrum antibiotics should be administered to any patient with acute liver failure who develops signs of the systemic inflammatory response syndrome, or unexplained progression to higher grades of encephalopathy. Other recommendations encompassing specific hematologic, renal, pulmonary, and endocrine complications of acute liver failure patients are provided, including their management during and after orthotopic liver transplantation. CONCLUSIONS The present consensus details the intensive care management of patients with acute liver failure. Such guidelines may be useful not only for the management of individual patients with acute liver failure, but also to improve the uniformity of practices across academic centers for the purpose of collaborative studies.
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Affiliation(s)
- R Todd Stravitz
- Section of Hepatology, Virginia Commonwealth University, Richmond, USA.
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44
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Emergency Subtotal Hepatectomy: A New Concept for Acetaminophen-Induced Acute Liver Failure. Ann Surg 2008; 247:238-49. [DOI: 10.1097/sla.0b013e31816401ec] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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45
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Wright G, Shawcross D, Olde Damink SWM, Jalan R. Brain cytokine flux in acute liver failure and its relationship with intracranial hypertension. Metab Brain Dis 2007; 22:375-88. [PMID: 17899343 DOI: 10.1007/s11011-007-9071-4] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND In acute liver failure (ALF), it is unclear whether the systemic inflammatory response associated with intracranial hypertension is related to brain cytokine production. AIM To determine the relationship of brain cytokine production with severity of intracranial hypertension in ALF patients. METHOD We studied 16 patients with ALF. All patients were mechanically ventilated and cerebral blood flow measured using the Kety-Schmidt technique and intracranial pressure (ICP) measured with a Camino subdural catheter. We sampled blood from an artery and a reverse jugular catheter to measure proinflammatory cytokines (TNF-alpha, IL-6 and IL-1beta) and ammonia. Additionally, in 3 patients, serial samples were obtained over a 72 h period. RESULTS In ALF patients a good correlation between arterial pro-inflammatory cytokines and ICP (r (2) = 0.34, 0.50 and 0.52; for IL-6, IL-1beta and TNF-alpha respectively) was observed. There was a positive cerebral cytokine 'flux' (production), in ALF patients with uncontrolled ICP. Plasma ammonia between groups was not statistically significant. In the ALF patients studied longitudinally, brain proinflammatory cytokine production was associated with uncontrolled ICP. CONCLUSION Our results provide novel data supporting brain production of cytokines in patients with uncontrolled intracranial hypertension indicating activation of the inflammatory cascade in the brain. Also, the appearance of these cytokines in the jugular bulb catheter may indicate a compromised blood brain barrier at this late stage.
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Affiliation(s)
- Gavin Wright
- Liver Failure Group, The Institute of Hepatology, Division of Medicine, University College London, 69-75 Chenies Mews, London, UK
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46
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Norenberg MD, Jayakumar AR, Rama Rao KV, Panickar KS. New concepts in the mechanism of ammonia-induced astrocyte swelling. Metab Brain Dis 2007; 22:219-34. [PMID: 17823859 DOI: 10.1007/s11011-007-9062-5] [Citation(s) in RCA: 134] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
It is generally accepted that astrocyte swelling forms the major anatomic substrate of the edema associated with acute liver failure (ALF) and that ammonia represents a major etiological factor in its causation. The mechanisms leading to such swelling, however, remain elusive. Recent studies have invoked the role of oxidative stress in the mechanism of hepatic encephalopathy (HE), as well as in the brain edema related to ALF. This article summarizes the evidence for oxidative stress as a major pathogenetic factor in HE/ALF and discusses mechanisms that are triggered by oxidative stress, including the induction of the mitochondrial permeability transition (MPT) and activation of signaling kinases. We propose that a cascade of events initiated by ammonia-induced oxidative stress results in cell volume dysregulation leading to cell swelling/brain edema. Blockade of this cascade may provide novel therapies for the brain edema associated with ALF.
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Affiliation(s)
- M D Norenberg
- Veterans Affairs Medical Center, Miami, FL 33101, USA.
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47
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Abstract
Liver transplantation has revolutionized the management of acute or fulminant liver failure. Overall success rates of liver transplantation are satisfactory, although not as high as for elective transplantation. Although the bulk of liver transplants use standard whole grafts, interesting data are emerging on auxiliary liver grafts and donations from living donors. Liver transplantation is an integral part of management protocols complementing the sophisticated critical care protocols that have contributed significantly to the overall improved outcomes seen in acute liver failure. The potential for liver support devices to have an impact on the need for liver transplantation and outcomes after transplantation remains exciting.
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Affiliation(s)
- John O'Grady
- Institute of Liver Studies, King's College Hospital, Denmark Hill, London SE5 9RS, United Kingdom. john.o'
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48
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Affiliation(s)
- Amit Singhal
- The Liver Unit, Queen Elizabeth Hospital, Birmingham and University of Birmingham, UK
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49
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Uemura T, Randall HB, Sanchez EQ, Ikegami T, Narasimhan G, McKenna GJ, Chinnakotla S, Levy MF, Goldstein RM, Klintmalm GB. Liver retransplantation for primary nonfunction: analysis of a 20-year single-center experience. Liver Transpl 2007; 13:227-33. [PMID: 17256780 DOI: 10.1002/lt.20992] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Initial graft function following liver transplantation is a major determinant of postoperative survival and morbidity. Primary graft nonfunction (PNF) is uncommon; however, it is one of the most serious and life-threatening conditions in the immediate postoperative period. The risk factors associated with PNF and short-term outcome have been previously reported, but there are no reports of long-term follow-up after retransplant for PNF. At our institution, 52 liver transplants had PNF (2.22%) among 2,341 orthotopic liver transplants in 2,130 patients from 1984 to 2003. PNF occurred more often in the retransplant setting. Female donors, donor age, donor days in the intensive care unit, cold ischemia time, and operating room time were significant factors for PNF. Patient as well as graft survival of retransplant for PNF was not different compared to retransplant for other causes. However, PNF for a second or third transplant did not demonstrate long-term survival, and hospital mortality was 57%. In conclusion, retransplant for PNF in the initial transplant can achieve relatively good long-term survival; however, if another transplant is needed in the setting of a second PNF, the third retransplant should probably not be done due to poor expected outcome.
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Affiliation(s)
- Tadahiro Uemura
- Transplantation Services, Baylor University Medical Center, Dallas, TX 75246, USA
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50
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Detry O, De Roover A, Delwaide J, Hans MF, Canivet JL, Meurisse M, Honoré P. 60 h of anhepatic state without neurologic deficit. Transpl Int 2006; 19:769. [PMID: 16918538 DOI: 10.1111/j.1432-2277.2006.00352.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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