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1.
Transplant Proc ; 51(7): 2420-2424, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31405742

RESUMO

Sepsis causes life-threatening organ dysfunction and is the leading cause of morbidity and mortality in critically ill patients worldwide. Mortality rate of sepsis is close to 30% to 50% despite better understanding of the pathophysiology of sepsis, and advances in antimicrobial therapy, resuscitation strategies, and mechanical ventilation. Liver failure is characterized by accumulation of potentially toxic substances in the systemic circulation of the patient. Toxic effects of these molecules can induce cellular injuries leading to multiorgan dysfunction. Hydrophobic unconjugated bilirubin and bile acids, hydrophilic conjugated bilirubin, and ammonium are the main toxins accumulated in liver failure. We carried out cytokine adsorbtion (CytoSorb) procedure with continuous venovenous hemodialysis in 12-hour sessions. The biochemical values of the patients before and after the use of the filter were recorded. The parameters compared were as follows: total bilirubin, direct bilirubin, C-reactive protein, leukocyte, neutrophil, alanine aminotransferase, aspartate aminotransferase, creatinine, colloid oncotic pressure, ammonia, gamma-glutamyl transferase, alkaline phosphatase, procalcitonin, hematocrit, hemoglobin, pH, albumin, international normalized ratio, fibrinogen, lactate dehydrogenase, platelet, temperature, changes in vasoactive medication requirement, temperature. According to these results, cytokine adsorption systems can be considered as an option to lower bilirubin levels in cases of liver failure. Its inability to lower ammonia level is considered a disadvantage compared with other bilirubin-lowering methods. Although further studies are needed to compare different methods, cytokine adsorption systems may be considered in treatment planning as it contributes to the treatment of sepsis and hyperbilirubinemia in liver failure patients with sepsis.


Assuntos
/métodos , Citocinas/sangue , Hiperbilirrubinemia/sangue , Falência Hepática/terapia , Sepse/sangue , Adsorção , Amônia/sangue , Bilirrubina/sangue , Feminino , Humanos , Hiperbilirrubinemia/complicações , Falência Hepática/sangue , Falência Hepática/etiologia , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Sepse/complicações , Resultado do Tratamento
2.
Dig Surg ; 36(2): 158-165, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-29421802

RESUMO

BACKGROUND: Post-hepatectomy liver failure (PHLF) is a serious complication after major hepatectomy with extrahepatic bile duct resection (Hx with EBDR) that may cause severe morbidity and even death. The purpose of this study was to compare several criteria systems as predictors of PHLF-related mortality following Hx with EBDR for perihilar cholangiocarcinoma (PHCC). METHODS: The study cohort consisted of 222 patients who underwent Hx with EBDR for PHCC. We compared several criteria systems, including previously established criteria (the International Study Group of Liver Surgery (ISGLS) criterion; and the "50-50" criterion), and our institution's novel systems "Max T-Bili" defined as total bilirubin (T-Bili) >7.3 mg/dL during post-operative days (POD) 1-7, and the "3-4-50" criterion, defined as total bilirubin >4 mg/dL and prothrombin time <50% on POD #3. RESULTS: Thirteen patients (5.8%) died from PHLF-related causes. The 3-4-50 criterion showed high positive predictive values (39.1%), the 3-4-50, Max T-Bili, and 50-50 criterion showed high accuracies (91.7, 86.9, and 90.5%, respectively) and varying sensitivities (69.2, 69.2, and 38.5% respectively). CONCLUSIONS: The 3-4-50, Max T-Bili, and 50-50 criterion were all useful for predicting PHLF-related mortality after Hx with EBDR for PHCC.


Assuntos
Neoplasias dos Ductos Biliares/cirurgia , Ductos Biliares Extra-Hepáticos/cirurgia , Colangiocarcinoma/cirurgia , Hepatectomia/efeitos adversos , Falência Hepática/sangue , Falência Hepática/mortalidade , Fígado/patologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias dos Ductos Biliares/complicações , Bilirrubina/sangue , Perda Sanguínea Cirúrgica , Proteína C-Reativa/metabolismo , Colangiocarcinoma/complicações , Colangite/complicações , Feminino , Humanos , Falência Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Duração da Cirurgia , Tamanho do Órgão , Contagem de Plaquetas , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/mortalidade , Tempo de Protrombina , Curva ROC , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida
3.
Blood Purif ; 47(1-3): 23-27, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30253392

RESUMO

AIMS: To establish the safety and efficacy of regional citrate anticoagulation (RCA) for pediatric liver failure (LF) patients receiving extracorporeal liver support (ELS) with albumin-assisted dialysis. METHODS: Retrospective review of pediatric LF patients receiving ELS from April 2014 to December 2016 at a tertiary children's hospital pediatric intensive care unit. Demographic and ELS data collected by chart review. Citrate accumulation (CA) was defined as total calcium (mmol/L): ionized calcium (mmol/L) > 2.5 (tCa:iCa). Efficacy was assessed by treatment duration. Safety was assessed by adverse events: bleeding, hemodynamic instability, arrhythmias, unplanned treatment discontinuation. RESULTS: Fifteen patients (median age 3 [interquartile range (IQR) 0.7-8.0]) received 108 ELS treatments (median 5 [IQR 4-7.5]). Sixty-eight episodes of CA were identified. Of those, 6 coincided with intervention and 1 coincided with ELS discontinuation. There were no deaths attributed to ELS or RCA. CONCLUSION: RCA provides safe and effective anticoagulation for pediatric LF patients requiring ELS.


Assuntos
Anticoagulantes/administração & dosagem , Ácido Cítrico/administração & dosagem , Hemofiltração/métodos , Unidades de Terapia Intensiva , Falência Hepática/terapia , Albumina Sérica Humana/administração & dosagem , Anticoagulantes/efeitos adversos , Criança , Pré-Escolar , Ácido Cítrico/efeitos adversos , Feminino , Humanos , Lactente , Falência Hepática/sangue , Masculino , Estudos Retrospectivos , Albumina Sérica Humana/efeitos adversos
4.
Transpl Int ; 32(1): 49-58, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30099788

RESUMO

Increasing evidence indicates a role of vitamin D in the immune system affecting response to infections. We aimed to characterize the role of vitamin D status, i.e. deficiency [25-OH vitamin D (25-OHD) <50 nmol/l] and no deficiency (25-OHD ≥50 nmol/l) in incident infections after liver transplantation. In 135 liver transplant recipients, blood samples drawn at time of liver transplantation and 6 months afterwards were used to determine 25-OHD levels. Incident infections episodes were prospectively collected within the Swiss Transplant Cohort Study database. Poisson regression was applied to address associations between vitamin D status and incident infections. Vitamin D deficiency was common at time of transplantation and 6 months afterwards without a significant change in median 25-OHD levels. In univariable analyses, vitamin D deficiency was a risk factor for incident infections in the first 6 months post-transplant incidence rate ratio (IRR 1.52, 95% CI 1.08-2.15, P = 0.018) and for bacterial infections occurring after 6 up to 30 months post-transplant (IRR 2.29, 95% CI 1.06-4.94, P = 0.034). These associations were not detectable in multivariable analysis with adjustment for multiple confounders. Efforts to optimize vitamin D supplementation in liver transplant recipients are needed. Our data question the role of vitamin D deficiency in incident infections.


Assuntos
Infecções Bacterianas/epidemiologia , Falência Hepática/cirurgia , Transplante de Fígado/efeitos adversos , Vitamina D/sangue , Adulto , Idoso , Feminino , Humanos , Falência Hepática/sangue , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Distribuição de Poisson , Complicações Pós-Operatórias , Estudos Prospectivos , Análise de Regressão , Fatores de Risco , Suíça , Deficiência de Vitamina D/complicações
5.
Blood Purif ; 47(1-3): 10-15, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30219813

RESUMO

BACKGROUND/AIMS: Many potentially toxic molecules accumulate in the blood during hepatic dysfunction. In clinical practice, it is very difficult to remove bilirubin, the most widely studied toxin, and particularly the unconjugated form, strongly albumin-bound. The aim of this in vitro study was to assess irreversible bilirubin adsorption as a protein-bound compound marker, using Cytosorb® (Cytosorbents Corp.), a new hemoadsorption device designed to remove cytokines. METHODS: We performed 4 in vitro experiments, dynamic and static, with different albumin-bilirubin solutions. RESULTS: All experiments showed the resin's ability to break the albumin-bilirubin complex (Experiment 1, 2), leading to efficient bilirubin removal for 24 h (Removal Rate: 90% Experiment 3) with minimal albumin loss. No sign of bilirubin release from the charged resin was detected (Experiment 4). CONCLUSION: Cytosorb® seems a promising artificial liver support, thanks to its ability to adsorb bilirubin and its proven ability to modulate the cytokines involved in hepatic dysfunction.


Assuntos
Bilirrubina/sangue , Falência Hepática/sangue , Falência Hepática/terapia , Desintoxicação por Sorção/instrumentação , Desintoxicação por Sorção/métodos , Humanos , Albumina Sérica Humana
6.
Pediatr Neonatol ; 60(4): 382-388, 2019 08.
Artigo em Inglês | MEDLINE | ID: mdl-30314728

RESUMO

BACKGROUND: Transient abnormal myelopoiesis (TAM) is a neonatal preleukemic syndrome that occurs exclusively in neonates with Down syndrome (DS). Most affected infants spontaneously resolve, although some patients culminate in hepatic failure despite the hematological remission. It is impossible to determine the patients who are at high risk of progressive liver disease and leukemic transformation. The objective is to search for biomarkers predicting the development of hepatic failure in DS infants with TAM. METHODS: Among 60 newborn infants with DS consecutively admitted to our institutions from 2003 to 2016, 41 infants with or without TAM were enrolled for the study. Twenty-two TAM-patients were classified into "progression group" (n = 7) that required any therapy and "spontaneous resolution group" (n = 15). Serum concentrations of chemokines (CXCL8, CXCL9, CXCL10, CCL2 and CCL5) and transforming growth factor (TGF)-ß1 were measured at diagnosis of TAM for assessing the outcome of progressive disease. RESULTS: Three patients developed leukemia during the study period (median, 1147 days; range, 33-3753). Three died of hepatic failure. All patients in the progression group were preterm birth <37 weeks of gestational age and were earlier than those in the spontaneous resolution group (median, 34.7 vs. 37.0 weeks, p < 0.01). The leukocyte counts and CXCL8 and CCL2 levels at diagnosis in the progression group were higher than those in the spontaneous resolution group (leukocyte: median, 81.60 vs. 27.30 × 109/L, p = 0.01; CXCL8: 173.8 vs. 34.3 pg/ml, p < 0.01; CCL2: 790.3 vs. 209.8 pg/mL, p < 0.01). Multivariate analyses indicated that an increased CCL2 value was independently associated with the progression and CXCL8 with the death of liver failure, respectively (CCL2: standardized coefficient [sc], 0.43, p < 0.01; CXCL8: sc = -0.46, p = 0.02). CONCLUSION: High levels of circulating CXCL8 and CCL2 at diagnosis of TAM may predict progressive hepatic failure in DS infants.


Assuntos
Quimiocinas/sangue , Síndrome de Down/sangue , Leucemia Megacarioblástica Aguda/sangue , Reação Leucemoide/sangue , Falência Hepática/sangue , Fator de Crescimento Transformador beta1/sangue , Estudos de Casos e Controles , Quimiocina CCL2/sangue , Quimiocina CCL5/sangue , Quimiocina CXCL10/sangue , Quimiocina CXCL9/sangue , Estudos de Coortes , Progressão da Doença , Síndrome de Down/complicações , Feminino , Humanos , Hiperbilirrubinemia/epidemiologia , Lactente , Recém-Nascido , Recém-Nascido Prematuro , Interleucina-8/sangue , Coeficiente Internacional Normatizado , Leucemia , Leucemia Megacarioblástica Aguda/epidemiologia , Reação Leucemoide/complicações , Falência Hepática/epidemiologia , Falência Hepática/etiologia , Masculino , Mortalidade , Nascimento Prematuro/epidemiologia , Prognóstico , Tempo de Protrombina , Medição de Risco
7.
PLoS One ; 13(11): e0207162, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30408125

RESUMO

BACKGROUND: Vitamin D is required to maintain the integrity of the intestinal barrier and inhibits inflammatory signaling pathways. OBJECTIVE: Vitamin D deficiency might be involved in cirrhosis-associated systemic inflammation and risk of hepatic decompensation in patients with liver cirrhosis. METHODS: Outpatients of the Hepatology Unit of the University Hospital Frankfurt with advanced liver fibrosis and cirrhosis were prospectively enrolled. 25-hydroxyvitamin D (25(OH)D3) serum concentrations were quantified and associated with markers of systemic inflammation / intestinal bacterial translocation and hepatic decompensation. RESULTS: A total of 338 patients with advanced liver fibrosis or cirrhosis were included. Of those, 51 patients (15%) were hospitalized due to hepatic decompensation during follow-up. Overall, 72 patients (21%) had severe vitamin D deficiency. However, patients receiving vitamin D supplements had significantly higher 25(OH)D3 serum levels compared to patients without supplements (37 ng/mL vs. 16 ng/ml, P<0.0001). Uni- and multivariate analyses revealed an independent association of severe vitamin D deficiency with the risk of hepatic decompensation during follow-up (multivariate P = 0.012; OR = 3.25, 95% CI = 1.30-8.2), together with MELD score, low hemoglobin concentration, low coffee consumption, and presence of diabetes. Of note, serum levels of C-reactive protein, IL-6 and soluble CD14 were significantly higher in patients with versus without severe vitamin D deficiency, and serum levels of soluble CD14 levels declined in patients with de novo supplementation of vitamin D (median 2.15 vs. 1.87 ng/mL, P = 0.002). CONCLUSIONS: In this prospective cohort study, baseline vitamin D levels were inversely associated with liver-cirrhosis related systemic inflammation and the risk of hepatic decompensation.


Assuntos
Inflamação/etiologia , Cirrose Hepática/complicações , Falência Hepática/etiologia , Deficiência de Vitamina D/complicações , Idoso , Translocação Bacteriana , Biomarcadores/sangue , Calcifediol/sangue , Estudos de Coortes , Feminino , Humanos , Inflamação/sangue , Inflamação/microbiologia , Receptores de Lipopolissacarídeos/sangue , Cirrose Hepática/sangue , Cirrose Hepática/microbiologia , Falência Hepática/sangue , Falência Hepática/microbiologia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco , Deficiência de Vitamina D/sangue , Deficiência de Vitamina D/microbiologia
8.
Br J Surg ; 105(10): 1254-1261, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29999190

RESUMO

BACKGROUND: Emerging evidence suggests that the perioperative platelet count (PLT) can predict posthepatectomy liver failure (PHLF). In this systematic review and meta-analysis, the impact of perioperative PLT on PHLF and mortality was evaluated. METHODS: MEDLINE and Web of Science databases were searched systematically for relevant literature up to January 2018. All studies comparing PHLF or mortality in patients with a low versus high perioperative PLT were included. Study quality was assessed using methodological index for non-randomized studies (MINORS) criteria. Meta-analyses were performed using Mantel-Haenszel tests with a random-effects model, and presented as odds ratios (ORs) with 95 per cent confidence intervals. RESULTS: Thirteen studies containing 5260 patients were included in the meta-analysis. Two different cut-off values for PLT were used: 150 and 100/nl. Patients with a perioperative PLT below 150/nl had higher PHLF (4 studies, 817 patients; OR 4·79, 95 per cent c.i. 2·89 to 7·94) and mortality (4 studies, 3307 patients; OR 3·78, 1·48 to 9·62) rates than patients with a perioperative PLT of 150/nl or more. Similarly, patients with a PLT below 100/nl had a significantly higher risk of PHLF (4 studies, 949 patients; OR 4·65, 2·60 to 8·31) and higher mortality rates (7 studies, 3487 patients; OR 6·35, 2·99 to 13·47) than patients with a PLT of 100/nl or greater. CONCLUSION: A low perioperative PLT correlates with higher PHLF and mortality rates after hepatectomy.


Assuntos
Hepatectomia , Falência Hepática/etiologia , Contagem de Plaquetas , Complicações Pós-Operatórias/etiologia , Humanos , Falência Hepática/sangue , Falência Hepática/mortalidade , Modelos Estatísticos , Razão de Chances , Período Perioperatório , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/mortalidade , Prognóstico , Fatores de Risco
9.
Interact Cardiovasc Thorac Surg ; 27(6): 813-818, 2018 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-29893857

RESUMO

OBJECTIVES: Prognosis after pericardiectomy for constrictive pericarditis (CP) is affected by the aetiology of the constriction as well as by concomitant cardiac and non-cardiac disease, including liver dysfunction. However, few data exist on the risk stratification that accounts for liver function in patients with CP. We evaluated the effectiveness of the model for end-stage liver disease (MELD) score, an established measure of liver dysfunction, in predicting long-term survival and identifying other risk factors for death. METHODS: A total of 79 patients who underwent pericardiectomy for CP at a single centre between 2009 and 2016 were analysed. The prognostic utility of the MELD score was evaluated in our cohort. Logistic regression and Cox proportional hazard regression analyses were performed to assess the association of various clinical variables with 1-year and overall mortality rates. RESULTS: With multivariable analysis, only the MELD score was an independent predictor of 1-year mortality (P < 0.001); apart from the MELD (P = 0.003) score, post-surgical CP (P = 0.016), total bilirubin level (P = 0.042) and the European System for Cardiac Operative Risk Evaluation score II (P = 0.002) were independent predictors of overall mortality after pericardiectomy. Overall survival decreased as the MELD score increased. Scores ≤ 7.5, 7.51-15.50 and >15.5 were associated with overall survival rates of 92.9%, 69.8% and 8.3%, respectively. CONCLUSIONS: In addition to the underlying aetiology, we demonstrated that assessment of liver dysfunction using the MELD score provides additional information about risk because it is associated with postoperative death in patients undergoing pericardiectomy for CP.


Assuntos
Falência Hepática/epidemiologia , Pericardiectomia/efeitos adversos , Pericardite Constritiva/cirurgia , Complicações Pós-Operatórias/epidemiologia , Biomarcadores/sangue , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Falência Hepática/sangue , Falência Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Pericardite Constritiva/mortalidade , Complicações Pós-Operatórias/sangue , Complicações Pós-Operatórias/etiologia , Prognóstico , Estudos Retrospectivos , Fatores de Risco , Taxa de Sobrevida/tendências
10.
Eur Rev Med Pharmacol Sci ; 22(8): 2432-2438, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29762845

RESUMO

OBJECTIVE: Liver failure (LF) is a clinically complex disorder that characterizes with hepatic dysfunction. This study aimed at observing the therapeutic effects of peritoneal dialysis on liver function in LF patients. PATIENTS AND METHODS: This study involves 62 patients diagnosed as LF hospitalized from February 2005 to December 2016. The 62 LF patients were randomly divided into 3 groups, including artificial liver applying plasma exchange group (PE, n = 28), peritoneal dialysis group (PD, n = 22), and conservative treatment group (CT, n=12). Laboratory indexes, including serum total bilirubin (TBiL), alanine aminotransferase (ALT), albumin (ALB), blood ammonia (AMMO), international normalized ratio (INR), and creatinine (Cr) were evaluated. Inflammatory cytokines, including tumor necrosis factor α (TNF-α), interleukin-6 (IL-6), and procalcitonin (PCT) were examined using enzyme-linked immunosorbent assay (ELISA) kit. RESULTS: Peritoneal dialysis significantly improves clinical outcomes, including decreased mortality, increased survival rate and total effective rate, compared to conservative treatment (p < 0.05). Peritoneal dialysis reduced hospitalization expenses compared to PE method and conservative treatment (p < 0.05). Peritoneal dialysis significantly removed toxic substances (including TBiL, AMMO, Cr) compared to conservative treatment (p < 0.05). The post-treatment level of Cr in peritoneal dialysis group was significantly lower compared to post-treatment level of Cr in PE group (p < 0.05). Peritoneal dialysis significantly improved liver function compared to conservative treatment (p < 0.05). Peritoneal dialysis prevented bleeding tendency compared to conservative treatment (p < 0.05). Peritoneal dialysis alleviated inflammatory response compared to conservative treatment (p < 0.05). CONCLUSIONS: Peritoneal dialysis effectively removed toxic substances and improved liver functions of liver failure patients and with a lower therapeutic cost.


Assuntos
Mediadores da Inflamação/sangue , Falência Hepática/sangue , Falência Hepática/terapia , Fígado/metabolismo , Diálise Peritoneal/métodos , Adulto , Idoso , Feminino , Humanos , Fígado/fisiologia , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Distribuição Aleatória , Estudos Retrospectivos , Resultado do Tratamento , Fator de Necrose Tumoral alfa/sangue
11.
Liver Transpl ; 24(9): 1178-1185, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-29679437

RESUMO

Living donor right hepatectomy (LDRH) is a common procedure in adult-to-adult living donor liver transplantation, but it is associated with a higher risk of posthepatectomy liver failure (PHLF) compared with left hepatectomy because of a smaller remnant. We identified risk factors for PHLF and other complications in LDRH, verified the appropriateness of the criteria, and explored the possibility of adjusting the minimum remnant liver volume (RLV) based on individual risk. Between October 2005 and November 2017, 254 donors undergoing LDRH at Kyoto University Hospital were enrolled. Clinical data were collected retrospectively. All complications were graded according to the Clavien-Dindo classification. No donors had grade 4 or 5 complications or clinically significant grade B or C PHLF. Grade A PHLF occurred in 30 donors (11.8%). Male sex (P = 0.01), lower preoperative platelet count (PLT; P = 0.01), higher prothrombin time-international normalized ratio (P = 0.03), higher total bilirubin (P = 0.01), smaller RLV (P = 0.03), and greater blood loss (P = 0.04) were associated with increased risk of PHLF in the univariate analysis, whereas PLT, RLV, and blood loss remained significant in the multivariate analysis. Grade 2 or 3 complications were observed in 32 (12.6%) donors. Higher body mass index (BMI; P = 0.002) and larger blood loss (P = 0.02) were identified as risk factors for complications (Clavien-Dindo grade ≥ 2) in univariate analysis. Only BMI remained significant in the multivariate analysis. In conclusion, LDRH is performed safely with acceptable morbidity under the current criteria. Minimum RLV may be marginally adjusted by PLT and reducing intraoperative blood loss minimizes PHLF risk. Liver Transplantation 00 000-000 2018 AASLD.


Assuntos
Plaquetas , Hepatectomia/efeitos adversos , Falência Hepática/etiologia , Transplante de Fígado/efeitos adversos , Doadores Vivos , Adulto , Idoso , Seleção do Doador , Feminino , Humanos , Falência Hepática/sangue , Falência Hepática/diagnóstico , Transplante de Fígado/métodos , Masculino , Pessoa de Meia-Idade , Contagem de Plaquetas , Valor Preditivo dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
12.
Eur Rev Med Pharmacol Sci ; 22(4): 1118-1125, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29509265

RESUMO

OBJECTIVE: Hepatic failure (HF) is a kind of complex disease characterizing with liver dysfunction and a few clinical complications. Artificial liver support system (ALSS) has been applied to HF patients to improve dysfunctional liver in recent years. This study aims to evaluate therapeutic effects of ALSS approaches, including plasma exchange (PE), plasma diafiltration (PDF) and plasma bilirubin adsorption (PBA), on liver function of HF patients. PATIENTS AND METHODS: This study is a retrospective analysis involving 516 patients diagnosed as HF between February 2014 and February 2015. Patients were randomly divided into PE, PDF, PE plus PBA, and PDF plus PBA group. Meanwhile, single-drug group and combined-drug group were also divided. The liver functions, capability of removing toxic substances and coagulation functions were evaluated both pre-treatment and post-treatment. The side effects and hospital improvement rate were also observed post-treatment. RESULTS: Hospital improvement rate achieves to 69.6%. TBIL levels and MELD scores were significantly decreased post-treatment compared to pre-treatment (p<0.05). PTA values were significantly increased post-treatment compared to pre-treatment (p<0.05). Reduction value in PE+PBA group was significantly higher compared to PE and PDF group (p=0.002, 0.002, respectively). MELD scores were significantly decreased post-treatment compared to pre-treatment in each group (p<0.05). Combined-drug treatment is superior to single-drug treatment for removing toxic substances and improving liver functions. PE treatment, PDF treatment and PE+PBA treatment induced more side effects compared to PDF+PBA treatment. CONCLUSIONS: PE combining with PBA plays a better role in removing toxic substances, improving liver functions of HF patients.


Assuntos
Bilirrubina/sangue , Falência Hepática/sangue , Falência Hepática/terapia , Fígado/fisiologia , Troca Plasmática/métodos , Adsorção/efeitos dos fármacos , Adsorção/fisiologia , Adulto , Idoso , Gluconato de Cálcio/administração & dosagem , Dexametasona/administração & dosagem , Quimioterapia Combinada , Feminino , Humanos , Fígado/efeitos dos fármacos , Masculino , Pessoa de Meia-Idade , Distribuição Aleatória , Estudos Retrospectivos , Resultado do Tratamento
13.
J Endocrinol Invest ; 41(7): 821-829, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-29289983

RESUMO

PURPOSE: The debate about the impact of intensified hyperglycemia treatment is still ranging. The main objective was to assess whether intensive glycemic control in hospitalized diabetic patients undergoing a liver transplant is associated with a lower rate of graft rejection at 3 months and at 5 years post-transplant. METHODS: Cross-sectional study comparing a cohort of patients undergoing liver transplant in 2010 and 2011, in whom an intensive insulin protocol was applied, with a retrospective group of patients undergoing a liver transplant in 2005 and 2006, in whom a conventional insulin protocol was applied. Both diabetics and non-diabetics were compared. As intensive insulin therapy is applied mainly in diabetic patients, it is expected that, when comparing both periods, the treatment would only benefit those patients. RESULTS: The logistic regression model showed a statistically significant interaction between the treatment group and the presence of diabetes for the rejection rate 3 months and 5 years post-transplant. At both time points, the intensive insulin treatment group had lower rejection rates in the case of diabetic patients, which did not occur in non-diabetic patients. CONCLUSIONS: Our study shows a decrease in the rate of liver graft rejection in diabetic patients undergoing intensive insulin treatment.


Assuntos
Glicemia/efeitos dos fármacos , Diabetes Mellitus/tratamento farmacológico , Sobrevivência de Enxerto/efeitos dos fármacos , Insulina/administração & dosagem , Falência Hepática/cirurgia , Transplante de Fígado , Adulto , Idoso , Glicemia/metabolismo , Estudos Transversais , Complicações do Diabetes/sangue , Complicações do Diabetes/cirurgia , Diabetes Mellitus/sangue , Diabetes Mellitus/cirurgia , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Estudo Historicamente Controlado , Humanos , Falência Hepática/sangue , Falência Hepática/complicações , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
HPB (Oxford) ; 20(4): 321-326, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29373299

RESUMO

BACKGROUND: Post-hepatectomy Liver Failure (PHLF) remains the primary cause of perioperative death. The kinetics of transaminase levels are usually measured as markers of hepatocellular injury following partial hepatectomy, but their correlation with PHLF and post-operative mortality is unclear. The aim of study was to compare the post-operative transaminase kinetics with short term survival in those patients that developed PHLF. METHODS: A retrospective review of patients with HBV-related HCC and who developed PHLF was performed. Logistic regression analysis was conducted to analyze risk factors for postoperative delayed elevation of ALT (PDE-ALT) PHLF and lethal PHLF. RESULT: Of the 69 patients who developed PHLF 36 (52%) died. In those patients who died the mean ± SD ALT and AST rose from day (POD) 1-3 and continued to fluctuate with highly abnormal levels beyond day 3 with a mean ± SD peak ALT level beyond POD 3 of 1851 ± 1644 U/L (p < 0.001). CONCLUSIONS: The kinetics of the post-operative transaminases were significantly correlated with perioperative mortality in those patients who developed PHLF. PDE-ALT indicates an increased risk of death in HBV-related HCC patients with PHLF.


Assuntos
Alanina Transaminase/sangue , Carcinoma Hepatocelular/cirurgia , Hepatectomia/mortalidade , Hepatite B , Falência Hepática/sangue , Falência Hepática/mortalidade , Neoplasias Hepáticas/cirurgia , Adulto , Idoso , Biomarcadores/sangue , Carcinoma Hepatocelular/sangue , Carcinoma Hepatocelular/mortalidade , Carcinoma Hepatocelular/virologia , Feminino , Hepatectomia/efeitos adversos , Hepatite B/sangue , Hepatite B/mortalidade , Hepatite B/virologia , Humanos , Cinética , Neoplasias Hepáticas/sangue , Neoplasias Hepáticas/mortalidade , Neoplasias Hepáticas/virologia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Regulação para Cima
15.
Liver Int ; 38(3): 494-502, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-28685924

RESUMO

BACKGROUND AND AIMS: Accurate assessment of liver functional reserve pre-operatively is vital for safe hepatic resection. The ALBI score is a new model for assessing liver function. This study aimed to evaluate the value of combining ALBI score with sFLR in predicting post-operative morbidity and PHLF in HCC patients who underwent hepatectomy. METHODS: Patients undergoing three-dimensional CT reconstruction prior to hepatectomy for HCC between January 2015 and January 2017 were enrolled. The values of the CP score, ALBI score and sFLR in predicting post-operative outcomes were evaluated. RESULTS: A total of 229 HCC patients were enrolled; 24 (10.5%) experienced major complications and 21 (9.2%) developed PHLF. The incidence of major complications and PHLF increased with increasing ALBI grade. The ALBI grade classified patients with CP grade A into two subgroups with different incidences of PHLF (P=.029). sFLR and ALBI scores were identified as independent predictors of PHLF. The AUC values for the CP score, ALBI score, sFLR and sFLR×ALBI for predicting major complications were 0.600, 0.756, 0.660 and 0.790 respectively. The AUC values of the CP score, ALBI score, sFLR and sFLR×ALBI for predicting PHLF were 0.646, 0.738, 0.758 and 0.884 respectively. CONCLUSIONS: The ALBI score showed superior predictive value of post-operative outcomes over CP score, and the combination of sFLR and ALBI score was identified as a stronger predictor of post-operative outcomes than the sFLR or ALBI score alone.


Assuntos
Carcinoma Hepatocelular/cirurgia , Hepatectomia , Hepatite B/complicações , Falência Hepática/mortalidade , Neoplasias Hepáticas/cirurgia , Adolescente , Adulto , Idoso , Bilirrubina/sangue , Biomarcadores Tumorais/sangue , Carcinoma Hepatocelular/virologia , China/epidemiologia , Feminino , Humanos , Fígado/fisiopatologia , Falência Hepática/sangue , Falência Hepática/etiologia , Neoplasias Hepáticas/virologia , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Prognóstico , Curva ROC , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Albumina Sérica , Índice de Gravidade de Doença , Adulto Jovem
16.
World J Gastroenterol ; 23(35): 6540-6545, 2017 Sep 21.
Artigo em Inglês | MEDLINE | ID: mdl-29085203

RESUMO

We report the first case of a patient with hepatitis C virus (HCV) infection and idiopathic thrombocytopenic purpura (ITP), who later developed acquired amegakaryocytic thrombocytopenia (AAMT), with autoantibodies to the thrombopoietin (TPO) receptor (c-Mpl). A 64-year-old woman, with chronic hepatitis C, developed severe thrombocytopenia and was diagnosed with ITP. She died of liver failure. Autopsy revealed cirrhosis and liver carcinoma. In the bone marrow, a marked reduction in the number of megakaryocytes was observed, while other cell lineages were preserved. Therefore, she was diagnosed with AAMT. Additionally, autoantibodies to c-Mpl were detected in her serum. Autoantibodies to c-Mpl are one of the causes of AAMT, acting through inhibition of TPO function, megakaryocytic maturation, and platelet formation. HCV infection induces several autoantibodies. HCV infection might also induce autoantibodies to c-Mpl, resulting in the development of AAMT. This mechanism may be one of the causes of thrombocytopenia in patients with HCV infection.


Assuntos
Autoanticorpos/sangue , Doenças da Medula Óssea/diagnóstico , Hepatite C Crônica/imunologia , Falência Hepática/sangue , Púrpura Trombocitopênica Idiopática/diagnóstico , Púrpura Trombocitopênica/diagnóstico , Autoanticorpos/imunologia , Medula Óssea/patologia , Células da Medula Óssea/patologia , Doenças da Medula Óssea/sangue , Doenças da Medula Óssea/imunologia , Doenças da Medula Óssea/patologia , Diagnóstico Diferencial , Evolução Fatal , Feminino , Hepacivirus/isolamento & purificação , Hepatite C Crônica/sangue , Hepatite C Crônica/virologia , Humanos , Fígado/imunologia , Fígado/patologia , Falência Hepática/etiologia , Falência Hepática/imunologia , Falência Hepática/patologia , Megacariócitos/patologia , Pessoa de Meia-Idade , Púrpura Trombocitopênica/sangue , Púrpura Trombocitopênica/imunologia , Púrpura Trombocitopênica/patologia , Púrpura Trombocitopênica Idiopática/sangue , Receptores de Trombopoetina/imunologia , Trombopoetina/metabolismo
17.
Medicine (Baltimore) ; 96(42): e8039, 2017 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-29049191

RESUMO

RATIONALE: Invasive pulmonary aspergillosis is associated with significant morbidity and mortality in patients with liver failure. Voriconazole (VRCZ) is recommended as a primary therapeutic agent for the treatment of invasive aspergillosis and metabolized in the liver. Now, data are still lacking on the safety and appropriate dosage of VRCZ in patients with liver failure. Here, we report a representative case of invasive pulmonary fungal infection in a patient with liver failure who was treated with low-dose VRCZ. PATIENT CONCERNS: A 21-year-old man, presented with subacute liver failure caused suspected by viral infection, was admitted on June 22, 2014. Liver function was not improved by the treatment of gancicolovir and methylprednisolone. The patient presented with fever, cough, and hyperpyrexia on July 14. Laboratory tests revealed raised neutrophil percentage (82.1%, normal range [NR] 50-70), international normalized ratio (INR) (2.32, NR 0.8-1.2) and levels of serum lactic acid (4.308 mmol/L, NR 0.6-2.2), alanine transaminase (165 U/L,NR 0-40), aspartate transaminase (99 U/L, NR 8-40), and total bilirubin (654 mmol/L, NR 3.4-20.5). Furthermore, CD4+ T cell, CD8+T cell, and B cell count were low (169, 221, and l8/mL, respectively). Sputum smear microscopy for bacteria was negative, but the direct observation for fungal elements was positive. Thoracic CT scan revealed bilateral pulmonary high-density shadow. Sputum cultures were positive 2 days later with the presence of Aspergillus fumigatus. DIAGNOSES: Therefore, this patient diagnosed with suspected pulmonary a spergillosis. INTERVENTIONS: VRCZ was used on July 15th and its dosage was 400 mg twice on day 1 followed by a maintenance dose of 100 mg twice daily according to drug usage instruction. However, some side effects, such as tremors, lips twitching, and hair loss, occurred. Plasma VRCZ trough concentration was 8.1 mg/mL which was much higher than the recommend level. Therefore, VRCZ dosage was adjusted according to its plasma concentration. VRCZ plasma concentration fluctuated between 2.5 to 4.7 mg/mL when its dosage was 100 mg once daily and side effects disappeared. OUTCOMES: VRCZ was administered for 2 months. This patient's symptoms and liver function were improved. A follow-up CT scan performed at the end of VRCZ therapy indicated that the high-density shadow had diminished. LESSONS: This case demonstrated that low-dose VRCZ (maintenance dose, 100 mg/day) can achieve effective plasma concentration and reduce side effects without liver damage. We believe that VRCZ is safe to be administered in patients with liver failure, but its plasma concentration should be carefully monitored.


Assuntos
Antifúngicos/sangue , Doença Hepática Induzida por Substâncias e Drogas/prevenção & controle , Monitoramento de Medicamentos/métodos , Aspergilose Pulmonar Invasiva/tratamento farmacológico , Falência Hepática/sangue , Voriconazol/sangue , Antifúngicos/administração & dosagem , Doença Hepática Induzida por Substâncias e Drogas/parasitologia , Humanos , Aspergilose Pulmonar Invasiva/parasitologia , Falência Hepática/tratamento farmacológico , Falência Hepática/parasitologia , Masculino , Resultado do Tratamento , Voriconazol/administração & dosagem , Adulto Jovem
18.
Toxins (Basel) ; 9(9)2017 08 31.
Artigo em Inglês | MEDLINE | ID: mdl-28858213

RESUMO

In January 2015, a 20-month-old child and her family took part in recreational activities at Carrasco and Malvín beaches (Montevideo, Uruguay). An intense harmful algae bloom (HAB) was developing along the coast at that time. A few hours after the last recreational exposure episode, the family suffered gastrointestinal symptoms which were self-limited except in the child's case, who was admitted to hospital in Uruguay with diarrhea, vomiting, fatigue, and jaundice. The patient had increased serum levels of liver enzymes and bilirubin and five days later presented acute liver failure. She was referred to the Italian Hospital in Buenos Aires, being admitted with grade II-III encephalopathy and hepatomegaly and requiring mechanical respiratory assistance. Serology tests for hepatitis A, B, and C, Epstein-Barr virus, and cytomegalovirus were negative. Laboratory features showed anemia, coagulopathy, and increased serum levels of ammonium, alanine aminotransferase (ALT), aspartate aminotransferase (AST), and bilirubin. Autoimmune Hepatitis Type-II (AH-II) was the initial diagnosis based on a liver kidney microsomal type 1 antibodies (LKM-1) positive result, and twenty days later a liver transplant was performed. The liver histopathology had indicated hemorrhagic necrosis in zone 3, and cholestasis and nodular regeneration, which were not characteristic of AH-II. LC/ESI-HRMS (liquid chromatography electrospray ionization high-resolution mass spectrometry) analysis of MCs in the explanted liver revealed the presence of Microsytin-LR (MC-LR) (2.4 ng·gr-1 tissue) and [D-Leu¹]MC-LR (75.4 ng·gr-1 tissue), which constitute a toxicological nexus and indicate a preponderant role of microcystins in the development of fulminant hepatitis.


Assuntos
Proliferação Nociva de Algas , Falência Hepática/etiologia , Microcistinas/toxicidade , Poluentes da Água/toxicidade , Alanina Transaminase/sangue , Aspartato Aminotransferases/sangue , Praias , Bilirrubina/sangue , Exposição Ambiental , Feminino , Humanos , Lactente , Fígado/metabolismo , Fígado/patologia , Falência Hepática/sangue , Falência Hepática/patologia , Uruguai
19.
Crit Care ; 21(1): 218, 2017 Aug 21.
Artigo em Inglês | MEDLINE | ID: mdl-28826408

RESUMO

BACKGROUND: The development of renal and liver dysfunction may be accompanied by initially subtle derangements in the gluconeogenetic function. Discrepantly low glucose levels combined with high lactate levels might indicate an impaired Cori cycle. Our objective was to examine the relation between early lactate and glucose levels with subsequent renal and liver dysfunction and hospital mortality in critically ill patients. METHODS: Over a 4-year period (2011 to 2014), all adult patients admitted to our adult 48-bed teaching hospital intensive care unit (ICU) for at least 12 h were retrospectively analyzed. Lactate and glucose were regularly measured with point-of-care analyzers in all ICU patients. Lactate and glucose measurements were collected from 6 h before to 24 h after ICU admission. Patients with fewer than four lactate/glucose measurements were excluded. Patients received insulin according to a computer-guided control algorithm that aimed at a glucose level <8.0 mmol/L. Renal dysfunction was defined as the development of acute kidney injury (AKI) within 7 days, and liver function was based on the maximal bilirubin in the 7-day period following ICU admission. Mean lactate and mean glucose were classified into quintiles and univariate and multivariate analyses were related with renal and liver dysfunction and hospital mortality. Since glucose has a known U-shaped relation with outcome, we also accounted for this. RESULTS: We analyzed 92,000 blood samples from 9074 patients (63% males) with a median age of 64 years and a hospital mortality of 11%. Both lactate quintiles (≤1.0; 1.0-1.3; 1.3-1.7; 1.7-2.3; >2.3 mmol/L) and glucose quintiles (≤7.0; 7.0-7.6; 7.6-8.2; 8.2-9.0; >9.0 mmol/L) were related with outcome in univariate analysis (p < 0.001). Acute Physiology and Chronic Health Evaluation (APACHE) IV, lactate, and glucose were associated with renal and liver dysfunction in multivariate analysis (p < 0.001), with a U-shaped relationship for glucose. The combination of the highest lactate quintile with the lowest glucose quintile was associated with the highest rates of renal dysfunction, liver dysfunction, and mortality (p < 0.001) with a significant interaction between lactate and glucose (p ≤ 0.001). CONCLUSIONS: Abnormal combined lactate and glucose measurements may provide an early indication of organ dysfunction. In critically ill patients a 'normal' glucose with an elevated lactate should not be considered desirable, as this combination is related with increased mortality.


Assuntos
Glucose/análise , Ácido Láctico/análise , Falência Hepática/fisiopatologia , Insuficiência Renal/fisiopatologia , APACHE , Adulto , Idoso , Estado Terminal/mortalidade , Feminino , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/organização & administração , Ácido Láctico/sangue , Falência Hepática/sangue , Masculino , Pessoa de Meia-Idade , Países Baixos , Valor Preditivo dos Testes , Insuficiência Renal/sangue , Estudos Retrospectivos , Estatísticas não Paramétricas
20.
PLoS One ; 12(5): e0178237, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28542386

RESUMO

AIM: To investigate the relationship between the degree of liver dysfunction, quantified by maximal liver function capacity (LiMAx test) and endothelin-1, TNF-α and IL-6 in septic surgical patients. METHODS: 28 septic patients (8 female, 20 male, age range 35-80y) were prospectively investigated on a surgical intensive care unit. Liver function, defined by LiMAx test, and measurements of plasma levels of endothelin-1, TNF-α and IL-6 were carried out within the first 24 hours after onset of septic symptoms, followed by day 2, 5 and 10. Patients were divided into 2 groups (group A: LiMAx ≥100 µg/kg/h, moderate liver dysfunction; group B: LiMAx <100 µg/kg/h, severe liver dysfunction) for analysis and investigated regarding the correlation between endothelin-1 and the severity of liver failure, quantified by LiMAx test. RESULTS: Group B showed significant higher results for endothelin-1 than patients in group A (P = 0.01, d5; 0.02, d10). For TNF-α, group B revealed higher results than group A, with a significant difference on day 10 (P = 0.005). IL-6 showed a non-significant trend to higher results in group B. The Spearman's rank correlation coefficient revealed a significant correlation between LiMAx and endothelin-1 (-0.434; P <0.001), TNF-α (-0.515; P <0.001) and IL-6 (-0.590; P <0.001). CONCLUSIONS: Sepsis-related hepatic dysfunction is associated with elevated plasma levels of endothelin-1, TNF-α and IL-6. Low LiMAx results combined with increased endothelin-1 and TNF-α and a favourable correlation between LiMAx and cytokine values support the findings of a crucial role of Endothelin-1 and TNF-α in development of septic liver failure.


Assuntos
Endotelina-1/sangue , Falência Hepática/sangue , Testes de Função Hepática , Choque Séptico/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Progressão da Doença , Feminino , Humanos , Unidades de Terapia Intensiva , Interleucina-6/sangue , Falência Hepática/terapia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Índice de Gravidade de Doença , Choque Séptico/terapia , Fator de Necrose Tumoral alfa/sangue
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