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1.
Braz J Med Biol Res ; 53(11): e9728, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33053116

RESUMO

The aim of this study was to propose a stem cell therapy for hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) based on plasma exchange (PE) for peripheral blood stem cell (PBSC) collection and examine its safety and efficacy. Sixty patients (n=20 in each group) were randomized to PE (PE alone), granulocyte colony-stimulating factor (G-CSF) (PE after G-CSF treatment), and PBSC transplantation (PBSCT) (G-CSF, PE, PBSC collection and hepatic artery injection) groups. Patients were followed-up for 24 weeks. Liver function and adverse events were recorded. Survival analysis was performed. PBSCT improved blood ammonia levels at 1 week (P<0.05). The level of total bilirubin, international normalized ratio, and creatinine showed significant differences in the 4th week of treatment (P<0.05). The survival rates of the PE, G-CSF, and PBSCT groups were 50, 65, and 85% at 90 days (P=0.034). There was a significant difference in 90-day survival between the PE and PBSCT groups (P=0.021). The preliminary results suggested that PBSCT was safe, with a possibility of improved 90-day survival in patients with HBV-ACLF.


Assuntos
Insuficiência Hepática Crônica Agudizada , Vírus da Hepatite B , Hepatite B/complicações , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Adulto , Feminino , Fator Estimulador de Colônias de Granulócitos , Humanos , Masculino , Pessoa de Meia-Idade , Troca Plasmática , Transplante de Células-Tronco
2.
Medicine (Baltimore) ; 99(41): e22585, 2020 Oct 09.
Artigo em Inglês | MEDLINE | ID: mdl-33031310

RESUMO

BACKGROUND: Acute chronic liver failure (ACLF) is the most common type of liver failure. The clinical symptoms are complex and changeable, the treatment is difficult and the fatality rate is high. It has become an urgent problem to actively seek effective treatment means and improve the clinical efficacy of ACLF patients. Studies have shown that decreased intestinal barrier function and bacterial endotoxin translocation in ACLF patients are considered to be the key causes of enterogenic endotoxemia, and traditional Chinese medicine enema has certain advantages in adjuvant treatment of this disease. However, due to the lack of evidence, there is no specific method or suggestion, so it is necessary to carry out systematic evaluation on Traditional Chinese medicine enema for ACLF and provide effective evidence for further research. METHODS: We will search the following electronic databases from their inception to July 2020: Electronic database includes PubMed, Embase, Cochrane Library, Chinese Biomedical Database WangFang, VIP medicine information, and China National Knowledge Infrastructure. Primary outcomes: survival rates, TCM syndrome score. SECONDARY OUTCOMES: liver function (alanine aminotransferase, aspartic acid amino transferase, total bilirubin), blood coagulation function (prothrombin activity), adverse events. Data will be extracted by 2 researchers independently, risk of bias of the meta-analysis will be evaluated based on the Cochrane Handbook for Systematic Reviews of Interventions. All data analysis will be conducted by data statistics software Review Manager V.5.3. and Stata V.12.0. RESULTS: The results of this study will systematically evaluate the effectiveness and safety of Traditional Chinese medicine enema for ACLF. CONCLUSION: The systematic review of this study will summarize the currently published evidence of Traditional Chinese medicine enema for ACLF to further guide its promotion and application.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Enema , Medicina Tradicional Chinesa , Projetos de Pesquisa , Humanos , Metanálise como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Revisões Sistemáticas como Assunto
3.
Z Gastroenterol ; 58(9): 855-867, 2020 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-32947631

RESUMO

BACKGROUND: The economic effects of spontaneous bacterial peritonitis (SBP), nosocomial infections (nosInf) and acute-on-chronic liver failure (ACLF) have so far been poorly studied. We analyzed the impact of these complications on treatment revenues in hospitalized patients with decompensated cirrhosis. METHODS: 371 consecutive patients with decompensated liver cirrhosis, who received a paracentesis between 2012 and 2016, were included retrospectively. DRG (diagnosis-related group), "ZE/NUB" (additional charges/new examination/treatment methods), medication costs, length of hospital stay as well as different kinds of specific treatments (e. g., dialysis) were considered. Exclusion criteria included any kind of malignancy, a history of organ transplantation and/or missing accounting data. RESULTS: Total treatment costs (DRG + ZE/NUB) were higher in those with nosInf (€â€Š10,653 vs. €â€Š5,611, p < 0.0001) driven by a longer hospital stay (23 d vs. 12 d, p < 0.0001). Of note, revenues per day were not different (€â€Š473 vs. €â€Š488, p = 0.98) despite a far more complicated treatment with a more frequent need for dialysis (p < 0.0001) and high-complex care (p = 0.0002). Similarly, SBP was associated with higher total revenues (€â€Š10,307 vs. €â€Š6,659, p < 0.0001). However, the far higher effort for the care of SBP patients resulted in lower daily revenues compared to patients without SBP (€â€Š443 vs. €â€Š499, p = 0.18). ACLF increased treatment revenues to €â€Š10,593 vs. €6,369 without ACLF (p < 0.0001). While treatment of ACLF was more complicated, revenue per day was not different to no-ACLF patients (€â€Š483 vs. €â€Š480, p = 0.29). CONCLUSION: SBP, nosInf and/or ACLF lead to a significant increase in the effort, revenue and duration in the treatment of patients with cirrhosis. The lower daily revenue, despite a much more complex therapy, might indicate that these complications are not yet sufficiently considered in the German DRG system.


Assuntos
Insuficiência Hepática Crônica Agudizada/economia , Infecções Bacterianas/economia , Infecção Hospitalar/economia , Grupos Diagnósticos Relacionados/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Peritonite/economia , Insuficiência Hepática Crônica Agudizada/terapia , Infecções Bacterianas/terapia , Infecção Hospitalar/complicações , Infecção Hospitalar/terapia , Grupos Diagnósticos Relacionados/estatística & dados numéricos , Alemanha/epidemiologia , Humanos , Tempo de Internação , Cirrose Hepática/complicações , Peritonite/tratamento farmacológico , Estudos Retrospectivos
5.
Aliment Pharmacol Ther ; 52(2): 222-232, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32490550

RESUMO

BACKGROUND: Data on liver transplantation (LT) in acute on chronic liver failure (ACLF) are scanty. AIM: To perform meta-analysis on outcomes after LT for ACLF compared with ACLF patients not receiving LT or with LT recipients for indications other than ACLF. METHODS: We pooled data from 12 studies on LT outcomes among ACLF patients. RESULTS: Among nine studies, 22 238 LT recipients for ACLF vs 30 791 for non-ACLF were younger by 1.1 years, less males (64% vs 66.4%), and higher model for end-stage disease score by 14.5 (14.4-14.6), P < 0.01 for all. Post-transplant patient survival at 30 day, 90 day, 6 months, 1 year and 5 years was lower in ACLF: 96.2% vs 98.1%, 92.6% vs 96.2%, 89.9% vs 94.4%, 86.0% vs 91.9%, 66.9% vs 80.7% respectively, P < 0.01 for all. ACLF patients stayed longer in hospital and ICU by 5.7 and 10.5 days respectively, P < 0.001, with similar post-transplant complications [74.4% vs 55.5%, P = 0.12]. Among three studies, 441 LT recipients for ACLF vs 301 ACLF patients not selected for LT had better 30 day and 1 year survival: 95.2% vs 60% and 85.3% vs 28.2% respectively, P < 0.001. Outcomes were worse in ACLF-3 and better for ACLF-1 and ACLF-2 patients at the time of LT. CONCLUSION: In this pooled analysis with a large sample size across the globe, LT for select patients with ACLF provided survival benefit. However, larger prospective studies are needed to further refine selection criteria, especially for ACLF-3 patients as basis for improving outcomes and optimal utilisation of scarce donor pool.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Transplante de Fígado , Insuficiência Hepática Crônica Agudizada/mortalidade , Humanos , Resultado do Tratamento
6.
Zhonghua Gan Zang Bing Za Zhi ; 28(5): 391-396, 2020 May 20.
Artigo em Chinês | MEDLINE | ID: mdl-32536054

RESUMO

Objective: To compare the clinical features between patients with acute-on-chronic liver failure (ACLF) and decompensated liver cirrhosis (DC) combined with acute kidney injury (AKI). Methods: Demographic data, clinical examination results, diagnosis and treatment information of ACLF and DC patients were collected retrospectively. Clinical characteristics of ACLF combined with AKI and DC combined with AKI and their impact on the 90-day mortality risk were compared. Results: The clinical characteristics of patients with ACLF-AKI and DC-AKI were compared. The results showed that the leukocyte count, absolute neutrophil count, alanine aminotransferase (ALT), aspartate aminotransferase (AST), total bilirubin (TBil) of ACLF-AKI patients were higher than those of DC-AKI patients, while prothrombin activity (PTA), and albumin were lower than those of DC-AKI patients, and the difference was statistically significant (P < 0.05). The co-infection rate in patients with ACLF-AKI was significantly higher than that of DC-AKI group (96.9% vs. 39.5%) (P < 0.05), and during the diagnosis of AKI, the median value of serum creatinine in ACLF patients was 147 µmol / L (IQR: 122-189), while that in DC group was 123.5 µmol / L (IQR: 103.8-155.5), and the difference between the two groups was statistically significant (P < 0.05). According to the HRS-AKI diagnostic criteria for liver cirrhosis, 44 (68.8%) cases of ACLF-AKI met the diagnosis of HRS -AKI, which was significantly higher than the proportion of 18 (47.4%) cases of DC-AKI (P < 0.05). Four (10.5%) cases of DC-AKI had died or underwent liver transplantation within 30 days and eight (21.1%) cases had died or underwent liver transplantation within 90 days, while 22 (34.4%) cases of ACLF-AKI patients had died or underwent liver transplantation within 30 days and 35 (54.7%) cases had died or underwent liver transplantation within 90 days, and χ (2) values was 7.140 and 11.062, respectively (P < 0.05). The results of multivariate regression analysis suggested that the independent risk factors that affect the 90-days mortality rate of DC patients were hepatic encephalopathy, gastrointestinal bleeding, and TBil, while the independent risk factors affecting the 90-days death risk of ACLF patients included AKI, PTA and TBil. Conclusion: Compared with DC-AKI patients, ACLF-AKI patients have a higher proportion of infection rate, higher serum creatinine level when diagnosed AKI, and faster disease progression, leading to a greater risk of death.


Assuntos
Lesão Renal Aguda , Insuficiência Hepática Crônica Agudizada , Cirrose Hepática , Lesão Renal Aguda/diagnóstico , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Creatinina , Humanos , Cirrose Hepática/complicações , Prognóstico , Estudos Retrospectivos
8.
Liver Int ; 40(7): 1590-1593, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32369658

RESUMO

The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a highly infectious viral disease that predominantly causes respiratory symptoms. Elevated liver enzymes have been reported during the course of disease and appear to be common. We present a 56-year-old woman with a history of decompensated alcoholic cirrhosis who presented with abdominal pain, fever and diarrhoea and was found to have acute on chronic liver failure secondary to SARS-CoV-2 infection. The patient was treated with empiric antibiotic and supportive care with subsequent improvement.


Assuntos
Insuficiência Hepática Crônica Agudizada/virologia , Betacoronavirus/patogenicidade , Infecções por Coronavirus/virologia , Cirrose Hepática Alcoólica/complicações , Pneumonia Viral/virologia , Insuficiência Hepática Crônica Agudizada/diagnóstico , Insuficiência Hepática Crônica Agudizada/terapia , Antibacterianos/uso terapêutico , Infecções por Coronavirus/complicações , Infecções por Coronavirus/diagnóstico , Infecções por Coronavirus/terapia , Feminino , Hidratação , Interações Hospedeiro-Patógeno , Humanos , Cirrose Hepática Alcoólica/diagnóstico , Cirrose Hepática Alcoólica/terapia , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/complicações , Pneumonia Viral/diagnóstico , Pneumonia Viral/terapia , Resultado do Tratamento
9.
Transplantation ; 104(7): e188-e198, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32150034

RESUMO

BACKGROUND: Cystatin C (CysC) is an early biomarker of renal dysfunction scarcely studied in patients awaiting liver transplantation (LT). Sarcopenia is frequent in cirrhosis and impacts prognosis. We aimed to assess the capability of these factors to predict survival and acute-on-chronic liver failure (ACLF) in patients awaiting LT, as well as early post-LT outcomes. METHODS: Single-center study that included all cirrhotic patients listed for LT between 2014 and 2017. Competing risk regression analysis was used to evaluate the capability of liver-, kidney-, and global status-related variables at waitlist (WL) inclusion to predict WL mortality and ACLF. Variables associated with post-LT outcomes were evaluated with logistic regression analysis. RESULTS: One-hundred-and-eighty patients were included. Fifty-six (31%) patients developed ACLF, 54 (30%) underwent LT and 35 (19%) died. In the adjusted competing risk regression analysis, CysC ≥ 1.5 mg/L, sarcopenia and MELD-Na were independent predictors of ACLF in the WL, while CysC ≥ 1.5 mg/L, sarcopenia and albumin were independent predictors of mortality. The cumulative incidence of ACLF and mortality at 12 months were 50% and 34% in patients with sarcopenia and CysC ≥1.5 mg/L. An estimated glomerular filtration rate by chronic kidney disease (CKD)-EPI-CysC-creatinine <60 mL/min/1.73 m at WL inclusion was an independent predictor of the need for renal replacement therapy (RRT) in the first month post-LT. CONCLUSIONS: Higher levels of CysC and sarcopenia are strongly associated with the ACLF and mortality in WL. The assessment of both risk factors may improve the prognostic evaluation and allow identifying a group of patients with a very high risk of poor outcomes while awaiting LT.


Assuntos
Insuficiência Hepática Crônica Agudizada/diagnóstico , Cistatina C/sangue , Doença Hepática Terminal/mortalidade , Cirrose Hepática/mortalidade , Transplante de Fígado/efeitos adversos , Sarcopenia/embriologia , Lesão Renal Aguda/sangue , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/etiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Idoso , Biomarcadores/sangue , Creatinina/sangue , Doença Hepática Terminal/sangue , Doença Hepática Terminal/complicações , Doença Hepática Terminal/diagnóstico , Feminino , Taxa de Filtração Glomerular , Humanos , Incidência , Cirrose Hepática/sangue , Cirrose Hepática/complicações , Cirrose Hepática/diagnóstico , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Prognóstico , Insuficiência Renal Crônica/sangue , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/etiologia , Insuficiência Renal Crônica/terapia , Terapia de Substituição Renal/estatística & dados numéricos , Estudos Retrospectivos , Medição de Risco/métodos , Fatores de Risco , Sarcopenia/sangue , Sarcopenia/etiologia , Índice de Gravidade de Doença , Listas de Espera/mortalidade
10.
Clin Nephrol ; 93(4): 187-194, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32101519

RESUMO

BACKGROUND: Incident acute kidney injury (AKI) in critically ill patients with acute on chronic liver failure (ACLF) is associated with poor prognosis. The role of continuous renal replacement therapy (CRRT) is not well established for patients with ACLF and AKI. MATERIALS AND METHODS: We conducted a retrospective cohort study to examine clinical outcomes in 66 patients with ACLF and AKI requiring CRRT. RESULTS: All-cause hospital mortality was 89.4%. Five (7.6%) patients were listed for liver transplantation, of whom 1 (1.5%) was eventually subjected to transplantation. Etiology of AKI included type 1 hepatorenal syndrome (HRS) with or without some degree of acute tubular necrosis (ATN) in 20 (30.3%) patients, and primarily ATN in 46 (69.7%) patients. When evaluated at the time of CRRT initiation, Child-Pugh-Turcotte (CPT) and Model for End-stage Liver Disease (MELD) (area under the receiver operating characteristics curve (AUROC) 0.67 for both) had fair performance for prediction of mortality, whereas Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure (CLIF)-SOFA performed better for the prediction of mortality (AUROC 0.87 for both). SOFA and CLIF-SOFA also performed well when determined at the time of ICU admission (AUROC 0.86 and 0.85, respectively). Etiology of liver disease or AKI did not influence prognosis. CONCLUSION: Critically ill patients with ACLF and AKI requiring CRRT have poor hospital survival, even with provision of extracorporeal support therapy. SOFA and CLIF-SOFA are good prognostic tools of mortality in this susceptible population.


Assuntos
Lesão Renal Aguda/mortalidade , Insuficiência Hepática Crônica Agudizada/mortalidade , Terapia de Substituição Renal Contínua , Estado Terminal , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/terapia , Adulto , Idoso , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
12.
Crit Care Med ; 48(3): e173-e191, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32058387

RESUMO

OBJECTIVES: To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU. DESIGN: The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. SETTING: The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology. INTERVENTIONS: We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS: In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence. CONCLUSIONS: Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.


Assuntos
Falência Hepática Aguda/terapia , Guias de Prática Clínica como Assunto/normas , Lesão Renal Aguda/epidemiologia , Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/epidemiologia , Insuficiência Hepática Crônica Agudizada/terapia , Corticosteroides/uso terapêutico , Adulto , Aminoácidos de Cadeia Ramificada/administração & dosagem , Anticoagulantes/classificação , Anticoagulantes/uso terapêutico , Glicemia , Pressão Sanguínea , Doença Hepática Induzida por Substâncias e Drogas/diagnóstico , Proteínas na Dieta/administração & dosagem , Nutrição Enteral/métodos , Prática Clínica Baseada em Evidências , Hidratação/métodos , Hemodinâmica , Hemoglobinas/análise , Hemorragia/induzido quimicamente , Hemorragia/prevenção & controle , Síndrome Hepatopulmonar/epidemiologia , Síndrome Hepatopulmonar/terapia , Humanos , Hipóxia/epidemiologia , Hipóxia/terapia , Unidades de Terapia Intensiva , Falência Hepática Aguda/epidemiologia , Transplante de Fígado/métodos , Derivação Portossistêmica Transjugular Intra-Hepática/métodos , Terapia de Substituição Renal/métodos , Respiração Artificial/métodos , Tromboelastografia/métodos , Vasoconstritores/uso terapêutico , Tromboembolia Venosa/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle
13.
Curr Opin Crit Care ; 26(2): 171-179, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-31977332

RESUMO

PURPOSE OF REVIEW: Patients with cirrhosis are frequently hospitalized with acute decompensation and organ system failure - a syndrome referred to as acute on chronic liver failure (ACLF). These patients often require critical care intervention and experience significant mortality; however, established diagnostic and prognostic criteria are lacking. Given this, it remains imperative for intensivists to develop an expertise in common ACLF complications and management. RECENT FINDINGS: Liver transplantation serves as the definitive management strategy in ACLF. Traditional organ allocation procedures are based on the Model for Endstage Liver Disease score, which may not correlate with ACLF severity and the associated need for urgent liver transplantation. Recent studies have suggested favorable postliver transplantation outcomes in ACLF patients with multiorgan failure, emphasizing the need for further studies to elucidate optimal timing and candidacy for liver transplantation. SUMMARY: Cirrhosis is a chronic and progressive condition leaving patients vulnerable to acute decompensation necessitating the need for critical care intervention. Prompt recognition and implementation of targeted supportive therapies, together with consideration of urgent liver transplantation, are essential to combat the high short-term mortality of ACLF patients.


Assuntos
Insuficiência Hepática Crônica Agudizada , Cuidados Críticos , Transplante de Fígado , Insuficiência Hepática Crônica Agudizada/terapia , Humanos , Cirrose Hepática , Prognóstico
14.
World J Gastroenterol ; 26(2): 219-245, 2020 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-31988586

RESUMO

BACKGROUND: Acute liver failure (ALF) and acute-on-chronic liver (ACLF) carry high short-term mortality rate, and may result from a wide variety of causes. Plasma exchange has been shown in a randomized control trial to improve survival in ALF especially in patients who did not receive a liver transplant. Other cohort studies demonstrated potential improvement in survival in patients with ACLF. AIM: To assess utility of plasma exchange in liver failure and its effect on mortality in patients who do not undergo liver transplantation. METHODS: Databases MEDLINE via PubMed, and EMBASE were searched and relevant publications up to 30 March, 2019 were assessed. Studies were included if they involved human participants diagnosed with liver failure who underwent plasma exchange, with or without another alternative non-bioartificial liver assist device. RESULTS: Three hundred twenty four records were reviewed, of which 62 studies were found to be duplicates. Of the 262 records screened, 211 studies were excluded. Fifty-one articles were assessed for eligibility, for which 7 were excluded. Twenty-nine studies were included for ALF only, and 9 studies for ACLF only. Six studies included both ALF and ACLF patients. A total of 44 publications were included. Of the included publications, 2 were randomized controlled trials, 14 cohort studies, 12 case series, 16 case reports. All of three ALF studies which looked at survival rate or survival days reported improvement in outcome with plasma exchange. In two out of four studies where plasma exchange-based liver support systems were compared to standard medical treatment (SMT) for ACLF, a biochemical improvement was seen. Survival in the non-transplanted patients was improved in all four studies in patients with ACLF comparing plasma exchange vs SMT. Using the aforementioned studies, plasma exchange based therapy in ACLF compared to SMT improved survival in non-transplanted patients at 30 and 90-d with a pooled OR of 0.60 (95%CI 0.46-0.77, P < 0.01). CONCLUSION: The level of evidence for use of high volume plasma exchange in selected ALF cases is high. Plasma exchange in ACLF improves survival at 30-and 90-d in non-transplanted patients. Further well-designed randomized control trials will need to be carried out to ascertain the optimal duration and amount of plasma exchange required and assess if the use of high volume plasma exchange can be extrapolated to patients with ACLF.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Falência Hepática Aguda/terapia , Troca Plasmática/métodos , Insuficiência Hepática Crônica Agudizada/mortalidade , Mortalidade Hospitalar , Humanos , Falência Hepática Aguda/mortalidade , Ensaios Clínicos Controlados Aleatórios como Assunto , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
16.
Artif Organs ; 44(1): 91-99, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31267563

RESUMO

Acute-on-chronic liver failure (ACLF) requiring intensive medical care and associated with acute kidney injury (AKI) has a mortality rate as high as 90% due to the lack of effective therapies. In this study, we assessed the effects of intermittent high-flux single-pass albumin dialysis (SPAD) coupled with continuous venovenous hemodialysis (CVVHD) on 28-day and 90-day survival and an array of clinical and laboratory parameters in patients with severe ACLF and renal insufficiency. Sixteen patients were studied. The diagnosis of ACLF and AKI was made in accordance with current EASL Clinical Practice Guidelines, including the recommendations of the International Club of Ascites. All patients received SPAD/CVVHD treatments as the blood purification therapy to support liver, kidneys, and other organs. Five patients were transplanted and 11 were not listed for transplantation because of active alcoholism. Data at the initiation of SPAD/CVVHD were compared with early morning data after the termination of the extracorporeal treatment phase. All patients had ACLF and renal insufficiency with 13/16 additionally fulfilling the AKI criteria. A total of 37 SPAD/CVVHD treatments were performed [2.3 ± 1.4]. The baseline MELD-Na score was 37.6 ± 6.6 and decreased to 33.4 ± 8.7 after SPAD/CVVHD (P < 0.001). In parallel, the CLIF-C ACLF grade and OF score, estimated at 28- and 90-day mortality, AKI stage, hepatic encephalopathy grade, and liver function tests were lowered (P = 0.001-0.032). The 28- and 90-day survivals were 56.2% overall and 53.8% in AKI. Survival in patients not transplanted (n = 11) was 45.4%. In patients with severe ACLF and AKI, the renal replacement therapy coupled with high-performance albumin dialysis improved estimated 28- and 90-day survival and several key clinical and laboratory parameters. It is postulated that these results may be further improved with earlier intervention and more SPAD treatments per patient. High-performance albumin dialysis improves survival and key clinical and laboratory parameters in severe ACLF and AKI.


Assuntos
Lesão Renal Aguda/terapia , Insuficiência Hepática Crônica Agudizada/terapia , Terapia de Substituição Renal Contínua/métodos , Albumina Sérica Humana/uso terapêutico , Lesão Renal Aguda/complicações , Insuficiência Hepática Crônica Agudizada/complicações , Adulto , Idoso , Feminino , Humanos , Transplante de Fígado , Masculino , Pessoa de Meia-Idade , Diálise Renal/métodos
17.
Biomed Res Int ; 2019: 3757149, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31871940

RESUMO

Background: Hepatitis B virus-associated acute-on-chronic liver failure (HBV-ALCF) is a complicated syndrome with extremely high short-term mortality. The artificial liver support system (ALSS) may improve the liver function for patients with HBV-ACLF, but the data on its short-term outcomes are insufficient in China. Methods: We recruited HBV-ACLF patients in this nationwide, multicenter, retrospective study. Patients with HBV-ACLF were diagnosed by the COSSH-ACLF criteria. Propensity score matching (PSM) analysis was used to generate compared pairs. The short-term (28/90 days) survival rates between the standard medical therapy (SMT) group and ALSS group were calculated using a Kaplan-Meier graph. Result: In total, 790 patients with HBV-ACLF were included in this retrospective study; 412 patients received SMT only (SMT group), and 378 patients received SMT and ALSS treatment (ALSS group). PSM generated 310 pairs and eliminated the baseline differences between the two groups (p > 0.05 for all baseline variables). The probabilities of survival on day 28 were 65.2% (205/310) in the ALSS group and 59.0% (185/310) in the SMT group; on day 90, they were 51.0% (163/310) and 42.3% (136/310). The short-term (28/90 days) survival rates of the ALSS group were significantly higher than those of the SMT group (p=0.0452 and p=0.0187, respectively). Compared to receiving SMT alone, treatment with ALSS was associated with a significant reduction in serum bilirubin levels and the model for end-stage liver disease (MELD) scores at day 7 and day 28. Multivariate logistic regression analysis revealed that older age, high total bilirubin (T-Bil), low albumin, high ALT, high MELD scores, and high COSSH-ACLF grade were independent baseline factors associated with poor prognosis. Conclusions: This retrospective study found that compared to SMT, the ALSS improved the short-term (28/90 days) survival rates and laboratory parameters in HBV-ACLF patients. The ALSS had a better therapeutic effect than SMT for patients with HBV-ACLF in China.


Assuntos
Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/terapia , Hepatite B/complicações , Fígado Artificial , Insuficiência Hepática Crônica Agudizada/mortalidade , Adulto , Idoso , Bilirrubina/sangue , China , Feminino , Vírus da Hepatite B/patogenicidade , Humanos , Testes de Função Hepática/métodos , Masculino , Pessoa de Meia-Idade , Pontuação de Propensão , Estudos Retrospectivos , Taxa de Sobrevida/tendências
18.
Clin Transl Gastroenterol ; 10(12): e00095, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31789934

RESUMO

OBJECTIVES: Acute liver failure (ALF) and acute-on-chronic liver failure (AOCLF) are critical medical conditions with urgent therapy requirements. When ALF or AOCLF are due to alcohol intoxication or based on chronic alcohol abuse, virtually, no therapeutic options are available as liver transplantation is prohibited. In this case series, treatment of alcohol-induced ALF/AOCLF with adipose--derived stem cells (ASC) was tested under compassionate use. METHODS: ASC from 2 donors were isolated, cultured, and expanded by established protocols. ASC were administered to 3 individuals with either ALF or AOCLF due to alcohol abuse under compassionate use. Clinical presentation, serum measurements, and other diagnostic methods were compiled before ASC treatment and during the disease course after ASC administration. RESULTS: Three patients were admitted to the Department of Gastroenterology, Hepatology, and Infectious Diseases (University Hospital Magdeburg) with acute or AOCLF due to alcohol abuse. All 3 patients presented in impaired general condition and with elevated, in 1 case drastically elevated, serum liver enzyme concentrations. Treatment with ASC led to improvements in general condition and reduction of serum transaminases. In 2 cases, reduction of liver stiffness and increase of liver function by the C methacetin breath test were observed after ASC treatment. Recovery to a normal condition was achieved between 1 and 2 months after ASC treatment. No adverse effects associated to ASC treatment were observed. DISCUSSION: ASC treatment may be a feasible option to enhance recovery from alcohol-induced ALF or AOCLF. ASC treatment seems safe in the presented cases.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Tecido Adiposo/citologia , Alcoolismo/complicações , Etanol/toxicidade , Transplante de Células-Tronco/métodos , Insuficiência Hepática Crônica Agudizada/etiologia , Adulto , Ensaios de Uso Compassivo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transplante de Células-Tronco/efeitos adversos , Transplante Homólogo/efeitos adversos , Transplante Homólogo/métodos , Resultado do Tratamento
19.
Sci Rep ; 9(1): 16462, 2019 11 11.
Artigo em Inglês | MEDLINE | ID: mdl-31712684

RESUMO

Artificial liver support systems (ALSS) are widely used to treat patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). The aims of the present study were to investigate the subgroups of patients with HBV-ACLF who may benefit from ALSS therapy, and the relevant patient-specific factors. 489 ALSS-treated HBV-ACLF patients were enrolled, and served as derivation and validation cohorts for classification and regression tree (CART) analysis. CART analysis identified three factors prognostic of survival: hepatic encephalopathy (HE), prothrombin time (PT), and total bilirubin (TBil) level; and two distinct risk groups: low (28-day mortality 10.2-39.5%) and high risk (63.8-91.1%). The CART model showed that patients lacking HE and with a PT ≤ 27.8 s and a TBil level ≤455 µmol/L experienced less 28-day mortality after ALSS therapy. For HBV-ACLF patients with HE and a PT > 27.8 s, mortality remained high after such therapy. Patients lacking HE with a PT ≤ 27.8 s and TBil level ≤ 455 µmol/L may benefit markedly from ALSS therapy. For HBV-ACLF patients at high risk, unnecessary ALSS therapy should be avoided. The CART model is a novel user-friendly tool for screening HBV-ACLF patient eligibility for ALSS therapy, and will aid clinicians via ACLF risk stratification and therapeutic guidance.


Assuntos
Insuficiência Hepática Crônica Agudizada/terapia , Vírus da Hepatite B/isolamento & purificação , Hepatite B Crônica/complicações , Fígado Artificial/estatística & dados numéricos , Medição de Risco/métodos , Insuficiência Hepática Crônica Agudizada/etiologia , Insuficiência Hepática Crônica Agudizada/patologia , Bilirrubina/metabolismo , Estudos de Coortes , Feminino , Seguimentos , Encefalopatia Hepática/diagnóstico , Encefalopatia Hepática/etiologia , Encefalopatia Hepática/mortalidade , Hepatite B Crônica/virologia , Humanos , Testes de Função Hepática , Masculino , Pessoa de Meia-Idade , Prognóstico , Tempo de Protrombina/estatística & dados numéricos , Análise de Regressão , Taxa de Sobrevida
20.
Arch Med Res ; 50(5): 271-284, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31593852

RESUMO

Chronic inflammatory liver disease with an acute deterioration of liver function is named acute-on-chronic inflammation and could be regulated by the metabolic impairments related to the liver dysfunction. In this way, the experimental cholestasis model is excellent for studying metabolism in both types of inflammatory responses. Along the evolution of this model, the rats develop biliary fibrosis and an acute-on-chronic decompensation. The acute decompensation of the liver disease is associated with encephalopathy, ascites, acute renal failure, an acute phase response and a splanchnic increase of pro- and anti-inflammatory cytokines. This multiorgan inflammatory dysfunction is mainly associated with a splanchnic and systemic metabolic switch with dedifferentiation of the epithelial, endothelial and mesothelial splanchnic barriers. Furthermore, a splanchnic infiltration by mast cells occurs, which suggests that these cells could carry out a compensatory metabolic role, especially through the modulation of hepatic and extrahepatic mitochondrial-peroxisome crosstalk. For this reason, we propose the hypothesis that mastocytosis in the acute-on-chronic hepatic insufficiency could represent the development of a survival metabolic mechanisms that mitigates the noxious effect of the hepatic functional deficit. A better understanding the pathophysiological response of the mast cells in liver insufficiency and portal hypertension would help to find new pathways for decreasing the high morbidity and mortality rate of these patients.


Assuntos
Insuficiência Hepática Crônica Agudizada/metabolismo , Insuficiência Hepática Crônica Agudizada/terapia , Inflamação/metabolismo , Animais , Humanos , Ratos
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