Liver transplantation for autoimmune hepatitis: fulminant versus chronic hepatitis presentation

AIMS: The aim of this study was to analyse long-term outcomes of patients with liver transplantation for autoimmune hepatitis and to determine if fulminant/subfulminant hepatic failure (FSHF) at presentation was a predictor of outcome after ortothopic liver transplantation. PATIENTS AND METHODS: Between April 1990 and October 2002, 18 patients with autoimmune hepatitis underwent 21 liver transplants. Three patients were excluded because of coexisting causes of hepatitis. Seven patients had FSHF and eight patients had chronic disease. The initial immunosuppressive regimen was cyclosporine based in 80%, and all but one patient received steroids or azathioprine. RESULTS: Mean age at time of transplant was 44.2+/-15.5 years. Patients were followed for 38.9+/-29.6 months. Five patients (33.3%) had seven episodes of acute rejection (two steroid-resistant). Three patients developed chronic rejection. One patient displayed histologically proven recurrent autoimmune hepatitis. Actuarial patient and graft survival rates at 1 and 5 years were 80% and 56% and 78.6% and 51%, respectively. No differences in the clinical characteristics of the patients, rates of acute or chronic rejection episodes, end biliary or arterial complications were observed between FSHF and chronic autoimmune hepatitis. The study suggests a better survival for autoimmune FSHF (P=.003). CONCLUSIONS: Liver transplant is indicated for patients displaying autoimmune chronic liver disease and FSHF with similar clinical courses at however, patients with FSHF at presentation had better survivals.     

Liver transplantation for fulminant hepatitis

Liver transplantation has been recognized as an effective therapeutic method for end-stage liver disease in Japan. Fulminant hepatic failure is also an indication for liver transplantation, and the number of patients undergoing liver transplantation has been increasing. Reversibility and urgency are characteristics of fulminant hepatitis. If given appropriate critical support, many patients recover spontaneously. However, many patients develop cerebral edema or multiorgan failure before the liver can regenerate. Indications, operative procedures, and outcome of liver transplantation for fulminant hepatitis are discussed here. At Shinshu University, 23 of 169 cases of liver transplantation were for fulminant hepatitis. One transplantation was from a cadaveric donor and 22 from living donors. The actuarial 5-year patient and graft survival rate was 85.4%. Although some problems remain in liver transplantation for fulminant hepatitis, the results are better than those of conventional therapy. Therefore patients with fulminant hepatic failure should be listed for liver transplantation when grade 2 hepatic encephalopathy develops. Moreover, in cases of severe acute hepatitis, i.e., before patients develop grade 2 encephalopathy, liver transplantation should be considered among choices of therapy in the near future.     

重型肝炎肝移植疗效初步分析

目的 探讨重型肝炎患者肝移植术后的疗效。方法 总结我院2002年9月至2004年10月期间37例重型肝炎行肝移植术患者的临床资料，回顾性分析重型肝炎患者肝移植术后疗效和并发症。结果 全组37例重型肝炎患者术后1年生存率为83．8％，围手术期死亡6例，死亡率为16．2％，死亡原因为多脏器功能衰竭（4例），原发性移植肝功能不良＋急性肾功能衰竭（1例），术后4个月因脑梗塞合并严重肺部感染（1例）。术后并发症：急性肾功能不全12例（32．4％），其中2例行血液滤过治疗，12例患者经有效治疗后肾功能均恢复；肺部感染14例（37．8％），其中细菌感染9例，细菌合并真菌感染5例，气管切开2例，14例患者经治疗后痊愈；术后胆道并发症2例（5．4％），经ERCP介入治疗病情缓解；急性排斥反应2例（5．4％），予激素冲击治疗后排斥反应得到控制。结论 肝移植是治疗重型肝炎的有效方法，应加强围手术期管理，提高重型肝炎患者移植术后的生存率。     

Non-invasive diagnosis of severe alcoholic hepatitis: Usefulness of cross-sectional imaging

PurposeTo describe the computed tomography (CT) and magnetic resonance imaging (MRI) features of severe acute alcoholic hepatitis (SAAH) and estimate the capabilities of CT and MRI in differentiating SAAH from alcoholic cirrhosis and non-alcoholic steato-hepatitis (NASH) cirrhosis.Materials and methodsFifty patients with pathologically proven SAAH (SAAH group) who underwent CT or MRI examinations up to 30 days before or 15 days after liver biopsy between January 2008 and June 2018 were retrospectively included. There were 31 men and 29 women with a mean age of 52 ± 9 (SD) years (range: 33–67 years). Imaging features of the SAAH group were compared to those obtained in two control groups including 62 patients with alcoholic cirrhosis without acute alcoholic hepatitis (control group 1) and 19 patients with NASH cirrhosis (control group 2) by two independent radiologists blinded to the final diagnosis. Univariate analyses were performed to compare imaging characteristics between the three groups, followed by diagnostic performance analysis for the diagnosis of SAAH of the main CT features.ResultsHeterogeneous steatosis was significantly more frequent in SAAH group than in the control groups (41/50; 82% vs. 7/62; 10% and 1/19; 5% in control groups 1 and 2, respectively for reader 1 and 34/50; 68% vs. 8/62; 13% and 1/19; 5% in control groups 1 and 2, respectively for reader 2; both P = 0.01). Transient perfusion disorders were more frequent in SAAH group than in the control groups (35/50; 70% vs. 12/62; 21% and 5/19; 26% in control groups 1 and 2, respectively for reader 1 and 39/50; 78% vs. 14/62; 23% and 13/19; 6% in control groups 1 and 2, respectively for reader 2; both P = 0.01). The combination of these two findings yielded 100% specificity (45/45; 95% CI: 92–100) for readers 1 and 2 for the diagnosis of SAAH vs. alcoholic cirrhosis and NASH cirrhosis.ConclusionThe imaging features of SAAH are specific and mainly associate transient heterogeneous steatosis and liver perfusion disorders. CT/MRI may be useful to differentiate SAAH from alcoholic cirrhosis and NASH cirrhosis.     

Cohort study of the treatment of severe HIV-associated nephropathy with corticosteroids

BACKGROUND: Human immunodeficiency virus-associated nephropathy (HIVAN) results in rapidly progressive azotemia. The effectiveness and safety of corticosteroids in the treatment of HIVAN, however, remains controversial. METHODS: We conducted a retrospective cohort study of patients with biopsy-proven HIVAN and progressive azotemia who were eligible for corticosteroid treatment and who had no clinical or histologic evidence of an alternative cause of acute renal failure. Selected patients were treated with 60 mg of prednisone for one month, followed by a several-month taper. RESULTS: Twenty-one eligible patients were identified. Thirteen subjects had received corticosteroid treatment, whereas eight had not. The mean serum creatinine was 6.2 and 6.8 mg/dL, respectively (P > 0.05). The relative risk (95% CI) for progressive azotemia with corticosteroid treatment at three months was 0.20 (0.05, 0.76, P < 0.05). This association remained significant despite adjustment in separate logistical regression analyses for baseline creatinine, 24-hour proteinuria, CD4 count, history of intravenous drug use, hepatitis B, and hepatitis C. In an additional logistic regression model, using backward stepwise selection of the previously mentioned covariates, only corticosteroid treatment (P = 0.02) and baseline serum creatinine (P = 0.10) were retained within the model. In the corticosteroid-treated group, the mean level of proteinuria decreased by 5.5 g/24 hour (P = 0.01). On long-term follow-up, there was no significant difference in the incidence of hospitalizations (1 per 2.1 vs. 1 per 2.3 patient months) or of serious infections (1 per 2.6 vs. 1 per 2.3 patient months), but there was a significantly longer duration of hospitalization in the corticosteroid-treated group (3.2 vs. 2 days per patient month). At six months, only one of the non-corticosteroid-treated patients but seven of the corticosteroid-treated group continued to have independent renal function (P = 0.06). Three of the corticosteroid-treated group continued to have independent function at two years of follow-up. CONCLUSION: A limited course of corticosteroid therapy in selected patients was beneficial and safe. Further research is required for the role of corticosteroids in the treatment of HIVAN.     

自身免疫性肝炎后肝硬化伴脾功能亢进外科手术治疗体会

目的：探讨自身免疫性肝炎后肝硬化伴脾功能亢进行脾切除术的治疗效果。方法对自身免疫性肝炎后肝硬化伴脾功能亢进9例患者行脾切除术及贲门周围血管断流术。结果9例患者恢复良好,术后2周肝功能恢复到术前水平,手术前后转氨酶、胆红素变化差异无统计学意义（P＞0．05）,白细胞及血小板升至正常水平,较术前差异有统计学意义（P＜0．05）,脾功能亢进症状得到纠正,凝血功能较前明显好转,差异有统计学意义（P＜0．05）。术后随访12～18个月无一例再发消化道出血,行贲门周围血管离断术术后3个月复查胃镜提示食道静脉曲张较前好转。结论脾切除及贲门周围血管断流术是自身免疫性肝炎后肝硬化失代偿期的一项有效措施,对改善患者脾功能亢进、提高患者的凝血功能,减少出血有较明显的作用。     

人工肝支持系统联合肝移植治疗晚期重型肝炎的临床经验

目的总结人工肝支持系统 (artificialliversupportsystem ,ALSS)联合肝移植治疗晚期重型肝炎患者的临床经验。方法我院 1993年 4月至 2 0 0 3年 12月共实施 2 2 3例原位肝移植 ,其中 2 3例晚期重型肝炎患者在移植前共进行了 5 8例次的ALSS治疗 ,现就其临床诊治资料进行回顾性分析 ,并与常规内科治疗组、未施行肝移植的单纯ALSS治疗组疗效进行比较。结果ALSS治疗后患者临床症状好转 ,肝功能、内毒素等各项实验室指标显著改善 ,能维持的中位时间为 12d( 2～ 2 2 6d) ;2 3例患者实施肝移植 ,移植术前血清总胆红素 (TB)水平显著低于患者首次ALSS治疗前水平 (P <0 0 0 1) ;自首次ALSS治疗日计算 ,该组患者等待供肝的中位时间为 12d( 2～ 2 2 6d) ,本组晚期重型肝炎患者半年存活率达 73 9% ,显著高于常规内科治疗组和未施行肝移植的ALSS治疗组 (P <0 0 0 1)。结论ALSS能显著改善晚期重型肝炎病情 ,发挥顺利过渡到肝移植的桥梁作用     

Surgical treatment of severe forms of metabolic syndrome

The authors analyze the components of the metabolic syndrome in patients with morbid obesity treated at the surgical department. The effects of a modified operation of jejunal-ileal shunt on the components of the metabolic syndrome were shown in 220 patients operated upon at the clinic of Faculty surgery of the Pavlov Medical Academy in St. Petersburg. The indications to the operative treatment of the metabolic syndrome were substantiated on the basis of etiopathogenesis. The estimation of long-term results of the operation of jejunal-ileal shunt in patients with the metabolic syndrome is given.     

Usefulness of artificial liver support for pretransplant patients with fulminant hepatic failure

This study assessed the usefulness of artificial liver support (ALS) for pretransplant patients with fulminant hepatic failure (FHF). Five patients (age 14 to 52 years, 3 men and 2 women) with FHF who were being prepared for living donor liver transplantation (LDLTx) were enrolled in this study. ALS included plasma exchange, using 40 to 50 units of fresh frozen plasma per session, and high-flow hemodiafiltration, using a high-performance polysulfone membrane. Variables such as circulatory and respiratory function, coma grade, and neurologic disorders were evaluated. Although systolic and diastolic blood pressures showed no statistical differences between pre-ALS and post-ALS, the difference in heart rates was statistically significant. After ALS initiation in the pre-LDLTx period, one of the three patients who needed mechanical ventilation was weaned from it. After LDLTx, all patients recovered neurologically; no neurologic disorder was observed. These results suggested that ALS could predict neurologic status after LDLTx. The difference in coma grades also achieved statistical significance. Our study indicates that short-term ALS is useful for improving circulatory and respiratory function prior to liver transplantation, as well as for predicting posttransplantation neurologic status. Although some patients recover by ALS alone, the survival rate of ALS-only patients is less than 50%. ALS prolongs intensive treatment, thus increasing both the risk of infection and the medical costs. Further investigation to determine a precise marker for liver regeneration will be needed to establish a consensus on the indications for long-term ALS. We conclude that ALS is useful to improve circulatory and respiratory functions among pretransplant patients, and to predict neurologic status after LDLTx.     

Hemodialysis with a high permeability membrane in the treatment of encephalopathy of fulminant hepatitis

Twenty-nine patients with fulminant hepatic failure and at least grade III encephalopathy were treated by haemodialysis with a polyacrylonitrile membrane. Aetiology was toxic in five patients, viral in eleven (2 due to hepatitis A virus and 9 presumed due to hepatitis B virus), not found in thirteen. Each patient was dialysed for 4 h every day, until he regained consciousness or died. Conscious level was improved after dialysis in 59% of patients. Thirteen patients survived (44.8%) :4 toxic hepatitis, 4 viral hepatitis B, 1 viral hepatitis A, 4 hepatitis of unknown aetiology. A comparison of plasma concentrations of amino acids measured by chromatography before and after 113 periods of haemodialysis in 23 patients showed significant decrease in aromatic amino acids (p less than 0.001), a significant increase in two branched-chain amino acids :leucine (p less than 0.001) and isoleucine (p less than 0.001), and a significant increase in Fischer's ratio (p less than 0.001). In survivors, factor V concentration on admission and Fischer's ratio on admission were significantly higher than in those who died (p less than 0.02 for both), but there was no significant difference in the difference between Fischer's ratio before and after haemodialysis. Haemodialysis was well tolerated, except for short periods of hypotension and a small but significant fall in platelet counts. Improvement in cerebral function during haemodialysis was previously demonstrated by various authors, but the effect on survival rate remained controversial. The survival rate obtained in this controlled study is clearly higher than those obtained by conservative management alone.     

肝脏移植治疗自身免疫性肝炎2例报告并文献复习

探讨肝脏移植治疗终末期自身免疫性肝炎(autoimmune hepatitis,AIH)的疗效.方法 对2例AIH肝硬化患者行肝脏移植手术(1例行经典原位肝脏移植术,1例行背驮式肝脏移植术),其中1例患者术中同时行脾切除术.术后应用他克莫司+麦考酚吗乙酯+甲泼尼龙三联免疫抑制方案治疗.结果 2例手术顺利,行脾切除术的患者术后19 d肠系膜上静脉血栓形成,给予抗凝、溶栓等治疗1周后缓解.2例患者术后均未出现排斥反应及其它并发症,出院时肝功能恢复正常,抗核抗体(ANA)转阴.随访至投稿日,两例已分别健康存活68个月及20个月,没有复发表现.结论 肝移植术可作为治疗终末期AIH的有效手段,并可获得良好的长期效果.     

Assessing the eligibility for liver transplantation of patients with fulminant hepatitis

The spleen to liver volume (S/L) ratio of 13 patients with fulminant hepatitis was determined using X-ray computed tomography (CT), and the correlation between S/L ratio and prognosis was evaluated. The S/L ratio of 6 patients who died was greater than 0.16, whereas that of the remaining 7 patients who survived was less than 0.15. These findings suggest that determining the S/L ratio using CT may be useful for assessing the eligibility of patients with fulminant hepatitis for liver transplantation.