Coagulation Studies as a Prognostic Index in Acute Liver Failure

A coagulation screen has been performed on 12 patients with acute liver failure. Six died and six recovered. All six fatal cases developed a haemorrhagic state with haemostatic failure. An attempt has been made to delineate the various mechanisms for the production of the coagulation defect. The significance of the different haematological parameters in assessing prognosis has been assessed. The study emphasizes the importance of the synthetic ability of the liver in determining survival prospects. A good correlation between the factor-VII level, which is a guide to liver synthesis, and recovery has been shown. The value of a specific factor-VII assay in acute liver failure appears considerable. Where this assay cannot be performed the clot opacity fibrinogen technique provides a reasonable guide to the prognosis. The presence or absence of DIC was not a determinant factor in survival in this series.     

Acute Liver Failure in Pregnancy: Causative and Prognostic Factors

Background/Aims:

Acute liver failure (ALF) in pregnancy is often associated with a poor prognosis. In this single-center observational study we aim to study the incidence, causes, and factors affecting mortality in pregnant women with ALF.

Patients and Methods:

Sixty-eight pregnant women reporting with clinical features of liver dysfunction were enrolled as cases. Their clinical course was followed and laboratory studies were performed. The presence of ALF was defined as the appearance of encephalopathy. The results were compared with a control group of 16 nonpregnant women presenting with similar complaints. The cases were further subdivided into two groups of survivors and nonsurvivors and were compared to find out the factors that contribute to mortality.

Results:

ALF was seen in significantly more number of pregnant women than the controls (P = 0.0019). The mortality rate was also significantly higher (P = 0.0287). Hepatitis E virus (HEV) caused jaundice in a higher number of pregnant women (P < 0.001). It also caused ALF in majority (70.3%) of pregnant women, but HEV infection was comparable between the survivors and nonsurvivors (P = 0.0668), hence could not be correlated with mortality.

Conclusions:

Pregnant women appear to be more susceptible for HEV infection and development of ALF. The mortality of jaundiced pregnant women increased significantly with appearance of ALF, higher bilirubin, lower platelet count, higher international normalized ratio, and spontaneous delivery.     

10 Comparison of Four Prognostic Indexes in Severe Acute Renal Failure

Background Several prognostic indexes and models are in use for acute renal failure (ARF) patients in intensive care units (ICU). Some were designed on general ICU populations (like APACHE II) and some were made specifically for ICU patients with ARF. The purpose of our prospective clinical study was to compare APACHE II and three ARF‐specific prognostic indexes in their ability to discriminate survivors and non‐survivors among critically ill ARF patients requiring dialysis. Methods Forty‐four critically ill patients with ARF requiring dialysis were included. Patients with chronic renal insufficiency (creatinine > 200 µmol/L), transplanted kidney or urinary tract obstruction were excluded. Four prognostic indexes were measured at the time of first dialysis: APACHE II score (0–71), Cleveland Clinic Foundation (CCF) score (0–20), predicted mortality by Mehta and by Liano model. Primary end‐points were ICU survival and recovery of renal function. Results Patients were 65 ± 5 years old, 75% were male, 50% recovered renal function (22/44). Mean APACHE II score was 21.9 ± 6.5, CCF score was 9.2 ± 2.5, predicted mortality by Mehta model was 64 ± 5% and by Liano model 47 ± 20%. Patients that recovered renal function and those that died in ARF did not differ significantly in any of the prognostic indexes measured. Intensive Care Unit survival data was available for 32 patients, this group was not significantly different in prognostic indexes from the group for which ICU survival data was not available. Intensive Care Unit mortality was 75% (24/32). There was significant difference in APACHE II value in ICU survivors and non‐survivors (16.6 ± 6.1 vs. 23.4 ± 6.5, P = 0.015), but no difference in the other three indexes. Conclusions Only the APACHE II values measured at first dialysis were significantly different between ICU survivors and non‐survivors, whereas other three prognostic indexes were not.     

Hypothermia in Acute Liver Failure

The development of encephalopathy in patients with acute liver injury defines the occurrence of liver failure. The encephalopathy of acute liver failure is characterized by brain edema which manifests clinically as increased intracranial pressure. Despite the best available medical therapies a significant proportion of patients with acute liver failure die due to brain herniation. The present review explores the experimental and clinical data to define the role of hypothermia as a treatment modality for increased intracranial pressure in patients with acute liver failure.     

Treatment of Acute Liver Failure

Metabolic Brain Disease -     

Prognostic Value of Abdominal CT Scanning and Hepatic Histopathology in Patients with Acute Liver Failure

Acute liver failure has extremely high mortality without liver transplantation. We attempted to determine the value of abdominal CT scanning and liver biopsy in its management. A retrospective analysis of patients with acute liver failure was performed; demographic, clinical, radiologic and histopathologic features were noted. Over a period of 13 years, 177 patients were evaluated. The mean age was 39 years and 63% were females. The patients were divided into three groups. Fourteen percent survived with medical management (group I), 37% died (group II), and 49% had liver transplantation (group III). Most patients showed diffuse low density of the liver on CT scanning and the proportions were similar in the three groups. Moderate to large ascites was not present in group I but occurred in 31% of patients in group II and in 15% in group III. Mean hepatic volumes were similar in the three groups; however, 97% of the patients with a liver volume of less than 1000 ml either died or required liver transplantation. Liver biopsies among patients with spontaneous recovery (group I) were distinguished by the presence of regenerative changes and a hepatic parenchymal necrosis of less than 50%. These results suggest that in patients with acute liver failure a liver volume of less than 1000 ml and/or hepatic parenchymal necrosis of greater than 50% is indicative of a poor prognosis. This information may assist decision making in such patients, in particular, regarding the need for liver transplantation.     

Validation of Various Prediction Scores for Cardiac Surgery-Associated Acute Kidney Injury

Background and objectivesFollowing cardiac surgery, acute kidney injury (AKI) is a well-known complication that increases morbidity and mortality. This study was carried out to determine the factors associated with acute kidney injury and to assess the predictive value of three predictive scores for the development of AKI post-cardiac surgery in the Saudi community.MethodsIn this retrospective study, the medical records of patients aged 18 years and above who underwent cardiac surgery on cardiopulmonary bypass (CPB) at Saud Albabtin Cardiac Center between January 2018 and March 2021 were reviewed. The first stage of both Kidney Disease Improving Global Outcomes (KDIGO) criteria and the risk, injury, failure, loss, end-stage (RIFLE) criteria were used to define AKI. The predicting value for acute kidney injury following cardiac surgery (AKICS score) and Renal replacement therapy for acute kidney injury (RRT-AKI) (Cleveland score, and SRI) were evaluated by area under receiver operating characteristic curve (AUROC) for the discrimination and Hosmer–Lemeshow test for the calibration.ResultsAmong the 329 patients evaluated, the total postoperative incidence of acute kidney injury was 26.4%. Moreover, the incidence of RRT-AKI was 2.1%. Using multivariate logistic analysis, the factors independently associated with AKI were CABG on pump-beating heart, presence of chronic kidney disease, pre-operative anemia, prolonged bypass time, and post-operative exposure to inotropes or vasopressors. For the prediction of CSA-AKI, the discrimination of AKICS (AUROC = 0.689) was poor, while the calibration (x2 = 9.380, P = 0.311) was fair. For RRT-AKI prediction, the discrimination of Cleveland score (AUROC = 0.717) was fair while the discrimination of SRI (AUROC = 0. 681) was poor. On the other hand, the calibration for both of them was fair (Cleveland score x2 = 3.339, P = 0.342; SRI x2 = 7.326, P = 0.120).ConclusionIn this single-center study, SRI score demonstrated a reasonably good prediction of RRT-AKI incidence. However, further researches are required to investigate the perioperative factors in order to create a unique risk score model that may be used in a population with widespread comorbidities.