Acute and chronic renal failure in liver transplantation

We have performed a retrospective review of the incidence and etiologies of acute renal failure (ARF) in 105 adult patients receiving liver transplants. The prevalence of chronic renal failure was also determined. ARF occurred in 94.2% of these patients. Acute tubular necrosis was the leading cause of ARF and was associated with the highest mortality. Factors associated with increased mortality included: (1) peak serum creatinine greater than 3 mg/dl, (2) multiple liver transplants and (3) the need for dialysis. Pretransplant renal failure did not increase mortality. Chronic renal failure developed in 83% of patients at latest follow-up (mean: 30.5 +/- 7.9 months).     

Partial hepatic resection under intermittent hepatic inflow occlusion in patients with chronic liver disease.

A partial hepatic resection was performed in 13 patients with chronic liver disease using intermittent hepatic inflow occlusion. Eleven patients had liver cirrhosis and two had chronic hepatitis. Seven patients were classified as Child's grade A and six as Child's grade B before operation. Dissection of the hepatic parenchyma was performed during intermittent inflow occlusion. The time of clamping and declamping was 10-20 min and 5-8 min, respectively. Postoperative data on liver function showed recovery to preoperative levels by about 10 days after operation. There were no life-threatening complications. These results indicate that intermittent hepatic inflow occlusion can be achieved easily and safely to allow non-anatomical resection in patients with chronic liver disease.     

Acute fulminant hepatic failure

Fulminant hepatic failure is the rapid onset of life-threatening hepatic decompensation in patients who have no previous history of liver disease. This condition has a multifactorial etiology, including viral hepatitis and drug toxicity. At this time there is no specific therapy for FHF. However, early diagnosis and treatment of the complications--in particular, cerebral edema--may prolong survival and prevent irreversible neurologic complications. Once the diagnosis has been made, patients with FHF should promptly be transferred to a specialized liver care unit where liver transplantation is available. Liver transplantation is now the treatment of choice for patients with clinical characteristics suggesting a poor chance of survival.     

Terbinafine-induced hepatic failure requiring liver transplantation.

Drug-induced liver disease accounts for about 50% of acute or subacute liver failure in the United States. United Network of Organ Sharing (UNOS) data suggest 8%-20% of liver transplantation in this country per year is for fulminant liver failure due to drugs. Even though the most common medication implicated in acute liver injury is acetaminophen (75%), there are numerous other drugs that are responsible for acute and chronic liver injury. A variety of antifungal medications are known to cause a wide range of liver injury from a mild hepatocellular-cholestatic injury pattern to acute/subacute liver failure. Terbinafine is one of the antifungals that have been associated with such liver injuries. We report a case of terbinafine-induced severe liver failure requiring liver transplantation.     

Acute liver failure

Acute liver failure (ALF) is a rare but life-threatening disease with varying aetiologies worldwide. Drug-induced liver injury, including paracetamol poisoning, is the main cause in Europe and the USA. Whereas in the developing world, viral hepatitis is most common. ALF is a multisystem illness that leads to development of hepatic encephalopathy, cerebral oedema, vasodilatory shock, coagulopathy, hypoglycaemia and multiple-organ failure. Early referral to a specialist liver unit is essential. The core principles of ALF management are to identify/treat the underlying cause, provide supportive care and treat any complications. Optimal management will allow time for spontaneous liver regeneration or liver transplantation, and result in improved survival rates. This article provides an overview of the key concepts in ALF diagnosis and management.     

Acute liver failure

Worldwide, viral infection is responsible for the majority of cases of acute liver failure, and the presence of co-existing chronic viral hepatitis may increase its severity. The newly described hepatotrophic viruses, hepatitis G virus and transfusion-transmitted virus, are unlikely to be major aetiological agents. In the USA and western Europe drug-induced hepatotoxicity is the most common cause, and most frequently results from acetaminophen. Hepatotoxicity caused by Ecstasy is increasingly important, particularly in young adults. Hepatic encephalopathy and cerebral oedema remain important and life-threatening complications, and their pathogenesis is not completely understood. The effects of the cerebral metabolism of the high levels of ammonia that circulate in hepatic failure appear to be important. Induced hypothermia is a promising modality of treatment for refractory cerebral oedema, but the only form of treatment known to improve survival is emergency liver transplantation. Living donor and auxiliary liver transplantation are likely to improve survival rates further and reduce the number of patients requiring long-term post-transplant immunosuppression.     

Acute liver failure

Acute liver failure involves disturbances of all major organ systems. The pathophysiology of these disturbances are reviewed and details of management for each system is discussed in clinical work in a special Liver Failure Unit is used to derive principles of treatment, and the use of extracorporeal charcoal haemoperfusion is outlined.     

Acute liver failure

Acute liver failure (ALF) is a life-threatening condition with many possible causes. In developed countries, common causes include paracetamol overdose, toxin exposure (e.g. mushrooms) and idiosyncratic drug reactions. Viral hepatitis is much more common in developing countries, although must be considered in any location. The clinical syndrome of ALF is remarkably independent of the cause and comprises the following key features: jaundice, encephalopathy with cerebral oedema, coagulopathy, vasodilatory state, renal dysfunction, hypoglycaemia and immune dysfunction. Management of the patient with severe ALF is threefold in aim: (i) prevent further liver damage by treating the underlying cause of ALF where possible; (ii) prevent and treat complications of ALF (e.g. cerebral oedema, shock and infection); and (iii) early referral to specialist centre for consideration of liver transplantation. Despite modern intensive care practices, the mortality of severe ALF remains high. Optimal supportive care aims to extend the period available to source an organ for transplantation and/or to allow full recovery. This article provides a practical approach to the diagnosis and management of critically ill patients with ALF.     

Acute phase response after liver transplantation for fulminant hepatic failure and cirrhosis

The hepatic acute phase response after orthotopic transplantation (OLT) was studied in patients with fulminant hepatic failure (FHF) and with cirrhosis, in relation to the pre-existing disease. Plasma levels of C-reactive protein (CRP) increased significantly on day 1 after OLT in both the FHF (=58 /ml) and cirrhosis (=94 /ml) groups and reached a peak 4–5 days post surgery. ₁-Antitrypsin reached normal levels on day 1 post-transplant and fibrinogen reached normal levels on the 3rd day. The main stimulator of acute phase protein synthesis IL-6 was significantly increased pre-OLT in plasma in both FHF (median 54 pg/ml) and cirrhosis (median 8.7 pg/ml) patients compared to controls (2.35 pg/ml, P<0.05). After OLT, IL-6 decreased rapidly in patients with FHF, indicating either removal of the source of IL-6 or clearance by the transplanted liver. In patients with cirrhosis, plasma IL-6 remained low, except in three patients who developed infection/rejection and whose IL-6 levels rose above 100 pg/ml. In conclusion, there is a marked acute phase response in the liver graft after transplantation, irrespective of the aetiology of the liver disease for which the transplant was performed.     

急性肝功能衰竭患者肝移植术后急性肾功能衰竭的病因分析及综合治疗

目的 分析急性肝功能衰竭(acute liver failure,ALF)患者肝移植术后肾功能衰竭的原因,评价以持续肾脏替代治疗(continuous renal replacement therapy,CRRT)为基础的综合疗法的疗效.方法 回顾性分析2001年1月至2006年6月在我院施行的412例肝移植资料,根据UNOS肝功能分级标准筛选出54例ALF患者(UNOS1和2A),其中17例移植术后出现急性肾功能衰竭(acute renal failure,ARF).在CRRT治疗基础上,进行抗排斥、抗感染、营养支持等治疗,并对患者围手术期情况、术后并发症、死亡原因及随访结果进行了分析.结果 CRRT治疗过程中无并发症发生.无ARF组围手术期死亡率为5.4%,术后并发症发生率为35.1%,1、3年生存率分别为89.2%和81.1%.ARF组围手术期死亡率为58.8%,术后并发症发生率为100%,1、3年生存率分别为41.2%和41.2%.结论 肝移植效果主要取决于肝外器官功能和术前肝功能状态.ALF患者围手术期死亡率较高,其中术前血肌酐高术后出现ARF率高,死亡率更高.以CRRT为基础的综合疗法能有效治疗ARF患者.