A qualitative study exploring patients perceived quality of life following an emergency liver transplant for acute liver failure.

Liver transplantation is now an accepted and successful therapy for both acute and chronic liver diseases. Whilst the study of health related quality of life (HRQoL) post-transplantation for chronic liver disease (CLD) has been well documented, there is little data measuring HRQoL following liver transplantation for acute liver failure (ALF), despite super urgent transplantation constituting 16.6% of all United Kingdom liver transplantation. Therefore, the aim of the present study was to document the HRQoL in patients who have received an emergency liver transplant for ALF. Data collection employed between method triangulation, using the Short Form 36 quality of life health questionnaire for both ALF (n=47) and CLD (n=49), and six semi-structured interviews. Only the qualitative element of the study is reported here. Phenomenological analysis of the semi-structured interviews identified four themes relating to the physical changes encountered (inactivity), physical recovery (health transition); changes made to the transplant recipients life styles (modification); and outlook. The majority of transplanted ALF transplant recipients' stated that they have a good quality of life, which was often comparable to their pretransplantation lifestyle. However, the initial recovery process was often difficult and was related to the physical changes instigated from their multi-organ failure and intensive care stay, which can present numerous physical and emotional challenges.     

The treatment of acute liver failure with fractionated plasma separation and adsorption system: Experience in 85 applications

Introduction: Artificial liver support systems represent a potential useful option for the treatment of liver failure. The outcomes of patients treated with the fractionated plasma separation and adsorption (FPSA) system are presented. Patients and methods: FPSA was performed 85 times for 27 patients (median 3 treatments/patient) with liver failure [85.2% acute liver failure (ALF) and 14.8% acute‐on‐chronic liver failure] using the Prometheus 4008H (Fresenius Medical Care) unit. Citrate was used for anticoagulation. A variety of clinical and biochemical parameters were assessed. Comparisons between pretreatment and post‐treatment data were performed using paired t‐test. Results: The 85 sessions had a mean duration of 6 h. There were significant decreases in total bilirubin (13.18 ± 9.46 mg/dL vs. 9.76 ± 7.05 mg/dL; P < 0.0001), ammonia (167.6 ± 75 mg/dL vs. 120 ± 43.8 mg/dL; P < 0.0001), blood urea nitrogen (BUN; 12.55 ± 13.03 mg/dL vs. 8.18 ± 8.15 mg/dL; P < 0.0001), creatinine (0.54 ± 0.47 mg/dL vs. 0.46 ± 0.37 mg/dL; P = 0.0022) levels, and in pH (7.48 ± 0.05 vs. 7.44 ± 0.08; P = 0.0045). Four patients (14.8%) received liver transplantation after the treatments; in nine patients, transplantation was not necessary anymore (33%); the remaining 14 patients did not receive a transplantation because they were either not appropriate candidates or no organ was available. Overall survival was 48.1% (4 transplanted and 9 treated patients). No hematological complications related to FPSA were observed. Conclusions: FPSA system is a safe and effective detoxification method for patients with liver dysfunction, including ALF. The system is useful as a symptomatic treatment before liver transplantation; in up to 1/3 of the cases, it can even be used as a sole method of treatment. J. Clin. Apheresis 25:195–201, 2010. © 2010 Wiley‐Liss, Inc.     

Prognostic factors and treatment effect of standard-volume plasma exchange for acute and acute-on-chronic liver failure: A single-center retrospective study

Patients with acute liver failure (ALF) and acute-on-chronic liver failure (ACLF) have a high risk of mortality. Few studies have reported prognostic factors for patients receiving plasma exchange (PE) for liver support. We conducted a retrospective analysis using data of 55 patients with severe ACLF (n?=?45) and ALF (n?=?10) who received standard-volume PE (1–1.5 plasma volume) in the ICU. Hepatitis B virus infection accounts for the majority of ACLF (87%) and ALF (50%) patients. PE significantly improved the levels of total bilirubin, prothrombin time and liver enzymes (P<0.05). Thirteen ACLF patients (29%) and one ALF patient (10%) underwent liver transplantation. Two ALF patients (20%) recovered spontaneously without transplantation. The overall in-hospital survival rates for ACLF and ALF patients were 24% and 30%, and the transplant-free survival rates were 0% and 20%, respectively. For the 14 transplanted patients, the one-year survival rate was 86%. Multivariate analysis showed that pre-PE hemoglobin (P?=?0.008), post-PE hemoglobin (P?=?0.039), and post-PE CLIF-C ACLF scores (P?=?0.061) were independent predictors of survival in ACLF. The post-PE CLIF-C ACLF scores ≥59 were a discriminator predicting the in-hospital mortality (area under the curve?=?0.719, P?=?0.030). Cumulative survival rates differed significantly between patients with CLIF-C ACLF scores ≤ 58 and those with CLIF-C ACLF scores ≥ 59 after PE (P< 0.05). The findings suggest that PE is mainly a bridge for liver transplantation and spontaneous recovery is exceptional even in patients treated with PE. A higher improvement in the post-PE CLIF-C ACLF score is associated with a superior in-hospital survival rate.     

Intact thrombin generation and decreased fibrinolytic capacity in patients with acute liver injury or acute liver failure

Summary. Background: It has been well established that hemostatic potential in patients with chronic liver disease is in a rebalanced status due to a concomitant decrease in pro‐ and antihemostatic drivers. The hemostatic changes in patients with acute liver injury/failure (ALI/ALF) are similar but not identical to the changes in patients with chronic liver disease and have not been studied in great detail. Objective: To assess thrombin generation and fibrinolytic potential in patients with ALI/ALF. Methods: We performed thrombin generation tests and clot lysis assays in platelet‐poor plasma from 50 patients with ALI/ALF. Results were compared with values obtained in plasma from 40 healthy volunteers. Results and conclusion: The thrombin generation capacity of plasma from patients with ALI/ALF sampled on the day of admission to hospital was indistinguishable from that of healthy controls, provided thrombomodulin was added to the test mixture. Fibrinolytic capacity was profoundly impaired in patients with ALI/ALF on admission (no lysis in 73.5% of patients, compared with 2.5% of the healthy controls), which was associated with decreased levels of the plasminogen and increased levels of plasminogen activator inhibitor type 1. The intact thrombin generating capacity and the hypofibrinolytic status persisted during the first week of admission. Patients with ALI/ALF have a normal thrombin generating capacity and a decreased capacity to remove fibrin clots. These results contrast with routine laboratory tests such as the PT/INR, which are by definition prolonged in patients with ALI/ALF and suggest a bleeding tendency.     

Managing patients with acute liver failure: developing a tool for practitioners

Patients with acute liver failure (ALF) are treated on the general intensive care unit (ICU) within this regional centre for hepatology and liver transplantation. This group of patients are at high risk of developing cerebral oedema, but because of the associated coagulopathy, intracranial pressure is not measured invasively. The safe management of these patients is vital to their outcome, and yet, there is no national or local guidance on the best practice for this group of patients. An absence of guidelines, or evidence base specific to caring for hepatology patients, was highlighted as we reviewed local clinical practices and those at other liver specialty centres, the British Liver Trust and published literature. We identified a need to develop evidence-based guidance for staff caring for patients with ALF within ICUs. A systematic approach enabled us to identify best practice to support the development of a structured evidence-based approach to care.     

肝移植治疗重型肝炎/肝衰竭的手术时机

肝移植已成为治疗各种原因所致的急慢性肝功能衰竭患者的一种有效治疗手段,但是关于重型肝炎/肝衰竭肝移植治疗的手术时机选择问题,目前国内外尚无统一标准。本文旨在通过总结国内外肝移植治疗肝衰竭的相关文献,结合我中心肝移植治疗重型肝炎/肝衰竭的经验,探讨肝移植治疗重型肝炎/肝衰竭的手术时机。     

Acute liver failure: A review for emergency physicians

Introduction

Acute liver failure (ALF) remains a high-risk clinical presentation, and many patients require emergency department (ED) management for complications and stabilization.

Successful treatment of drug‐induced acute liver failure with high‐volume plasma exchange

We report two patients with drug‐induced liver injury (DILI)‐related acute liver failure (ALF) who were successfully treated with high‐volume plasma exchange without liver transplantation. The first patient was a 66‐year‐old man admitted because of a perforated duodenal ulcer complicated with peritonitis and septic shock. After treatment with multiple antibiotics, the patient developed DILI and ALF. Grade 3 hepatic encephalopathy and profound jaundice were present. Symptoms and signs of ALF improved dramatically after initiation of plasma exchange. The patient was discharged uneventfully. The second patient was a 94‐year‐old man admitted for treatment of newly diagnosed pulmonary tuberculosis. DILI and ALF developed 5 days after initiation of anti‐tuberculosis treatment. Grade 4 hepatic encephalopathy was present. After plasma exchange, the patient's level of consciousness improved dramatically, and he recovered from ALF. These 2 cases show the potential of plasma exchange in the treatment of DILI despite occurrence acute liver failure. J. Clin. Apheresis, 28:430–434, 2013. © 2013 Wiley Periodicals, Inc.     

Definition and classification of acute-on-chronic liver diseases

Patients with chronic liver diseases (CLDs) develop acute liver injury and/or acute decompensation under the attack of various precipitants and present with significantly elevated alanine aminotransferase and/or total bilirubin levels, liver failure, or acute decompensation of liver cirrhosis, which is called acute-on-CLD (AoCLD). AoCLD accounts for the majority of patients hospitalized in the Department of Hepatology or Infectious Diseases. AoCLD is complicated by various clinical types, the severity of the disease, and may pose a high risk of death. To date, the definition of AoCLD is still vague, and a consensus concept of the clinical classification is lacking. This review aimed to define the concept and clinical types of AoCLD based on related studies and the literature.     

Fatigue, level of everyday physical activity and quality of life after liver transplantation.

OBJECTIVE: To assess whether liver transplant recipients have a hypoactive (sedentary) lifestyle and whether the level of everyday physical activity is related to complaints of fatigue. In addition, we explored the relationship between activity level and health-related quality of life. DESIGN: Case comparison. SUBJECTS: Eight persons 6-36 months after liver transplantation with varying severity of fatigue and 8 persons without known impairments (matched for gender, age, social situation and employment). METHODS: Activity levels were assessed during 2 randomly selected consecutive weekdays with an accelerometry-based Activity Monitor. In the transplantation group, severity of fatigue (Fatigue Severity Scale) and health-related quality of life (RAND-36) were also assessed. RESULTS: Five liver transplant recipients had a hypoactive lifestyle, but there was no significant difference in activity level between the transplantation group and comparison group. Severity of fatigue was correlated (p=0.01) with both duration of dynamic activities and intensity of everyday activity (r(s)=-0.81 and -0.84, respectively). Activity level was correlated (p< or =0.05) with several domains of health-related quality of life (r(s)=0.72-0.78). CONCLUSION: As a group, liver transplant recipients were not significantly less active than comparison subjects. Activity level was related with severity of fatigue and health-related quality of life. These findings have implications for the development of interventions needed to rehabilitate persons after liver transplantation.     

Liver and intestinal lactate metabolism in patients with acute hepatic failure undergoing liver transplantation.

OBJECTIVE: To determine the relative contribution of the gastrointestinal tract and the liver in lactate metabolism in patients with acute liver failure (ALF) and the effect of liver transplantation on this. We hypothesized that the liver and gut are net producers of lactate in ALF and that this is reversed after liver transplantation. SETTING: A university-affiliated specialist liver transplant operating theater. SUBJECTS: Eleven patients with ALF undergoing liver transplantation. MEASUREMENTS AND INTERVENTIONS: After ethical approval, 11 patients with ALF listed for orthotopic hepatic transplantation were studied. Whole blood was analyzed for lactate concentration from radial artery (RA) catheter, portal vein (PV), and hepatic vein (HV) during the dissection phase and was repeated postreperfusion of the liver graft. Gradients across the gut and the liver were calculated to see if there was net production or consumption. RESULTS: HV lactate was significantly higher than arterial (p =.028) in patients with ALF before liver transplantation, suggesting splanchnic production of lactate. Total splanchnic lactate gradient (HV-RA) is positive in ALF. Both the gut (PV-RA) and the liver (HV-PV) were net producers of lactate. After liver transplantation, hepatic venous lactate falls below arterial levels but not significantly. The gradient across the gut (PV-RA) remained positive, but the transhepatic gradient (HV-PV) became significantly negative, showing consumption by the graft (p =.021). The magnitude of lactate consumption after transplantation correlated positively with portal venous lactate concentration (p =.029) and inversely with graft cold ischemic time (p =.007). CONCLUSION: The liver is a net producer of lactate in patients with ALF and an elevated whole blood lactate. After liver transplantation, the graft becomes a consumer of lactate as shown by the negative lactate gradient. The degree of consumption is dependent on portal venous lactate concentration and cold ischemic time.     

Effects of a rehabilitation programme on daily functioning,participation, health-related quality of life,anxiety and depression in liver transplant recipients

Purpose.?Fatigue is a chronic problem in liver transplant recipients and may influence daily functioning and health-related quality of life (HRQoL). This study aimed to evaluate the effects of a fatigue-reducing physical rehabilitation programme on daily functioning, participation, HRQoL, anxiety and depression among liver transplant recipients.

Method.?Eighteen fatigued liver transplant recipients (mean age 51 years, 10 men/8 women) participated in a 12-week rehabilitation programme, which included supervised exercise training and daily physical activity counselling. We assessed pre- and post-programme health-related daily functioning, participation, HRQoL, anxiety and depression using questionnaires.

Results.?After the programme, patients showed improvements in daily functioning (23.6%, p?=?0.007), the participation domain ‘autonomy outdoors’ (34.1%, p?=?0.001), and the HRQoL domains ‘physical functioning’ (11.5%, p?=?0.007) and ‘vitality’ (21.5%, p?=?0.022). Anxiety and depression were unchanged post-programme.

Conclusions.?Rehabilitation using supervised exercise training and daily physical activity counselling can positively influence daily functioning, participation and HRQoL among fatigued liver transplant recipients.     

肝移植受者术后抑郁状况及影响因素的调查

目的探讨肝移植受者术后抑郁状态及影响因素。方法采用一般情况调查表、抑郁自评量表（self—ratingdepressionscale,SDS）和社会支持评定量表对42例肝移植受者在术后1个月、6个月、1年、2年和3年进行调查。结果肝移植受者术后时间越长其抑郁状态越轻,年龄和主观支持是影响肝移植受者术后抑郁状况的主要因素。结论临床和社区护理人员要注重肝移植受者术后心理状态,及时提供心理护理,充分调动肝移植受者的社会支持,以改善其抑郁状况。     

肝移植受者症状经历与生存质量的相关性研究

目的了解肝移植受者在术后长期生存过程中的生存质量及其症状经历情况,探索症状经历与生存质量的相关性,为临床加强移植术后受者的随访管理,提高受者生存质量提供依据。方法对1999-2008年在四川大学华西医院肝移植中心接受原位肝移植手术的137例移植受者通过问卷方式调查其生存质量及症状经历情况。结果肝移植受者日常承受的症状平均达17种,其中疲倦乏力、失眠、情绪问题、头昏头痛、腹胀、腹泻等是最常见的不适症状,困扰着半数以上的受者。与一般人群相比,移植受者生存质量显著降低(P0.01)。多元回归分析显示,受者的症状经历、移植术后生存时间、家庭收入、社会支持情况是其生存质量的主要影响因素,其中受者的症状经历对其生存质量的影响尤为突出。结论肝移植受者在术后长期存活过程中承受着复杂的症状经历,关注受者的症状并提供积极有效的干预应是移植术后随访护理的重要内容。     

Evaluation of plasma ammonia levels in patients with acute liver failure and chronic liver disease and its correlation with the severity of hepatic encephalopathy and clinical features of raised intracranial tension

OBJECTIVES: The present study was designed to (a) evaluate and compare plasma ammonia levels (PAL) in patients with acute liver failure (ALF) and chronic liver disease (CLD) with or without hepatic encephalopathy (HE); (b) correlate the severity of HE with PAL; and (c) correlate PAL with clinical features of raised intracranial tension in ALF. DESIGN AND METHODS: A total of 40 patients, comprised of 20 patients with ALF (Group A) and 20 patients with CLD (Group B, which was comprised of 8 patients with HE (subgroup B1) and 12 patients without HE (subgroup B2)), were studied. PAL was estimated using an enzymatic UV-method (RANDOX). The clinical and biochemical profile of all the patients was recorded. Correlation between the grade of HE and PAL was derived using Pearson's correlation coefficient. The mean PAL of ALF patients with and without raised intracranial tension was compared using the standard error of difference between the two means. RESULTS: The mean PAL (micromol/L) +/- SD was as follows: Group A: 172.1 +/- 52.55, subgroup B1: 58.75 +/- 29.38, subgroup B2: 42.17 +/- 18.19 (normal levels = 10-47 micromol/L). All patients with ALF showed PAL more than the upper limit of the normal range, and there was good correlation between the severity of HE and PAL [r = 0.91 at P < 0.05]. In subgroup B1 (CLD with HE), 3/8 patients (37.5%), and in subgroup B2 (CLD with HE), 4/12 patients (33.3%) patients had PAL more than the upper limit of normal range. Within Group A, 14 patients had clinical features of raised intracranial tension/cerebral edema, and the mean PAL of these patients (188.21 +/- 49.15 micromol/L) was significantly higher than those who did not have features of raised intracranial tension (134.5 +/- 42.36 micromol/L) (SE of difference between two means). CONCLUSIONS: Raised PAL appears to be an important laboratory abnormality seen in patients with ALF, and there seems to be a significant correlation between the severity of encephalopathy and PAL in these patients. However, among patients with CLD, the proportion of patients with PAL more than the upper limit of normal range is not significantly different between those with or without HE. Our study also suggests that high PAL in ALF patients appears to correlate with clinical features of cerebral edema and raised intracranial tension.     

Changes in health-related quality of life following percutaneous coronary intervention: a longitudinal study

BACKGROUND: Coronary artery disease (CAD) is a major cause of mortality and morbidity in developed countries. The percutaneous coronary intervention (PCI) is a frequently used treatment for CAD. In order to manage the disease more effectively and to promote the health-related quality of life (HRQoL) of these patients, understanding the current status of HRQoL before and after PCI procedure is essential. OBJECTIVES: This study was to examine the changes of HRQoL from before PCI to the first 3 months after PCI on Hong Kong Chinese. DESIGN: A longitudinal, one-group observational design was used. SETTING: Data collected from cardiac patients admitted into a regional public hospital at Hong Kong Island for PCI. PARTICIPANTS: Between August 2003 and February 2004, all patients admitted for non-emergency PCI at the study site and met the inclusion criteria were invited to take part in the study. Seventy-eight out of 85 eligible patients agreed to participate. However, 13 patients dropped out during data collection period. METHODS: HRQoL data using the Medical Outcomes Study 36-Item Short Form 36 (SF-36) and Seattle Angina Questionnaire (SAQ) were collected before PCI, 1 and 3 months after PCI. RESULTS: Sixty-five patents completed the study. All domains in SF-36 and SAQ improved at 1 month but the improvements did not continue in all domains at 3 months. The HRQoL measured by SF-36 improved significantly over time (p<0.05) for six out of the eight domains. Scores of all domains of SF-36 improved at 3 months when compared with baseline. Moreover, all five domains of SAQ changed significantly over time (p<0.05); however, the score of angina stability at the third month was lower than that at baseline. CONCLUSIONS: The results of this study quantify the benefits of PCI procedure on HRQoL of patients. Although PCI improved the HRQoL 1 month after PCI, the effect did not last long. Nursing interventions are needed to maintain and further enhance the HRQoL of these patients and the interventions should be introduced immediately post-PCI.     

The predictive value of four scoring systems in liver transplant recipients

Objective To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failre score. Design Retrospective, consecutive sample. Setting Adult intensive care unit in a university hospital. Patients 123 adult liver allograft recipients after admission to the intensive care unit. Measurements and main results The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p<0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p<0.001) and acute physiology and chronic health evaluation (Apache II) (p<0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24h had a total misclassification rate of 22% (SAPS=32%, Apache II=33%). MPM-admission failed in predicting mortality (sensitivity=52%). Organ systems failure score seemed not to be useful in liver transplant recipients. Conclusion General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.     

肝功能衰竭肝性脑病大鼠5-羟色胺和去甲肾上腺素的变化

目的研究5-羟色胺(5-HT)及去甲肾上腺素(NA)在大鼠急性肝功能衰竭(ALF)和慢性肝功能衰竭(CLF)肝性脑病时的变化。方法将110只SD大鼠随机分为正常对照组(20只)、ALF组(45只)及CLF组(45只)。ALF模型按500mg/kg硫代乙酰胺(TAA)间隔24h两次灌胃;CLF模型按质量分数为0.03%的TAA作为饮用水灌饲10周,并根据每周体重的变化增减50%的TAA含量。造模成功后从眼底静脉丛取血,检测5-HT、NA、血氨和肝功能指标;处死动物,取肝、脑组织,光镜下观察组织病理学变化。结果ALF组和CLF组均出现不同程度的肝功能损害表现,血中丙氨酸转氨酶(ALT)、天冬氨酸转氨酶(AST)、总胆红素(TBIL)、白蛋白(ALB)、白蛋白/球蛋白(A/G)、血氨均有明显变化(P<0.05或P<0.01);肝脏及脑组织病理学符合ALF和CLF肝性脑病表现。ALF组和CLF组5-HT(16.06±1.08)μmol/L和(15.32±1.48)μmol/L均较正常对照组(2.75±0.26)μmol/L显著升高(P均<0.01),CLF组NA值下降(94.0±2.13)pmol/L比(121.2±14.8)pmol/L,P<0.05。结论5-HT在大鼠ALF和CLF所致肝性脑病时明显升高;NA在大鼠CLF所致肝性脑病时明显下降。     

Vascular and nonvascular complications of liver transplants: sonographic evaluation and correlation with other imaging modalities and findings at surgery and pathology

Liver transplantation is performed in adults and children to treat patients with irreversible liver damage when medical or other surgical treatment has failed. The most common indications for transplantation are cirrhosis secondary to fulminant acute hepatitis or chronic active hepatitis, sclerosing cholangitis, primary biliary cirrhosis, Budd-Chiari syndrome, inborn errors of metabolism, and unresectable but local hepatocellular carcinoma. This article reviews the sonographic findings in the preoperative evaluation of liver transplant recipients, briefly describes the surgical technique, and demonstrates normal postoperative findings in liver transplant recipients as well as complications associated with liver transplantation.     

TECAI型生物人工肝支持系统治疗急性肝衰竭犬的实验研究

目的评价经改进的TECAI型生物人工肝脏支持系统（bioartificial liver supportsyst em,BALSS）治疗醋氨酚诱发急性肝衰竭(acute liver failure,ALF)犬的有效性和安全性。方法采用多次皮下注射醋氨酚的方法建立ALF模型犬。分离中国实验用小型猪肝细胞并培养于BALSS中,对ALF犬进行6小时的治疗,观察治疗前后犬生理、生化和组织学的变化,与常规药物治疗组和对照组进行比较。结果注射醋氨酚48小时后,可建立ALF犬模型,模型成功率为63.16%。应用我们改进的酶消化法,平均从每只小型猪的肝脏可得到（0.8～3.0）×10