Best practice & research. Clinical gastroenterology最新文献

Neurological complications in acute liver failure are the most common cause of mortality in this group of patients. Almost all neurologic complications arise from underlying increase in intracranial pressure in ALF. In addition to symptomatic management, the treatment relies on measures to bring down ICP. Recently role of renal replacement therapy is gaining a lot of ground in ALF management, primarily due to its ammonia lowering effects indirectly leading to decrease in ICP. In this review we cover the neurologic issues in ALF in detail. We discuss the various non invasive techniques for ICP monitoring & their current application in ALF patients. We also focus on the management protocols in ALF & their role in improving the ICP & hence the outcome.

ABO-compatible Orthotopic Liver Transplantation (OLT) is the standard treatment for patients with acute liver failure (ALF) who meet the criteria for poor prognosis. Contraindications to liver transplantation may be related to the presence of severe medical or psychiatric comorbidities, or to an unstable clinical state incompatible with transplantation. Early mortality predictive scores and factors have been developed to identify futile transplantations that exacerbate organ shortage. However, these scores are not sufficiently reliable to contraindicate transplantation. Auxiliary liver transplantation, two-stage transplantation (total hepatectomy with portal-caval anastomosis followed by delayed orthotopic liver transplantation), ABO-incompatible liver transplantation, living-donor transplantation, and living-auxiliary liver donor transplantation are alternatives to OLT. The selection of appropriate techniques must fulfill specific criteria. ABO-incompatible transplantation remains an exception, even though immunosuppressive strategies have improved prognosis. The overall survival and graft survival rates at 1 and 5 years after liver transplantation for ALF are 79 % and 72 % in Europe, and 84 % and 73 % in the United States, respectively. The survival rate has significantly improved in recent years.

Acute liver failure (ALF) is defined as the loss of hepatic function in conjunction with hepatic encephalopathy and coagulopathy. There is histological evidence of profound hepatocyte damage. If it is not aggressively managed, ALF can be fatal within a few days. It is a rare disease, often occurring in patients without prior liver disease. Despite numerous causes, ALF usually presents as acute liver necrosis with a clinical picture that includes cognitive dysfunction, increased aminotransferases, and severe coagulopathy. It is essential to distinguish between ALF and acute-on-chronic liver failure (ACLF). Causes for ALF include paracetamol Acute liver failure (ALF) is characterized by acute liver dysfunction associated with overdose, right heart failure (ischemic liver injury), viral hepatitis (A, B, D and E), autoimmune hepatitis and drug-induced liver injury (including some herbal and nutritional supplements). In developed countries, the prevalence of ALF is 1:1,000,000. Survival rates have increased due to improved ICU management.

Acute liver failure (ALF) is a rare but preventable cause of acute hepatic dysfunction which is associated with significant mortality, unless treated appropriately. There are significant regional variations in the etiologies of ALF globally and this determines the outcomes of the disease as well as the long-term survival in patients receiving liver transplantation for management. Improvements in understanding of disease pathophysiology and critical care medicine have led to better outcomes over the last few decades. Despite this, the burden of indeterminate ALF and the pathogenesis of many etiological agents are yet to be fully known. Improvements in diagnostic and prognostic modalities are expected to decrease the morbidity and mortality associated with ALF. Changes in vaccination programs and stronger legislative practices regarding over-the-counter sale of acetaminophen and non-proprietary drugs are expected to reduce the burden of disease globally.

Acute liver failure (ALF) is a rare and dynamic syndrome occurring as a sequela of severe acute liver injury (ALI). Its mortality ranges from 50% to 75% based on the aetiology, patients age and severity of encephalopathy at admission. With improvement in intensive care techniques, transplant-free survival in ALF has improved over time. Timely recognition of patients who are unlikely to survive with medical intervention alone is crucial since these individuals may rapidly develop multiorgan failure and render liver transplantation futile. Various predictive models, biomarkers and AI-based models are currently used in clinical practice, each with its fallacies. The King's College Hospital criteria (KCH) were initially established in 1989 to identify patients with acute liver failure (ALF) caused by paracetamol overdose or other causes who are unlikely to improve with conventional treatment and would benefit from a liver transplant. Since then, various models have been developed and validated worldwide. Most models include age, aetiology of liver disease, encephalopathy grade, and liver injury markers like INR, lactate, factor V level, factor VIII/V ratio and serum bilirubin. But none of the currently available models are dynamic and lack accuracy in predicting transplant free survival. There is an increasing interest in developing prognostic serum biomarkers that when used alone or in combination with clinical models enhance the accuracy of predicting outcomes in ALF. Genomics, transcriptomics, proteomics, and metabolomics as well as machine learning and artificial intelligence (AI) algorithms are areas of interest for developing higher-precision predictive models. Overall, the future of prognostic models in ALF is promising, with ongoing research paving the way for more accurate, personalized, and dynamic risk assessment tools that can potentially save lives in this challenging condition. This article summarizes the history of prognostic models in ALF and future trends.

Acute liver failure (ALF) is a rare but rapidly progressing syndrome, marked by severe liver dysfunction and altered mental status. While definitions of ALF vary across different guidelines, with timelines ranging from 4 to 26 weeks between jaundice onset and encephalopathy, the key defining features remain encephalopathy and coagulopathy. Elevated coagulation markers, particularly prothrombin time and international normalized ratio, have traditionally been associated with bleeding risks. However, emerging evidence suggests a rebalanced state of coagulation in ALF, similar to cirrhosis, where bleeding risks-both spontaneous and procedural-are surprisingly low. Viscoelastic hemostatic assays and thrombin generation assays further confirm this rebalanced hemostatic state. Current guidelines for correcting coagulopathy in ALF remain limited, typically reserved for active bleeding or prior to high-risk invasive procedures.

Acute liver failure (ALF) is a rare syndrome where rapid deterioration of liver function occurs after an acute insult in a patient without prior chronic liver disease and leads to jaundice, hepatic encephalopathy (HE), and oftentimes multiorgan failure (MOF). At this time, the only definitive treatment for ALF is LT but some patients, particularly APAP-induced ALF patients, may have ongoing regenerative capacity of the liver and may not require LT with ongoing supportive management. As a result, extracorporeal liver support (ECLS) has been a topic of interest both as a bridge to LT and as a bridge to spontaneous recovery and aims to remove damaging toxins that further aggravate liver failure, stimulate regeneration of the liver, and improve pathophysiologic consequences of liver failure. There are currently two categories of ECLS (artificial and bioartificial). Artificial ECLS does not incorporate active hepatocytes and are based on the principles of filtration and adsorption and includes renal replacement therapy (RRT), plasma adsorption including plasma exchange and Prometheus (Fractionated Plasma Separation and Adsorption), and albumin dialysis including MARS (Molecular Adsorbent Recirculating System) and SPAD (Single Pass Albumin Dialysis). Bioartificial ECLS incorporates active hepatocytes (human or porcine in origin) to improve liver detoxification capacity and to support hepatic synthetic function and includes ELAD (Extracorporeal Liver Assist Device) and HepatAssist.

Infections in acute liver failure (ALF) increase the associated morbidity and mortality, and often hamper the possibility of transplantation. Two-thirds of the infections in ALF are bacterial while one-third is fungal. High suspicion for infection is essential whenever there is clinical deterioration. Multi-drug resistant infections are frequently encountered with prolonged ICU stay, invasive lines, ventilation and renal replacement therapy. Since most of the infections in ALF are nosocomial, prevention of infections is crucial by infection control practices in the ICU. Although markers such as CRP, procalcitonin (for bacterial infections), 1,3-beta-D glucan, and galactomannan (fungal infections) aid in the diagnosis, the gold standard is blood culture. Therapy for respiratory infections must be based on BAL or mini-BAL culture. In this article, we discuss the common infections occurring in ALF, methods for early diagnosis and recommended prophylactic, pre-emptive as well as therapeutic options for treating infections in ALF.