Acute liver failure (ALF) is not an uncommon complication of a common disease such as acute hepatitis. Viral hepatitis followed by antituberculosis drug-induced hepatotoxicity are the commonest causes of ALF in India. Clinically, such patients present with appearance of jaundice, encephalopathy, and coagulopathy. Hepatic encephalopathy (HE) and cerebral edema are central and most important clinical event in the course of ALF, followed by superadded infections, and determine the outcome in these patients. The pathogenesis of encephalopathy and cerebral edema in ALF is unique and multifactorial. Ammonia plays a crucial role in the pathogenesis, and several therapies aim to correct this abnormality. The role of newer ammonia-lowering agents is still evolving. These patients are best managed at a tertiary care hospital with facility for liver transplantation (LT). Aggressive intensive medical management has been documented to salvage a substantial proportion of patients. In those with poor prognostic factors, LT is the only effective therapy that has been shown to improve survival. However, recognizing suitable patients with poor prognosis has remained a challenge. Close monitoring, early identification and treatment of complications, and couseling for transplant form the first-line approach to manage such patients. Recent research shows that use of dynamic prognostic models is better for selecting patients undergoing liver transplantation and timely transplant can save life of patients with ALF with poor prognostic factors.
Liver transplantation (LT) is a game changer in cirrhosis. Poor muscle mass defined as sarcopenia may potentially upset the LT scoreboard.
To assess the prevalence and impact of sarcopenia on the intraoperative and early postoperative outcomes in Indian patients undergoing LT.
Pre LT, single-slice routine computed tomography images at L3 vertebra of 115 LT recipients were analyzed, to obtain cross-sectional area of six skeletal muscles normalized for height in m
- skeletal muscle index (SMI; cm /m ). SMI< 52.4 in males and <38.5 in females was called sarcopenia. The intraoperative, postoperative outcome parameters and 90-day mortality were compared between sarcopenics and nonsarcopenics.
Sarcopenia was found in 47.8% of patients [M (90.4%); age, 46.3± 10; BMI, 24.5± 4.3kg/m2; child ABC= 1%22%77%; MELD, 20.6± 6.3; etiology alcohol nonalchohol=53%47%; Charlson Comorbidity Index (CCI) > 3≤3= 56.5%43.5%]. Sarcopenics vs. Nonsarcopenics; early postoperative complications [sepsis, 49(89%) vs. 3a higher incidence of postoperative sepsis, neurological complications, longer ICU stay and ventilatory support. Low SMI, ACLF presentation, and intraoperative blood loss were the independent predictors of early mortality.
Almost 50% of LT recipients had sarcopenia, who had a higher incidence of postoperative sepsis, neurological complications, longer ICU stay and ventilatory support. click here Low SMI, ACLF presentation, and intraoperative blood loss were the independent predictors of early mortality.
We describe our technique of exvivo organ perfusion and procurement in donation after deceased brain death (DBD) donors.
This technique comprises warm dissection of liver, kidneys, and heart, in hemodynamically stable DBD donors and perfusing them exvivo. The cardiac and abdominal dissection can take place simultaneously. As a precaution, the iliac arteries and the abdominal aorta are dissected and kept ready for rapid cannulation and perfusion, should the donor become unstable at any stage.The liver dissection is in principle similar to living donor hepatectomy, where portal dissection is combined with supra and infrahepatic caval dissection to completely mobilize liver to allow it to be removed and perfused exvivo. The renal dissection is done after hepatic dissection is complete. The sequence of recovery of organ was modified where kidneys were procured first followed by hepatic and cardiac procurement simultaneously.
Twelve multivisceral (liver and kidneys in all and heart in four) procurements have been performed. The average perfusion fluid volume for liver was 3.4L. All recipients had uneventful postoperative course.
Ourtechnique has not affected recipient outcomes and with benefits of less use of preservation solution, shortening bench surgery time, and decreasing the propensity of procurement injuries by avoiding cold-phase dissection.
Our technique has not affected recipient outcomes and with benefits of less use of preservation solution, shortening bench surgery time, and decreasing the propensity of procurement injuries by avoiding cold-phase dissection.
Acute liver failure (ALF) is rare and associated with poor outcomes. The outcomes of ALF and predictors of outcome may vary as per the etiology. There are limited data on the predictors of spontaneous survival among patients with ALF of non-A-E hepatitis or cryptogenic etiology. We aimed to assess clinical course, complications, and outcome of non-A-E etiology ALF.
In this prospective analysis, all consecutive ALF patients (n= 1555; January 1986-June 2018) were analyzed. Non-A-E-ALF was defined as ALF that could not be attributed to known etiologies such as drugs, viral hepatitis, autoimmune hepatitis, and Wilson's disease. Clinical course, complications, and outcomes of non-A-E-ALF patients who did not undergo liver transplantation were analyzed. Unadjusted and adjusted odds ratios (ORs) were calculated.
Non-A-E-ALF constituted 34.6% (n= 538) of all ALF patients, whereas hepatitis E virus (HEV), hepatitis B virus (HBV), and anti-tuberculosis therapy (ATT) accounted for 29.5% (n= 459), 8.6% (n= 134), and 7.4% (n= 115), respectively. Among non-A-E-ALF patients, mean age was 28.8±12.0 years, 50.9% females, majority (63.1%) had hyperacute presentation, and 79.2% had advanced encephalopathy at presentation. The frequency of cerebral edema in non-A-E-ALF (53.3%) was higher than that in HEV-ALF (41.2%) and ATT-ALF (44.2%), P < 0.001. The survival rate in non-A-E-ALF (37.5%) was poorer than HEV-ALF (54.9%) and was comparable to that in HBV (35.8%) and ATT (29.6%) induced ALF. The baseline prothrombin time prolongation (odds ratio[OR] 1.041; 95% confidence intervals [CI], 1.017-1.065) and infection (OR 2.366; 95%CI, 1.107-5.055) were independent predictors of outcome in non-A-E-ALF. The 3-days acute liver failure early dynamic model had the best value in predicting the outcome.
Non-A-E-ALF accounts for one-third of all cases of ALF and is associated with poor spontaneous survival.
Non-A-E-ALF accounts for one-third of all cases of ALF and is associated with poor spontaneous survival.click here
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