Utility of the Mayo End-Stage Liver Disease (MELD) score in assessing prognosis of patients with alcoholic hepatitis.
(65/874)
BACKGROUND: Alcoholic hepatitis is characterized by acute, or acute-on-chronic hepatic failure and associated with a high mortality. Specific therapies should be considered for those at high risk of mortality. The Mayo End-Stage Liver Disease (MELD) score is a marker of disease severity and mortality in persons with chronic alcoholic liver disease. Our aims were to assess the utility of the MELD score as a predictor of short-term mortality in persons with alcoholic hepatitis. METHODS: We assessed the utility of the MELD score and compared it with the Discriminant Function (DF) as a predictor of mortality in 34 patients hospitalized with alcoholic hepatitis. RESULTS: The area under the curve of a receiver operating characteristic curve for the MELD score was 0.82 (confidence intervals 0.65-0.98), and for the DF was 0.86 (confidence intervals 0.70-1.00). However, the sensitivity and specificity in predicting 30-day mortality for a MELD score of greater than 11 was 86% and 81%, but for a DF greater than 32 was 86% and 48% respectively. The presence of ascites and bilirubin greater than 8 mg/dL were also highly predictive of mortality with a sensitivity of 71% and a specificity of 96%. CONCLUSIONS: Alcoholic hepatitis remains associated with a high mortality in hospitalized patients. The MELD score performs as well as the DF in predicting mortality at 30 days. A MELD score of greater than 11, or the presence of both ascites and an elevated bilirubin greater than 8 mg/dL should prompt consideration of specific therapeutic interventions to reduce mortality. (+info)
TECA hybrid artificial liver support system in treatment of acute liver failure.
(66/874)
AIM: To assess the efficacy and safety of TECA type hybrid artificial liver support system (TECA-HALSS) in providing liver function of detoxification, metabolism and physiology by treating the patients with acute liver failure (ALF). METHODS: The porcine liver cells (1-2) x 10(10) were separated from the Chinese small swine and cultured in the bioreactor of TECA-BALSS at 37.0 degrees C and circulated through the outer space of the hollow fiber tubes in BALSS. The six liver failure patients with various degree of hepatic coma were treated by TECA-HALSS and with conventional medicines. The venous plasma of the patients was separated by a plasma separator and treated by charcoal adsorbent or plasma exchange. The plasma circulated through the inner space of the hollow fiber tubes of BALSS and mixed with the patients' blood cells and flew back to their blood circulation. Some small molecular weight substances were exchanged between the plasma and porcine liver cells. Each treatment lasted 6.0-7.0 h. Physiological and biochemical parameters were measured before,during and after the treatment. RESULTS: The average of porcine liver cells was (1.0-3.0) x 10(10) obtained from each swine liver using our modified enzymatic digestion method. The survival rate of the cells was 85%-93% by trypan blue stain and AO/PI fluorescent stain. After cultured in TECA-BALSS bioreactor for 6 h, the survival rate of cells still remained 70%-85%. At the end of TECA-HALSS treatment, the levels of plasma NH(3), ALT, TB and DB were significantly decreased. The patients who were in the state of drowsiness or coma before the treatment improved their appetite significantly and regained consciousness, some patients resumed light physical work on a short period after the treatment. One to two days after the treatment, the ratio of PTA increased warkedly. During the treatment, the heart rates, blood pressure, respiration condition and serum electrolytes (K(+), Na(+) and Cl(-)) were stable without thrombosis and bleeding in all the six patients. CONCLUSION: TECA-HALSS treatment could be a rapid, safe and efficacious method to provide temporary liver support for patients with ALF. (+info)
Pathophysiology of renal disease associated with liver disorders: implications for liver transplantation. Part I.
(67/874)
Renal and hepatic function are often intertwined through both the existence of associated primary organ diseases and hemodynamic interrelationships. This connection occasionally results in the chronic failure of both organs, necessitating combined liver-kidney transplantation (LKT). Since 1988, more than 850 patients in the United States have received such transplants, with patient survival somewhat less than that for patients receiving either organ alone. Patients with renal failure caused by acute injury or hepatorenal syndrome have classically not been included as candidates for combined transplantation because of the reversibility of renal dysfunction after liver transplantation. However, the rate and duration of renal failure before liver transplantation is increasing in association with prolonged waiting list times. Thus, the issue of acquired permanent renal damage in the setting of hepatic failure continues to confront the transplant community. The following article and its sequel (Part II, to be published in vol 8, no 3 of this journal) attempt to review the problem of primary and secondary renal disease in patients with end-stage liver disease, elements involved in renal disease progression and recovery, the impact of renal disease on liver transplant outcome, and results of combined LKT; outline the steps in the pretransplantation renal evaluation; and provide the beginnings of an algorithm for making the decision for combined LKT. (+info)
The new neuromuscular blocking agents: do they offer any advantages?
(68/874)
The pharmacodynamics and pharmacokinetics of the two most recent aminosteroid neuromuscular blocking drugs to become available, rapacuronium bromide (Org 9487) and rocuronium bromide are reviewed. Two new classes of drug with neuromuscular blocking properties, the bis-tetrahydroisoquinolinium chlorofumarates and the tropinyl diester derivatives are introduced. Comparisons between these drugs and mivacurium and cisatracurium are made. Rapacuronium 1.5 mg kg(-1) (ED95 1 mg kg(-1)), produces maximal neuromuscular block in 54 s. Time to recovery of the train-of-four ratio to 0.7 is achieved within 20 min after neostigmiine 0.05 mg kg(-1) given at 2 min. The plasma clearance of rapacuronium is 7-8 ml kg(-1) min(-1). Rapacuronium undergoes hepatic metabolism: no prolongation of effect has been reported after a single bolus or a short infusion in patients with hepatic or renal failure. Org 9488 is the 3-desacetyl metabolite of rapacuronium, which has neuromuscular blocking properties. Its much lower clearance (1.28 ml kg(-1) min(-1)) and plasma equilibration constant (0.105 min(-1)) may limit the prolonged use of rapacuronium. Rocuronium given at 2xED95 produces maximal neuromuscular block in 1 min. Spontaneous recovery of the train-of-four ratio to 0.7 takes over 40 min. Rocuronium has a plasma clearance of 4 ml kg(-1) min(-1). Its pharmacodynamics are altered in hepatic and renal disease. A number of anaphylactoid reactions to rocuronium have been reported recently. The bis-tetrahydroisoquinolinium chlorofumarate GW280430A has an ED95 of 0.19 mg kg(-1). Given at three times this dose, onset of neuromuscular block occurs within 100 s; the duration of block is 8-9 min. Following a 2 h infusion, the recovery index does not seem to be increased. Early studies suggest that this drug has no adverse cardiovascular or respiratory side-effects. The tropinyl diester derivative G-1-64 will produce 80-90% neuromuscular block in less than 2 min using 3xED80. Ninety per cent recovery of the first twitch of the train-of-four occurs after 5-7 min using one ED80. A recovery index of less than 2 min has been reported in rats. All the tropinyl diesters appear to produce vagal block. (+info)
Isolated liver transplantation in infants with end-stage liver disease associated with short bowel syndrome.
(69/874)
OBJECTIVE: To evaluate experience with isolated orthotopic liver transplantation in children with liver failure associated with short bowel syndrome (SBS). SUMMARY BACKGROUND DATA: Infants who have liver failure as a result of SBS are frequently referred for consideration for combined liver and small bowel transplantation. In a few patients the liver disease develops despite a seemingly adequate bowel, which if given time and appropriate management has the potential for full enteral adaptation. There is a limited literature suggesting the utility of OLT without replacement of the native bowel. The advantages over combined liver and small bowel transplantation are clear: organ availability is greater, liver-reduction techniques are well established, lower immunosuppression is required, and there is greater experience in the care of children after orthotopic liver transplantation. METHODS: Eleven infants, considered to have a good prospect of eventual gut adaptation to full enteral nutrition if it were not for their advanced liver disease, underwent isolated orthotopic liver transplantation. Age range was 6.5 to 17.7 months. All patients had been dependent on parenteral feeding but had also shown significant enteral tolerance at some time before listing for transplantation. Advanced liver disease was apparent both clinically and on histologic examination. All were jaundiced and had low albumin levels, and most had coagulopathy. As a group the infants had growth retardation. Estimated remaining length of small bowel beyond the ligament of Treitz was in the range of 25 to more than 100 cm. Six infants retained their ileocecal valve. RESULTS: Thirteen liver transplants were performed in the 11 patients. A combination of whole livers (n = 6) and reduced-size grafts, of which three were from living-related donors, were used. Biliary anastomosis was duct-to-duct in eight instances and involved a short Roux limb in the others. Eight patients are alive with follow-up of 15 to 66 months. Three deaths have occurred after transplantation as a result of sepsis. Of eight surviving patients, only two continue to receive intravenous support and in both there is increasing enteral tolerance. Since transplantation, all surviving children have shown adequate growth with maintenance of pretransplant centiles. CONCLUSIONS: In selected infants with liver failure secondary to short bowel syndrome in whom complete enteral autonomy is anticipated, isolated liver transplantation can offer long-term survival. (+info)
Monitoring extracellular concentrations of lactate, glutamate, and glycerol by in vivo microdialysis in the brain during liver transplantation in acute liver failure.
(70/874)
Swelling of cerebral glial cells is a characteristic complication in patients with acute liver failure (ALF). This astrocyte edema may result in high intracranial pressure (ICP) and brain herniation before or during liver transplantation. Metabolic alterations responsible for the development of high ICP in patients with ALF are not fully understood. We describe changes in neurochemistry during liver transplantation using a cerebral microdialysis technique in a young man with severe ALF and cerebral edema. We found that the extracellular content of lactate ([lactate](ec)) gradually increased during the operation. Because cerebral oxygen saturation and [lactate](ec) to [pyruvate](ec) ratio were within normal limits, hypoxia was not likely to be responsible for the increased [lactate](ec) levels. Instead, we found that [lactate](ec) levels correlated in this patient with arterial lactate concentrations during and after grafting (r(2) = 0.96; P <.05), but did not correlate with arterial glucose concentrations (r(2) = 0.20; P = not significant). Also, [glutamate](ec) and [glycerol](ec) levels were severely elevated before liver transplantation, but tended to decrease in the hours after grafting. These findings indicate disturbances in glutamate neurotransmission, arachidonic acid metabolism, and lactate flux across the blood-brain barrier in patients with ALF. (+info)
Right-liver living donor transplantation for decompensated end-stage liver disease.
(71/874)
Adult-to-adult living donor liver transplantation (LDLT) for patients with decompensated end-stage liver disease (DELD) is controversial. Nevertheless, these patients are most in need of a timely liver transplant. We present the results of 7 patients who underwent transplantation with this procedure and discuss the rationale for its possible broader application. Seven of 51 patients who underwent right LDLT (segments 5 to 8) between August 1998 and April 2001 had DELD, defined as Child-Pugh-Turcotte score greater than 13 or Model for End-Stage Liver Disease score greater than 30. All patients also were listed for cadaveric liver transplantation. Mean age of the 7 transplant recipients was 54 years (range, 44 to 63 years). Three patients had ethyltoxic cirrhosis; 2 patients, hepatitis C; 1 patient, hepatitis B; and 1 patient, autoimmune hepatitis cirrhosis. The average intensive care unit stay was 23 days (range, 3 to 88 days), and average hospital stay was 77 days (range, 27 to 132 days). Three patients are alive 31, 21, and 17 months after LDLT. At a mean follow-up of 15.1 +/- 10 months, patient and graft survival rates are 43%. Four transplant recipients died day 30, 60, 117, and 180 after transplantation. Three of the seven donors (43%) experienced a complication. At present, all donors are well and have returned to their normal activities. No donors had regrets about the procedure, and all donors stated that they would donate again if presented with the same decision. In conclusion, with the lack of other therapeutic options, LDLT represents a timely and effective alternative to cadaveric liver transplantation. Better outcome is foreseeable with a decrease in posttransplantation complications and more experience in predicting survival of these critical patients. (+info)
Outcome of liver transplantation for patients with pulmonary hypertension.
(72/874)
It is generally believed that pulmonary hypertension (PHT) adversely affects outcome after liver transplantation (LT). Most transplant units consider severe PHT to be an absolute contraindication to LT. We examined the outcome of 145 patients who underwent LT between 1997 and 1999. Pulmonary artery pressures (PAPs) had been measured before surgery. Pre-LT workup included electrocardiography and echocardiography for the majority of patients. Also, the liver unit database was screened for patients with known PHT who had undergone LT before 1997. Based on pulmonary flotation catheter measurements made after the induction of anesthesia for LT, PHT was defined as mild or moderate to severe if the mean PAP (MPAP) exceeded 25 and 35 mm Hg, respectively. The incidence of PHT was 26% (38 of 145 patients); 31 of 38 patients had mild PHT. Kaplan-Meier survival analysis did not show a significant survival benefit for patients with normal PAPs compared with patients with PHT (all, mild, moderate to severe). For surviving patients, the duration of ventilation and intensive care unit stay was unaffected by PHT. Four of 5 patients (identified from the database 1982 to 1999) with MPAPs greater than 40 mm Hg survived LT by more than 1 year. PHT of this severity was usually associated with specific and suggestive abnormality of the echocardiogram. Mild PHT is common and does not affect patient outcome after LT. Moderate and severe PHT are uncommon. Our analysis suggests that when the cardiac index is preserved, the majority of patients with moderate and severe PHT can survive LT, and they will not die of PHT during long-term follow-up. Echocardiography detects most severe PHT, but not mild and moderate PHT. (+info)