Reference Citation Analysis: Find an Article, Find a Category, Find a Journal, Find a Scholar

For: Mitzner SR, Stange J, Klammt S, Risler T, Erley CM, Bader BD, Berger ED, Lauchart W, Peszynski P, Freytag J, Hickstein H, Loock J, Löhr JM, Liebe S, Emmrich J, Korten G, Schmidt R. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transpl 2000;6:277-286. [PMID: 10827226 DOI: 10.1053/lv.2000.6355] [Citation(s) in RCA: 401] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]

For:	Mitzner SR, Stange J, Klammt S, Risler T, Erley CM, Bader BD, Berger ED, Lauchart W, Peszynski P, Freytag J, Hickstein H, Loock J, Löhr JM, Liebe S, Emmrich J, Korten G, Schmidt R. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transpl 2000;6:277-286. [PMID: 10827226 DOI: 10.1053/lv.2000.6355] [Citation(s) in RCA: 401] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]

Number

Cited by Other Article(s)

Peluso L, Savi M, Coppalini G, Veliaj D, Villari N, Albano G, Petrou S, Pace MC, Fiore M. Management of hepatorenal syndrome and treatment-related adverse events. Curr Med Res Opin 2024;40:1155-1162. [PMID: 38773739 DOI: 10.1080/03007995.2024.2358242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 05/05/2024] [Accepted: 05/17/2024] [Indexed: 05/24/2024]

Abstract

Hepatorenal Syndrome is a critical complication of liver failure, mainly in cirrhotic patients and rarely in patients with acute liver disease. It is a complex spectrum of conditions that leads to renal dysfunction in the liver cirrhosis population; the pathophysiology is characterized by a specific triad: circulatory dysfunction, nitric oxide (NO) dysfunction and systemic inflammation but a specific kidney damage has never been demonstrated, in a clinicopathological study, kidney biopsies of patients with cirrhosis showed a wide spectrum of kidney damage. In addition, the absence of significant hematuria or proteinuria does not exclude renal damage. It is estimated that 40% of cirrhotic patients will develop hepatorenal syndrome with in-hospital mortality of about one-third of these patients. The burden of the problem is dramatic considering the worldwide prevalence of more than 10 million decompensated cirrhotic patients, and the age-standardized prevalence rate of decompensated cirrhosis has gone through a significant rise between 1990 and 2017. Given the syndrome's poor prognosis, the clinician must know how to manage early treatment and any complications. The widespread adoption of albumin and vasopressors has increased Hepatorenal syndrome-acute kidney injury reversal and may increase overall survival, as previously shown. Further research is needed to define whether the subclassification of patients may allow to find a personalized strategy to treat Hepatorenal Syndrome and to define the role of new molecules and extracorporeal treatment may allow better outcomes with a reduction in treatment-related adverse effects. This review aims to examine both pharmacological and non-pharmacological treatment of hepatorenal syndrome, with a particular focus on managing adverse events caused by treatment.

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Roozbeh J, Ezzatzadegan Jahromi S, Rezazadeh MH, Hamidianjahromi A, Malekmakan L. Management of hepatorenal syndrome and associated outcomes: a systematic reviews. BMJ Open Gastroenterol 2024;11:e001319. [PMID: 38631807 PMCID: PMC11033346 DOI: 10.1136/bmjgast-2023-001319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 03/11/2024] [Indexed: 04/19/2024] Open

Pose E, Piano S, Juanola A, Ginès P. Hepatorenal Syndrome in Cirrhosis. Gastroenterology 2024;166:588-604.e1. [PMID: 38246506 DOI: 10.1053/j.gastro.2023.11.306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 01/23/2024]

Delle Cave V, Di Dato F, Iorio R. Wilson's Disease with Acute Hepatic Onset: How to Diagnose and Treat It. CHILDREN (BASEL, SWITZERLAND) 2024;11:68. [PMID: 38255382 PMCID: PMC10814100 DOI: 10.3390/children11010068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 12/19/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024]

Jung CY, Chang JW. Hepatorenal syndrome: Current concepts and future perspectives. Clin Mol Hepatol 2023;29:891-908. [PMID: 37050843 PMCID: PMC10577351 DOI: 10.3350/cmh.2023.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/10/2023] [Accepted: 04/10/2023] [Indexed: 04/14/2023] Open

Sommerfeld O, Neumann C, Becker J, von Loeffelholz C, Roth J, Kortgen A, Bauer M, Sponholz C. Extracorporeal albumin dialysis in critically ill patients with liver failure: Comparison of four different devices-A retrospective analysis. Int J Artif Organs 2023;46:481-491. [PMID: 37609875 PMCID: PMC10483887 DOI: 10.1177/03913988231191952] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/26/2023] [Indexed: 08/24/2023]

Abstract

BACKGROUND

Besides standard medical therapy and critical care monitoring, extracorporeal liver support may provide a therapeutic option in patients with liver failure. However, little is known about detoxification capabilities, efficacy, and efficiency among different devices.

METHODS

Retrospective single-center analysis of patients treated with extracorporeal albumin dialysis. Generalized Estimating Equations with robust variance estimator were used to account for repeated measurements of several cycles and devices per patient.

RESULTS

Between 2015 and 2021 n = 341 cycles in n = 96 patients were eligible for evaluation, thereof n = 54 (15.8%) treatments with Molecular Adsorbent Recirculating System, n = 64 (18.7%) with OpenAlbumin, n = 167 (48.8%) Advanced Organ Support treatments, and n = 56 (16.4%) using Single Pass Albumin Dialysis. Albumin dialysis resulted in significant bilirubin reduction without differences between the devices. However, ammonia levels only declined significantly in ADVOS and OPAL. First ECAD cycle was associated with highest percentage reduction in serum bilirubin. With the exception of SPAD all devices were able to remove the water-soluble substances creatinine and urea and stabilized metabolic dysfunction by increasing pH and negative base excess values. Platelets and fibrinogen levels frequently declined during treatment. Periprocedural bleeding and transfusion of red blood cells were common findings in these patients.

CONCLUSIONS

From this clinical perspective ADVOS and OPAL may provide higher reduction capabilities of liver solutes (i.e. bilirubin and ammonia) in comparison to MARS and SPAD. However, further prospective studies comparing the effectiveness of the devices to support liver impairment (i.e. bile acid clearance or albumin binding capacity) as well as markers of renal recovery are warranted.

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Song Z, Xie Q, Zhou Y, Song S, Gao Z, Lan Y, Wu Z, Cai H, Yu D, Liu C, Liang J, Xie B, Sun S. Effect of Artificial Liver Support Systems on Gut Microbiota in Patients with HBV-Related Acute-on-Chronic Liver Failure. Pathogens 2023;12:1094. [PMID: 37764902 PMCID: PMC10534758 DOI: 10.3390/pathogens12091094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/29/2023] Open

Abstract

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a rare and severe form of end-stage liver disease with high mortality; gut microbes are strongly associated with the development of this severe liver disease but the exact association is unclear. Artificial liver support systems (ALSS) are clinically important in prolonging the waiting time for liver transplantation and in aiding drug therapy to achieve remission. The aim of this study was to investigate the effect of ALSS on the abundance and diversity of microorganisms in the gut of HBV-ACLF patients. In this study, 109 stool samples were collected from patients with hepatitis B virus-associated acute chronic liver failure (HBV-ACLF) for 16S rRNA sequencing. Among them, 44 samples were from patients treated with ALSS therapy as an adjunct to standard medical treatment (SMT) and 65 were from patients receiving SMT only. Analysis of the sequencing results suggested that there were significant differences in the abundance and diversity of gut microbiota between the with-ALSS and without-ALSS groups (p < 0.05). The operational taxonomic units and Shannon indexes indicated that the diversity and abundance of the gut microbiome, while decreasing after the first ALSS treatment, gradually increased after an increase in the number of ALSS therapies. The overall proportion of HBV-ACLF patients with coinfection was 27.59%; the coinfection can reduce the abundance of the Bacteroidetes phylum in the microbiome significantly whereas Proteobacteria were highly enriched. After ALSS therapy, HBV-ACLF patients had a decrease in potentially harmful bacteria, an increase in potentially beneficial bacteria, an increase in the diversity of the intestinal microbiota, and the intestinal microecological disorders were corrected to a certain extent. Serum alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) levels, as well as the international normalized ratio (INR), showed a decreasing trend whereas plasminogen activity (PTA) increased and the condition of patients with HBV-ACLF progressed in a favorable direction. In addition, the abundance of Blautia and Coprococcus was negatively correlated with TBIL and INR, positively correlated with PTA, and positively correlated with disease recovery. Our study shows that ALSS can alter the composition of the gut microbiota and have an ameliorating effect on the gut microecological imbalance in HBV-ACLF patients. It is worth mentioning that Blautia and Coprococcus may have great potential as biomarkers.

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Affiliation(s)

Zhiying Song Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Qiong Xie Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Yao Zhou Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Shufen Song Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Zhen Gao Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Yu Lan Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Zhiguo Wu Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Hongxin Cai School of Pharmaceutical Sciences, Zhejiang Chinese Medical University, Hangzhou 311400, China;
Dongshan Yu Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Cuiyun Liu Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)
Junrong Liang State Key Laboratory for Infectious Disease Prevention and Control, National Institute for Communicable Disease Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing 102206, China
Baogang Xie Department of Pharmaceutics, Medical College of Jiaxing University, Jiaxing 314033, China
Shuilin Sun Department of Infectious Diseases, The Second Affiliated Hospital of Nanchang University, Nanchang 330006, China; (Z.S.); (Q.X.); (Y.Z.); (Y.L.); (Z.W.); (D.Y.); (C.L.)

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Monet C, De Jong A, Aarab Y, Piron L, Prades A, Carr J, Belafia F, Chanques G, Guiu B, Pageaux GP, Jaber S. Adverse events, short- and long-term outcomes of extra corporeal liver therapy in the intensive care unit: 16 years experience with MARS® in a single center. Crit Care 2022;26:282. [PMID: 36123713 PMCID: PMC9484245 DOI: 10.1186/s13054-022-04165-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/10/2022] [Indexed: 12/04/2022] Open

Abstract

Background

Molecular Adsorbent Recirculating System (MARS®) is a non-biological artificial liver device. The benefit risk ratio between uncertain clinical effects and potential adverse events remains difficult to assess. We sought to describe adverse events related to MARS® therapy as well as biological and clinical effects.

Methods

All intensive care unit (ICU) admissions to whom MARS® therapy was prescribed from March 2005 to August 2021 were consecutively and prospectively included. The main endpoint was the incidence of adverse events related to MARS® therapy. Secondary endpoints were the biological and clinical effects of MARS® therapy.

Results

We reported 180 admissions treated with MARS® therapy. Among the 180 admissions, 56 (31.1%) were for acute-on-chronic liver failure, 32 (17.8%) for acute liver failure, 28 (15.5%) for post-surgery liver failure, 52 (28.9%) for pruritus and 12 (6.7%) for drug intoxication. At least one adverse event occurred in 95 (52.8%) admissions. Thrombocytopenia was the most frequent adverse event which was recorded in 55 admissions (30.6%). Overall, platelets count was 131 (± 95) × 10⁹/L before and 106 (± 72) × 10⁹/L after MARS® therapy (p < .001). After MARS® therapy, total bilirubin was significantly decreased in all groups (p < 0.05). Hepatic encephalopathy significantly improved in both the acute-on-chronic and in the acute liver failure group (p = 0.01). In the pruritus group, pruritus intensity score was significantly decreased after MARS® therapy (p < 0.01).

Conclusion

In this large cohort of patients treated with MARS® therapy we report frequent adverse events. Thrombocytopenia was the most frequent adverse event. In all applications significant clinical and biological improvements were shown with MARS® therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04165-z.

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Ramakrishnan S, Hans R, Duseja A, Sharma RR. Therapeutic plasma exchange is a safe and effective bridge therapy in patients with alcohol-associated ACLF not having immediate prospects for liver transplantation-A case-control, pilot study. J Clin Apher 2022;37:553-562. [PMID: 36065827 DOI: 10.1002/jca.22010] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 01/08/2022] [Accepted: 08/19/2022] [Indexed: 11/11/2022]

Abstract

BACKGROUND

Therapeutic plasma exchange (TPE) is a well-established treatment modality in acute liver failure patients, but its efficacy in treating acute on chronic liver failure (ACLF) patients is yet to be established.

AIM

To assess the efficacy and safety of TPE in patients with alcohol-associated ACLF who were nonresponders to standard medical treatment (SMT) and without immediate prospects for liver transplantation.

METHODS

Twenty-eight alcohol-related ACLF (grade II) patients (14 cases and 14 controls) were enrolled in the study. Cases underwent standard volume TPE along with SMT while the controls were on SMT alone. The change (baseline to day 10) in laboratory parameters, cytokine concentrations, clinical severity scores along with 30 and 90 day mortality rates were noted and compared between the two groups. The adverse events (AEs) were noted in the groups and analyzed.

RESULTS

A total of 51 TPE procedures were performed in 14 patients (average of 3.62 procedures/patient). TPE was effective in reduction of serum bilirubin, ammonia, activated partial thromboplastin time, prothrombin time, international normalized ratio, and severity scores (ACLF Research Consortium, Maddrey's discriminant function, and model for end-stage liver disease) (P < .05). There was no significant difference in the reduction of serum interleukin-6 (IL-6), IL-10, and tumor necrosis factor-α concentrations among cases. Among the cases who received the complete TPE interventions, 30- and 90-day mortality rates were lower in the cases as compared to controls albeit only the 90-day mortality was significantly different. Procedure-related AEs was observed in 2% of procedures.

CONCLUSION

TPE is an effective and well-tolerated bridge therapy in patients with alcohol-associated ACLF of moderate severity not improving on SMT and without immediate prospects for liver transplantation.

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Buccheri S, Da BL. Hepatorenal Syndrome: Definitions, Diagnosis, and Management. Clin Liver Dis 2022;26:181-201. [PMID: 35487604 DOI: 10.1016/j.cld.2022.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]

Habas E, Ibrahim AR, Moursi MO, Shraim BA, Elgamal ME, Elzouki AN. Update on hepatorenal Syndrome: Definition, Pathogenesis, and management. Arab J Gastroenterol 2022;23:125-133. [PMID: 35473682 DOI: 10.1016/j.ajg.2022.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 12/25/2021] [Accepted: 01/27/2022] [Indexed: 12/18/2022]

Liu S, Meng Q, Xu Y, Zhou J. Hepatorenal syndrome in acute-on-chronic liver failure with acute kidney injury: more questions requiring discussion. Gastroenterol Rep (Oxf) 2021;9:505-520. [PMID: 34925848 PMCID: PMC8677535 DOI: 10.1093/gastro/goab040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 07/04/2021] [Accepted: 07/29/2021] [Indexed: 12/13/2022] Open

Tinti F, Umbro I, D’Alessandro M, Lai S, Merli M, Noce A, Di Daniele N, Mazzaferro S, Mitterhofer AP. Cholemic Nephropathy as Cause of Acute and Chronic Kidney Disease. Update on an Under-Diagnosed Disease. Life (Basel) 2021;11:1200. [PMID: 34833076 PMCID: PMC8620937 DOI: 10.3390/life11111200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 12/14/2022] Open

Hepatorenal syndrome: pathophysiology and evidence-based management update. ROMANIAN JOURNAL OF INTERNAL MEDICINE 2021;59:227-261. [DOI: 10.2478/rjim-2021-0006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Indexed: 11/20/2022] Open

Vipani A, Lindenmeyer CC, Sundaram V. Treatment of Severe Acute on Chronic Liver Failure: Management of Organ Failures, Investigational Therapeutics, and the Role of Liver Transplantation. J Clin Gastroenterol 2021;55:667-676. [PMID: 34028394 DOI: 10.1097/mcg.0000000000001568] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]

Liver Transplantation in Acute-on-chronic Liver Failure. Transplantation 2021;105:1471-1481. [PMID: 33208692 DOI: 10.1097/tp.0000000000003550] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]

Juanola A, Solé C, Toapanta D, Ginès P, Solà E. Monitoring Renal Function and Therapy of Hepatorenal Syndrome Patients with Cirrhosis. Clin Liver Dis 2021;25:441-460. [PMID: 33838860 DOI: 10.1016/j.cld.2021.01.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]

Ocskay K, Kanjo A, Gede N, Szakács Z, Pár G, Erőss B, Stange J, Mitzner S, Hegyi P, Molnár Z. Uncertainty in the impact of liver support systems in acute-on-chronic liver failure: a systematic review and network meta-analysis. Ann Intensive Care 2021;11:10. [PMID: 33462764 PMCID: PMC7813174 DOI: 10.1186/s13613-020-00795-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/18/2020] [Indexed: 12/16/2022] Open

Cheungpasitporn W, Thongprayoon C, Zoghby ZM, Kashani K. MARS: Should I Use It? Adv Chronic Kidney Dis 2021;28:47-58. [PMID: 34389137 DOI: 10.1053/j.ackd.2021.02.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 01/20/2021] [Accepted: 02/02/2021] [Indexed: 11/11/2022]

Simonetto DA, Gines P, Kamath PS. Hepatorenal syndrome: pathophysiology, diagnosis, and management. BMJ 2020;370:m2687. [PMID: 32928750 DOI: 10.1136/bmj.m2687] [Citation(s) in RCA: 124] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]

Chen X, Bai M, Zhao L, Li Y, Yu Y, Zhang W, Ma F, Sun S, Chen X. Characteristics and outcomes of Stanford type A aortic dissection patients with severe post-operation hyperbilirubinemia: a retrospective cohort study. J Cardiothorac Surg 2020;15:195. [PMID: 32723390 PMCID: PMC7388495 DOI: 10.1186/s13019-020-01243-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/20/2020] [Indexed: 12/15/2022] Open

Abstract

BACKGROUND

Hyperbilirubinemia is one of the common complications after cardiac surgery and is associated with increased mortality. However, to the best of our knowledge, the reports on clinical significance of postoperative severe hyperbilirubinemia in Stanford type A aortic dissection (AAD) patients were limited.

METHODS

Patients who underwent surgical treatment for AAD in our center between January 2015 and December 2018 were retrospectively screened. In-hospital mortality, long-term mortality, acute kidney injury (AKI), and the requirement of continuous renal replacement therapy (CRRT) were assessed as endpoints. Univariate and multivariate regression models were employed to identify the risk factors of these endpoints.

RESULTS

After screening, 271 patients were included in our present study. Of the included patients, 222 (81.9%) experienced postoperative AKI, and 50 (18.5%) received CRRT. The in-hospital mortality was 30.3%. The 1-year, 2-year, and 3-year cumulative mortality were 32.9, 33.9, and 35.3%, respectively. Multivariate Logistic regression analysis indicated that age (P < 0.033), AKI stage 3 (P < 0.001), the amount of blood transfusion after surgery (P = 0.019), mean arterial pressure (MAP) in the first postoperative day (P = 0.012), the use of extracorporeal membrane oxygenation (ECMO) (P = 0.02), and the peak total bilirubin (TB) concentration (P = 0.023) were independent risk factors of in-hospital mortality. The optimal cut-off value of peak TB on predicting in-hospital mortality was 121.2 μmol/L. Patients with post-operation TB ≥ 121 μmol/L was associated with worse long-term survival as well.

CONCLUSIONS

Severe post-operation hyperbilirubinemia is a common clinical situation in patients had AAD repair. In AAD patients with severe post-operation hyperbilirubinemia, older age, lower MAP, increased blood transfusion, stage 3 AKI, the use of ECMO, and the increased peak TB lead to increase in-hospital mortality.

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Wang L, Long Y, Li KX, Xu GS. Pharmacological treatment of hepatorenal syndrome: a network meta-analysis. Gastroenterol Rep (Oxf) 2020;8:111-118. [PMID: 32280470 PMCID: PMC7136720 DOI: 10.1093/gastro/goz043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 08/06/2019] [Accepted: 08/09/2019] [Indexed: 12/15/2022] Open

Tomescu D, Popescu M, Biancofiore G. Liver transplantation for acute-on-chronic liver failure. Best Pract Res Clin Anaesthesiol 2019;34:25-33. [PMID: 32334784 DOI: 10.1016/j.bpa.2019.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Accepted: 12/03/2019] [Indexed: 11/24/2022]

Alshamsi F, Alshammari K, Belley-Cote E, Dionne J, Albrahim T, Albudoor B, Ismail M, Al-Judaibi B, Baw B, Subramanian RM, Steadman R, Galusca D, Huang DT, Nanchal R, Al Quraini M, Yuan Y, Alhazzani W. Extracorporeal liver support in patients with liver failure: a systematic review and meta-analysis of randomized trials. Intensive Care Med 2019;46:1-16. [PMID: 31588983 DOI: 10.1007/s00134-019-05783-y] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Accepted: 09/10/2019] [Indexed: 12/11/2022]

Affiliation(s)

Fayez Alshamsi Department of Internal Medicine, College of Medicine and Health Sciences, United Arab Emirates University, PO Box 17666, Al Ain, United Arab Emirates
Khalil Alshammari Department of Internal Medicine, Al Imam Mohammad Ibn Saud Islamic University (IMSIU), Riyadh, Saudi Arabia
Emilie Belley-Cote Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
Joanna Dionne Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada
Talal Albrahim Department of Anesthesiology and Critical Care Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
Budoor Albudoor Department of Critical Care Medicine, Shaikh Khalifa Medical City, Abu Dhabi, United Arab Emirates
Mona Ismail Division of Gastroenterology, Department of Internal Medicine, College of Medicine, Imam Abdulrahman Bin Faisal University, Al-Khobar, Saudi Arabia
Bandar Al-Judaibi Transplant Hepatology, University of Rochester Medical Center, 601 Elmwood Avenue, Rochester, NY, USA, 14642
Bandar Baw Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
Ram M Subramanian Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
Randolph Steadman Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA
Dragos Galusca Department of Anesthesiology, Henry Ford Hospital, Detroit, MI, USA
David T Huang Department of Critical Care Medicine, Director Multidisciplinary Acute Care Research Organization (MACRO), University of Pittsburgh Medical Center, Pittsburgh, PA, USA
Rahul Nanchal Department of Pulmonary, Critical Care and Sleep Medicine, Medical College of Wisconsin, Milwaukee, WI, USA
Mustafa Al Quraini Department of Pulmonary and Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia
Yuhong Yuan Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada
Waleed Alhazzani Division of Critical Care, Department of Medicine, McMaster University, Hamilton, ON, L8S 4K1, Canada. Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, ON, L8S 4K1, Canada.

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Bañares R, Ibáñez-Samaniego L, Torner JM, Pavesi M, Olmedo C, Catalina MV, Albillos A, Larsen FS, Nevens F, Hassanein T, Schmidt H, Heeman U, Jalan R, Moreau R, Arroyo V. Meta-analysis of individual patient data of albumin dialysis in acute-on-chronic liver failure: focus on treatment intensity. Therap Adv Gastroenterol 2019;12:1756284819879565. [PMID: 31632458 PMCID: PMC6767713 DOI: 10.1177/1756284819879565] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open

Abstract

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a common complication of cirrhosis characterized by single or multiple organ failures and high short-term mortality. Treatment of ACLF consists of standard medical care (SMC) and organ(s) support. Whether the efficacy of artificial liver support (ALS) depends on the severity of ACLF or on the intensity of this treatment, or both, is unclear. This study aimed to further assess these issues.

METHODS

We performed an individual patient data meta-analysis assessing the efficacy of Molecular Adsorbent Recirculating System (MARS) in ACLF patients enrolled in prior randomized control trials (RCTs). The meta-analysis was designed to assess the effect of patient severity (ACLF grade) and treatment intensity [low-intensity therapy (LIT), SMC alone or SMC plus ⩽ 4 MARS sessions, high-intensity therapy (HIT), SMC plus > 4 MARS sessions] on mortality.

RESULTS

Three RCTs suitable for the meta-analysis (n = 285, ACLF patients = 165) were identified in a systematic review. SMC plus MARS (irrespective of the number of sessions) did not improve survival compared with SMC alone, neither in the complete population nor in the ACLF patients. Survival, however, was significantly improved in the subgroup of patients receiving HIT both in the entire cohort (10-day survival: 98.6% versus 82.8%, p = 0.001; 30-day survival: 73.9% versus 64.3%, p = 0.032) and within the ACLF patients (10-day survival: 97.8% versus 78.6%, p = 0.001; 30-day survival: 73.3% versus 58.5%, p = 0.041). Remarkably, HIT increased survival independently of ACLF grade. Independent predictors of survival were age, Model for End-Stage Liver Disease (MELD), ACLF grade, number of MARS sessions received, and intensity of MARS therapy.

CONCLUSION

HIT with albumin dialysis may improve survival in patients with ACLF. Appropriate treatment schedules should be determined in future clinical trials.

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Affiliation(s)

Rafael Bañares
Luis Ibáñez-Samaniego Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
Josep María Torner EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EfClif), Barcelona, Spain
Marco Pavesi EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EfClif), Barcelona, Spain
Carmen Olmedo Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
María Vega Catalina Servicio de Medicina de Aparato Digestivo, Hospital General Universitario Gregorio Marañón, CIBERehd, Madrid, Spain Instituto de Investigación Sanitaria Gregorio Marañón, Madrid, Spain
Agustín Albillos Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, IRYCIS, Universidad de Alcalá, Madrid, Spain
Fin Stolze Larsen Department of Hepatology, Copenhagen University Rigshospitalet, Copenhagen, Denmark
Frederik Nevens Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Belgium
Tarek Hassanein The University of California, San Diego School of Medicine, Southern California Liver Centers, Southern California Research Center, San Diego, USA
Harmuth Schmidt Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
Uwe Heeman Department of Nephrology, Klinikum Rechts der Isar, Technische Universität München, Munich, Germany
Rajiv Jalan Division of Medicine, UCL Medical School, Royal Free Hospital, UCL Institute for Liver and Digestive Health, London, UK
Richard Moreau INSERM, Center de Recherche sur l’Inflammation (CRI); Université Paris Diderot, Sorbonne Paris; Service d’Hépatologie, Hôpital Beaujon, Clichy, France
Vicente Arroyo EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EfClif), Barcelona, Spain

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Best LMJ, Freeman SC, Sutton AJ, Cooper NJ, Tng E, Csenar M, Hawkins N, Pavlov CS, Davidson BR, Thorburn D, Cowlin M, Milne EJ, Tsochatzis E, Gurusamy KS. Treatment for hepatorenal syndrome in people with decompensated liver cirrhosis: a network meta-analysis. Cochrane Database Syst Rev 2019;9:CD013103. [PMID: 31513287 PMCID: PMC6740336 DOI: 10.1002/14651858.cd013103.pub2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]

Abstract

BACKGROUND

Hepatorenal syndrome is defined as renal failure in people with cirrhosis in the absence of other causes. In addition to supportive treatment such as albumin to restore fluid balance, the other potential treatments include systemic vasoconstrictor drugs (such as vasopressin analogues or noradrenaline), renal vasodilator drugs (such as dopamine), transjugular intrahepatic portosystemic shunt (TIPS), and liver support with molecular adsorbent recirculating system (MARS). There is uncertainty over the best treatment regimen for hepatorenal syndrome.

OBJECTIVES

To compare the benefits and harms of different treatments for hepatorenal syndrome in people with decompensated liver cirrhosis.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and trial registers until December 2018 to identify randomised clinical trials on hepatorenal syndrome in people with cirrhosis.

SELECTION CRITERIA

We included only randomised clinical trials (irrespective of language, blinding, or publication status) in adults with cirrhosis and hepatorenal syndrome. We excluded randomised clinical trials in which participants had previously undergone liver transplantation.

DATA COLLECTION AND ANALYSIS

Two authors independently identified eligible trials and collected data. The outcomes for this review included mortality, serious adverse events, any adverse events, resolution of hepatorenal syndrome, liver transplantation, and other decompensation events. We performed a network meta-analysis with OpenBUGS using Bayesian methods and calculated the odds ratio (OR), rate ratio, hazard ratio (HR), and mean difference (MD) with 95% credible intervals (CrI) based on an available-case analysis, according to National Institute of Health and Care Excellence Decision Support Unit guidance.

MAIN RESULTS

We included a total of 25 trials (1263 participants; 12 interventions) in the review. Twenty-three trials (1185 participants) were included in one or more outcomes. All the trials were at high risk of bias, and all the evidence was of low or very low certainty. The trials included participants with liver cirrhosis of varied aetiologies as well as a mixture of type I hepatorenal syndrome only, type II hepatorenal syndrome only, or people with both type I and type II hepatorenal syndrome. Participant age ranged from 42 to 60 years, and the proportion of females ranged from 5.8% to 61.5% in the trials that reported this information. The follow-up in the trials ranged from one week to six months. Overall, 59% of participants died during this period and about 35% of participants recovered from hepatorenal syndrome. The most common interventions compared were albumin plus terlipressin, albumin plus noradrenaline, and albumin alone.There was no evidence of a difference in mortality (22 trials; 1153 participants) at maximal follow-up between the different interventions. None of the trials reported health-related quality of life. There was no evidence of differences in the proportion of people with serious adverse events (three trials; 428 participants), number of participants with serious adverse events per participant (two trials; 166 participants), proportion of participants with any adverse events (four trials; 402 participants), the proportion of people who underwent liver transplantation at maximal follow-up (four trials; 342 participants), or other features of decompensation at maximal follow-up (one trial; 466 participants). Five trials (293 participants) reported number of any adverse events, and five trials (219 participants) reported treatment costs. Albumin plus noradrenaline had fewer numbers of adverse events per participant (rate ratio 0.51, 95% CrI 0.28 to 0.87). Eighteen trials (1047 participants) reported recovery from hepatorenal syndrome (as per definition of hepatorenal syndrome). In terms of recovery from hepatorenal syndrome, in the direct comparisons, albumin plus midodrine plus octreotide and albumin plus octreotide had lower recovery from hepatorenal syndrome than albumin plus terlipressin (HR 0.04; 95% CrI 0.00 to 0.25 and HR 0.26, 95% CrI 0.07 to 0.80 respectively). There was no evidence of differences between the groups in any of the other direct comparisons. In the network meta-analysis, albumin and albumin plus midodrine plus octreotide had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin.

FUNDING

two trials were funded by pharmaceutical companies; five trials were funded by parties who had no vested interest in the results of the trial; and 18 trials did not report the source of funding.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence, there is no evidence of benefit or harm of any of the interventions for hepatorenal syndrome with regards to the following outcomes: all-cause mortality, serious adverse events (proportion), number of serious adverse events per participant, any adverse events (proportion), liver transplantation, or other decompensation events. Low-certainty evidence suggests that albumin plus noradrenaline had fewer 'any adverse events per participant' than albumin plus terlipressin. Low- or very low-certainty evidence also found that albumin plus midodrine plus octreotide and albumin alone had lower recovery from hepatorenal syndrome compared with albumin plus terlipressin.Future randomised clinical trials should be adequately powered; employ blinding, avoid post-randomisation dropouts or planned cross-overs (or perform an intention-to-treat analysis); and report clinically important outcomes such as mortality, health-related quality of life, adverse events, and recovery from hepatorenal syndrome. Albumin plus noradrenaline and albumin plus terlipressin appear to be the interventions that should be compared in future trials.

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Affiliation(s)

Lawrence MJ Best University College LondonDivision of Surgery and Interventional ScienceRowland Hill StreetLondonUKNW32PF
Suzanne C Freeman University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
Alex J Sutton University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
Nicola J Cooper University of LeicesterDepartment of Health SciencesUniversity RoadLeicesterUKLE1 7RH
Eng‐Loon Tng Ng Teng Fong General Hospital National University Health SystemDepartment of Medicine1 Jurong East Street 21SingaporeSingapore609606
Mario Csenar University College LondonDivision of Surgery and Interventional ScienceRowland Hill StreetLondonUKNW32PF
Neil Hawkins University of GlasgowHEHTAUniversity Ave Glasgow G12 8QQGlasgowUK
Chavdar S Pavlov Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
Brian R Davidson University College LondonDivision of Surgery and Interventional ScienceRowland Hill StreetLondonUKNW32PF
Douglas Thorburn Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
Maxine Cowlin PSC SupportPO Box 6945LondonUK
Elisabeth Jane Milne Coventry UniversityCentre for Trust, Peace and Social RelationsCoventryUK
Emmanuel Tsochatzis Royal Free Hospital and the UCL Institute of Liver and Digestive HealthSheila Sherlock Liver CentrePond StreetLondonUKNW3 2QG
Kurinchi Selvan Gurusamy University College LondonDivision of Surgery and Interventional ScienceRowland Hill StreetLondonUKNW32PF 'Sechenov' First Moscow State Medical UniversityCenter for Evidence‐Based MedicinePogodinskja st. 1\1MoscowRussian Federation119881
Cochrane Hepato‐Biliary Group

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Renal Replacement Therapy in the Critical Care Setting. Crit Care Res Pract 2019;2019:6948710. [PMID: 31396416 PMCID: PMC6664494 DOI: 10.1155/2019/6948710] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Accepted: 05/29/2019] [Indexed: 12/16/2022] Open

Sarin SK, Choudhury A, Sharma MK, Maiwall R, Al Mahtab M, Rahman S, Saigal S, Saraf N, Soin AS, Devarbhavi H, Kim DJ, Dhiman RK, Duseja A, Taneja S, Eapen CE, Goel A, Ning Q, Chen T, Ma K, Duan Z, Yu C, Treeprasertsuk S, Hamid SS, Butt AS, Jafri W, Shukla A, Saraswat V, Tan SS, Sood A, Midha V, Goyal O, Ghazinyan H, Arora A, Hu J, Sahu M, Rao PN, Lee GH, Lim SG, Lesmana LA, Lesmana CR, Shah S, Prasad VGM, Payawal DA, Abbas Z, Dokmeci AK, Sollano JD, Carpio G, Shresta A, Lau GK, Fazal Karim M, Shiha G, Gani R, Kalista KF, Yuen MF, Alam S, Khanna R, Sood V, Lal BB, Pamecha V, Jindal A, Rajan V, Arora V, Yokosuka O, Niriella MA, Li H, Qi X, Tanaka A, Mochida S, Chaudhuri DR, Gane E, Win KM, Chen WT, Rela M, Kapoor D, Rastogi A, Kale P, Rastogi A, Sharma CB, Bajpai M, Singh V, Premkumar M, Maharashi S, Olithselvan A, Philips CA, Srivastava A, Yachha SK, Wani ZA, Thapa BR, Saraya A, Shalimar, Kumar A, Wadhawan M, Gupta S, Madan K, Sakhuja P, Vij V, Sharma BC, Garg H, Garg V, Kalal C, et alSarin SK, Choudhury A, Sharma MK, Maiwall R, Al Mahtab M, Rahman S, Saigal S, Saraf N, Soin AS, Devarbhavi H, Kim DJ, Dhiman RK, Duseja A, Taneja S, Eapen CE, Goel A, Ning Q, Chen T, Ma K, Duan Z, Yu C, Treeprasertsuk S, Hamid SS, Butt AS, Jafri W, Shukla A, Saraswat V, Tan SS, Sood A, Midha V, Goyal O, Ghazinyan H, Arora A, Hu J, Sahu M, Rao PN, Lee GH, Lim SG, Lesmana LA, Lesmana CR, Shah S, Prasad VGM, Payawal DA, Abbas Z, Dokmeci AK, Sollano JD, Carpio G, Shresta A, Lau GK, Fazal Karim M, Shiha G, Gani R, Kalista KF, Yuen MF, Alam S, Khanna R, Sood V, Lal BB, Pamecha V, Jindal A, Rajan V, Arora V, Yokosuka O, Niriella MA, Li H, Qi X, Tanaka A, Mochida S, Chaudhuri DR, Gane E, Win KM, Chen WT, Rela M, Kapoor D, Rastogi A, Kale P, Rastogi A, Sharma CB, Bajpai M, Singh V, Premkumar M, Maharashi S, Olithselvan A, Philips CA, Srivastava A, Yachha SK, Wani ZA, Thapa BR, Saraya A, Shalimar, Kumar A, Wadhawan M, Gupta S, Madan K, Sakhuja P, Vij V, Sharma BC, Garg H, Garg V, Kalal C, Anand L, Vyas T, Mathur RP, Kumar G, Jain P, Pasupuleti SSR, Chawla YK, Chowdhury A, Alam S, Song DS, Yang JM, Yoon EL. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update. Hepatol Int 2019;13:353-390. [PMID: 31172417 PMCID: PMC6728300 DOI: 10.1007/s12072-019-09946-3] [Show More Authors] [Citation(s) in RCA: 553] [Impact Index Per Article: 92.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/03/2019] [Indexed: 02/07/2023]

Abstract

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

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Affiliation(s)

Shiv Kumar Sarin Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
Ashok Choudhury Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Manoj K Sharma Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Rakhi Maiwall Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Mamun Al Mahtab Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
Salimur Rahman Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
Sanjiv Saigal Department of Hepatology, Medanta The Medicity, Gurgaon, India
Neeraj Saraf Department of Hepatology, Medanta The Medicity, Gurgaon, India
A S Soin Department of Hepatology, Medanta The Medicity, Gurgaon, India
Harshad Devarbhavi Department of Hepatology, St John Medical College, Bangalore, India
Dong Joon Kim Department of Internal Medicine, Hallym University College of Medicine, Seoul, South Korea
R K Dhiman Department of Hepatology, PGIMER, Chandigarh, India
Ajay Duseja Department of Hepatology, PGIMER, Chandigarh, India
Sunil Taneja Department of Hepatology, PGIMER, Chandigarh, India
C E Eapen Department of Hepatology, CMC, Vellore, India
Ashish Goel Department of Hepatology, CMC, Vellore, India
Q Ning Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Tao Chen Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
Ke Ma Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Z Duan Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
Chen Yu Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
Sombat Treeprasertsuk Department of Medicine, Chulalongkorn University, Bangkok, Thailand
S S Hamid Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Amna S Butt Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Wasim Jafri Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
Akash Shukla Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
Vivek Saraswat Department of Gastroenterology, SGPGIMS, Lucknow, India
Soek Siam Tan Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
Ajit Sood Department of Gastroenterology, DMC, Ludhiana, India
Vandana Midha Department of Gastroenterology, DMC, Ludhiana, India
Omesh Goyal Department of Gastroenterology, DMC, Ludhiana, India
Hasmik Ghazinyan Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
Anil Arora Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital and GRIPMER, New Delhi, Delhi, India
Jinhua Hu Department of Medicine, 302 Millitary Hospital, Beijing, China
Manoj Sahu Department of Gastroenterology and Hepatology Sciences, IMS & SUM Hospital, Bhubaneswar, Odisha, India
P N Rao Asian Institute of Gastroenterology, Hyderabad, India
Guan H Lee Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
Seng G Lim Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
Laurentius A Lesmana Digestive Disease and GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
Cosmas Rinaldi Lesmana Digestive Disease and GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
Samir Shah Department of Hepatology, Global Hospitals, Mumbai, India
V G Mohan Prasad Department of Gastroenterology, VGM Hospital, Coimbatore, India
Diana A Payawal Fatima University Medical Center Manila, Manila, Philippines
Zaigham Abbas Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
A Kadir Dokmeci Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
Jose D Sollano Department of Medicine, University of Santo Tomas, Manila, Philippines
Gian Carpio Department of Medicine, University of Santo Tomas, Manila, Philippines
Ananta Shresta Department of Hepatology, Foundation Nepal Sitapaila Height, Kathmandu, Nepal
G K Lau Department of Medicine, Humanity and Health Medical Group, New Kowloon, Hong Kong, China
Md Fazal Karim Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
Gamal Shiha Egyptian Liver Research Institute And Hospital, Cairo, Egypt
Rino Gani Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
Kemal Fariz Kalista Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
Man-Fung Yuen Department of Medicine, Queen Mary Hospital Hong Kong, The University of Hong Kong, Hong Kong, China
Seema Alam Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Rajeev Khanna Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Vikrant Sood Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Bikrant Bihari Lal Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Viniyendra Pamecha Department of Hepatobilliary Pancreatic Surgery and Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Ankur Jindal Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
V Rajan Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Vinod Arora Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Osamu Yokosuka Professor Emeritus, Chiba University, Chiba, Japan
Madunil A Niriella Department of Medicine, University of Kelaniya, Ragama, Sri Lanka
Hai Li Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
Xiaolong Qi CHESS Frontier Center, The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China
Atsushi Tanaka Department of Medicine, Tokyo University School of Medicine, Tokyo, Japan
Satoshi Mochida Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
Dominic Ray Chaudhuri New Zealand Liver Transplant Unit, Auckland Hospital, Auckland, New Zealand
Ed Gane New Zealand Liver Transplant Unit, Auckland Hospital, Auckland, New Zealand
Khin Maung Win Yangon GI and Liver Centre, Pabedan, Yangon, Myanmar
Wei Ting Chen Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
Mohd Rela Department of Liver Transplant Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
Dharmesh Kapoor Department of Hepatology, Global Hospitals, Mumbai, India
Amit Rastogi Department of Hepatology, Medanta The Medicity, Gurgaon, India
Pratibha Kale Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Archana Rastogi Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Chhagan Bihari Sharma Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Meenu Bajpai Department of Immunohematology and Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
Virender Singh Department of Hepatology, PGIMER, Chandigarh, India
Madhumita Premkumar Department of Hepatology, PGIMER, Chandigarh, India
Sudhir Maharashi Department of Gatroenterology, SMS Med College, Jaipur, India
A Olithselvan Division of Liver Transplantation and Hepatology, Manipal Hospitals, Bangalore, India
Cyriac Abby Philips The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, India
Anshu Srivastava Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
Surender K Yachha Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
Zeeshan Ahmad Wani Noora Hospital in Srinagar, Shrinagar, India
B R Thapa Department of Gastroenterology and Pediatric Gastroenterology, PGIMER, Chandigarh, India
Anoop Saraya Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi, India
Shalimar Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi, India
Ashish Kumar Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital and GRIPMER, New Delhi, Delhi, India
Manav Wadhawan Department of Gastroenterology, Hepatology and Liver Transplant, B L K Hospital, New Delhi, India
Subash Gupta Centre for Liver and Biliary Science, Max Hospital, New Delhi, India
Kaushal Madan Department of Gastroenterology, Hepatology and Liver Transplant, Max Hospital, New Delhi, India
Puja Sakhuja Department of Pathology, GB Pant Hospital, New Delhi, India
Vivek Vij Department of Liver Transplant and Hepatobilliary Surgery, Fortis Hospital, New Delhi, India
Barjesh C Sharma Department of Gastroenterology, GB Pant Hospital, New Delhi, India
Hitendra Garg Department of Gastroenterology, Hepatology and Liver Transplant, Apollo Hospital, New Delhi, India
Vishal Garg Department of Gastroenterology, Hepatology and Liver Transplant, Apollo Hospital, New Delhi, India
Chetan Kalal Department of Hepatology, Sir H N Reliance Hospital and Research Centre, Mumbai, India
Lovkesh Anand Department of Gastroenterology and Hepatology, Narayana Hospital, Gurugram, India
Tanmay Vyas Department of Hepatology, Parimal Multi-Speciality Hospital, Ahmedabad, India
Rajan P Mathur Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
Guresh Kumar Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
Priyanka Jain Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
Samba Siva Rao Pasupuleti Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
Yogesh K Chawla Department of Hepatology and Gastroenterology, Kalinga Institute of Med Sciences, KIIT University, Bhubaneswar, India
Abhijit Chowdhury Department of Hepatology, Institute of Post Graduate Medical Education and Research, Kolkata, India
Shahinul Alam Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
Do Seon Song Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
Jin Mo Yang Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
Eileen L Yoon Department Of Internal Medicine, Inje University College of Medicine, Busan, South Korea

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Kandiah PA, Subramanian RM. Extracorporeal Devices. Crit Care Clin 2019;35:135-150. [PMID: 30447776 DOI: 10.1016/j.ccc.2018.08.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]

Ning Q. Main Complications of AECHB and Severe Hepatitis B (Liver Failure). ACUTE EXACERBATION OF CHRONIC HEPATITIS B 2019. [PMCID: PMC7498917 DOI: 10.1007/978-94-024-1603-9_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]

García Martínez JJ, Bendjelid K. Artificial liver support systems: what is new over the last decade? Ann Intensive Care 2018;8:109. [PMID: 30443736 PMCID: PMC6238018 DOI: 10.1186/s13613-018-0453-z] [Citation(s) in RCA: 81] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Accepted: 11/07/2018] [Indexed: 12/16/2022] Open

Solé C, Pose E, Solà E, Ginès P. Hepatorenal syndrome in the era of acute kidney injury. Liver Int 2018;38:1891-1901. [PMID: 29845739 DOI: 10.1111/liv.13893] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 05/21/2018] [Indexed: 12/13/2022]

Ginès P, Solà E, Angeli P, Wong F, Nadim MK, Kamath PS. Hepatorenal syndrome. Nat Rev Dis Primers 2018;4:23. [PMID: 30213943 DOI: 10.1038/s41572-018-0022-7] [Citation(s) in RCA: 167] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]

KASL clinical practice guidelines for liver cirrhosis: Ascites and related complications. Clin Mol Hepatol 2018;24:230-277. [PMID: 29991196 PMCID: PMC6166105 DOI: 10.3350/cmh.2018.1005] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 04/06/2018] [Indexed: 02/07/2023] Open

Kim MY, Seo YS. [Acute Kidney Injury and Hepatorenal Syndrome]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2018;72:64-73. [PMID: 30145858 DOI: 10.4166/kjg.2018.72.2.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]

DellaVolpe J, Al-Khafaji A. Acute Kidney Injury Before and After Liver Transplant. J Intensive Care Med 2018;34:687-695. [PMID: 30060683 DOI: 10.1177/0885066618790558] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]

Mindikoglu AL, Pappas SC. New Developments in Hepatorenal Syndrome. Clin Gastroenterol Hepatol 2018;16:162-177.e1. [PMID: 28602971 PMCID: PMC5831376 DOI: 10.1016/j.cgh.2017.05.041] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 05/26/2017] [Accepted: 05/28/2017] [Indexed: 02/07/2023]

Abstract

Hepatorenal syndrome (HRS) continues to be one of the major complications of decompensated cirrhosis, leading to death in the absence of liver transplantation. Challenges in precisely evaluating renal function in the patient with cirrhosis remain because of the limitations of serum creatinine (Cr) alone in estimating glomerular filtration rate (GFR); current GFR estimating models appear to underestimate renal dysfunction. Newer models incorporating renal biomarkers, such as the Cr-Cystatin C GFR Equation for Cirrhosis appear to estimate measured GFR more accurately. A major change in the diagnostic criteria for HRS based on dynamic serial changes in serum Cr that regard HRS type 1 as a special form of acute kidney injury promises the possibility of earlier identification of renal dysfunction in patients with cirrhosis. The diagnostic criteria of HRS still include the exclusion of other causes of kidney injury. Renal biomarkers have been disappointing in assisting with the differentiation of HRS from prerenal azotemia and other kidney disorders. Serum metabolomic profiling may be a more powerful tool to assess renal dysfunction, although the practical clinical significance of this remains unclear. As a result of the difficulties of assessing renal function in cirrhosis and the varying HRS diagnostic criteria and the rigor with which they are applied, the precise incidence and prevalence of HRS is unknown, but it is likely that HRS occurs more commonly than expected. The pathophysiology of HRS is rooted firmly in the setting of progressive reduction in renal blood flow as a result of portal hypertension and splanchnic vasodilation. Progressive marked renal cortical ischemia in patients with cirrhosis parallels the evolution of diuretic-sensitive ascites to diuretic-refractory ascites and HRS, a recognized continuum of renal dysfunction in cirrhosis. Alterations in nitrous oxide production, both increased and decreased, may play a major role in the pathophysiology of this evolution. The inflammatory cascade, triggered by bacterial translocation and endotoxemia, increasingly recognized as important in the manifestation of acute-on-chronic liver failure, also may play a significant role in the pathophysiology of HRS. The mainstay of treatment remains vasopressor therapy with albumin in an attempt to reverse splanchnic vasodilation and improve renal blood flow. Several meta-analyses have confirmed the value of vasopressors, chiefly terlipressin and noradrenaline, in improving renal function and reversing HRS type 1. Other interventions such as renal replacement therapy, transjugular intrahepatic portosystemic shunt, and artificial liver support systems have a very limited role in improving outcomes in HRS. Liver transplantation remains the definitive treatment for HRS. The frequency of simultaneous liver-kidney transplantation has increased dramatically in the Model for End-stage Liver Disease era, with changes in organ allocation policies. This has resulted in a more urgent need to predict native kidney recovery from HRS after liver transplantation alone, to avoid unnecessary simultaneous liver-kidney transplantation.

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Doria C, Doyle HR, Mandalà L, Marino IR, Caruana G, Gruttadauria S, Lauro A, Magnone M, Scotti Foglieni C, Lamonaca V, Scott VL. Changes in Serum Electrolytes during Treatment of Patients in Liver Failure with Molecular Adsorbent Recirculating System. Int J Artif Organs 2018;26:918-23. [PMID: 14636008 DOI: 10.1177/039139880302601008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]

O'Beirne JP, Wendon JA. Liver support. Int J Artif Organs 2018;28:477-81. [PMID: 15883962 DOI: 10.1177/039139880502800508] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]

Fabrizi F, Dixit V, Messa P, Martin P. Terlipressin for Hepatorenal Syndrome: A Meta-Analysis of Randomized Trials. Int J Artif Organs 2018. [DOI: 10.1177/039139880903200303] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]

Abstract Background Hepatorenal syndrome (HRS) is a severe complication of end-stage renal disease whose management still constitutes a big challenge. Various approaches have been used for hepatorenal syndrome treatment, including vasoconstrictor therapy. Terlipressin, a vasopressin analogue, has frequently been used. Aim To evaluate the efficacy and safety of terlipressin in patients with HRS by performing a systematic review with a meta-analysis of controlled, clinical trials. Methods Only prospective, placebo-controlled, randomized clinical trials (RCTs) were included. We used the random effects model of DerSimonian and Laird, with heterogeneity and subgroups analyses. The primary end-point of interest was the HRS reversal after terlipressin (or placebo) therapy in study patients vs. control patients (as a measure of efficacy). The secondary outcome was the rate of ischemic side-effects in study patients vs. placebo patients (as a measure of tolerability). The additional end-point was the impact of terlipressin on survival in the HRS population. Results We identified five studies involving 243 unique patients with HRS. Pooling of study results showed a significant increase in HRS reversal among study (terlipressin) versus control (placebo) patients; the pooled odd ratio (OR) of HRS reversal was 8.09; 95% CI, 3.521; 18.59; p=0.0001. The p-value was 0.5 for our test of study heterogeneity. In a subgroup analysis excluding case-control trials these results did not change. The rate of severe ischemic events was higher in study than control patients, pooled OR=2.907; 95% CI, 1.094; 7.723 (p=0.032). The test for heterogeneity was not significant. Terlipressin use had no significant impact upon survival (pooled OR for survival rate, 2.064; 95% CI, 0.939; 4.538; p=0.07). No significant heterogeneity (NS) was found. Conclusions Our meta-analysis shows that terlipressin has higher efficacy than placebo in reversing renal function in the HRS population. There was no apparent impact of terlipressin therapy on survival in HRS patients but further large-size trials are needed. Terlipressin use in the HRS population requires careful selection of patients and close clinical surveillance. These results support the use of terlipressin for reversal of renal function in the HRS population. Collapse

Gong D, Ji D, Ren B, Tao J, Xu B, Ronco C, Li L. Significant Decrease in Dialysate Albumin Concentration during Molecular Adsorbent Recirculating System (M.A.R.S.) Therapy. Int J Artif Organs 2018;31:333-9. [PMID: 18432590 DOI: 10.1177/039139880803100410] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]

Abstract Aim The molecular adsorbent recirculating system (M.A.R.S.) is widely used as liver support therapy in patients with hepatic dysfunction. The goal of this study was to measure changes in dialysate albumin and bilirubin concentrations during clinical MARS treatments. Methods Eight patients with acute liver dysfunction and hyperbilirubinemia were enrolled in this study. Five of them received a total of 10 treatments with MARS, in which 600 mL of 20% human albumin was used as dialysate, continuously regenerated by two adsorbent columns in the circuit. Three patients received 4 treatments of a modified MARS, in which the two adsorbent columns were bypassed in the first course for 4 h, and then connected to the circuit in the second course for another 4 h. The total, conjugated and unconjugated bilirubin (TB, CB, UCB) and albumin concentrations in serum and albumin dialysate were dynamically measured, and the adsorbent column inlet pressures were recorded during each session. In one session, dialysate albumin levels were measured during the priming process, at the time points prior to the priming process, immediately after priming, and at the end of the treatment. Results During MARS therapies, the reduction ratio of serum TB, CB and UCB was 26.6±9.0%, 29.5±9.6% and 14.8±12.3%, respectively. The molar ratio of TB/albumin in serum was approximately 20-fold higher than dialysate at all time points. A significant albumin concentration decrease from baseline in the dialysate was found (mean±SD, 34.6±16.6%). For the first four hours of modified treatments, in which only albumin dialysis without albumin regeneration by adsorbent columns was performed, the dialysate albumin decrease was substantially smaller (mean, 8.3±1.5%). After switching to standard MARS, there was a further decrease in the dialysate albumin concentration of 35.1±14.5%. In one session, dialysate albumin concentrations were measured during the priming process, and levels decreased from 196.9 g/L to 144.4 g/L. Adsorber inlet pressure increased from 40±10mmHg at the start of priming to 150±50mmHg at the end of priming, and further increased to 340±100mmHg at the end of treatment. Conclusion There is a significant reduction in dialysate albumin concentration during MARS therapy. Binding of albumin to the adsorbent columns used for albumin regeneration is largely responsible for this decrease. Collapse

Olson JC, Karvellas CJ. Critical care management of the patient with cirrhosis awaiting liver transplant in the intensive care unit. Liver Transpl 2017;23:1465-1476. [PMID: 28688155 DOI: 10.1002/lt.24815] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 06/28/2017] [Accepted: 06/29/2017] [Indexed: 02/07/2023]

Molecular Adsorbent Recirculating System Can Reduce Short-Term Mortality Among Patients With Acute-on-Chronic Liver Failure-A Retrospective Analysis. Crit Care Med 2017. [PMID: 28640024 PMCID: PMC5598913 DOI: 10.1097/ccm.0000000000002562] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]

Abstract

Supplemental Digital Content is available in the text.

Objectives:

Acute-on-chronic liver failure is associated with numerous consecutive organ failures and a high short-term mortality rate. Molecular adsorbent recirculating system therapy has demonstrated beneficial effects on the distinct symptoms, but the associated mortality data remain controversial.

Design:

Retrospective analysis of acute-on-chronic liver failure patients receiving either standard medical treatment or standard medical treatment and molecular adsorbent recirculating system. Secondary analysis of data from the prospective randomized Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure trial by applying the recently introduced Chronic Liver Failure-criteria.

Setting:

Medical Departments of University Hospital Muenster (Germany).

Patients:

This analysis was conducted in two parts. First, 101 patients with acute-on-chronic liver failure grades 1–3 and Chronic Liver Failure-C-Organ Failure liver subscore equals to 3 but stable pulmonary function were identified and received either standard medical treatment (standard medical treatment, n = 54) or standard medical treatment and molecular adsorbent recirculating system (n = 47) at the University Hospital Muenster. Second, the results of this retrospective analysis were tested against the Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure trial.

Interventions:

Standard medical treatment and molecular adsorbent recirculating system.

Measurements and Main Results:

Additionally to improved laboratory variables (bilirubin and creatinine), the short-term mortality (up to day 14) of the molecular adsorbent recirculating system group was significantly reduced compared with standard medical treatment. A reduced 14-day mortality rate was observed in the molecular adsorbent recirculating system group (9.5% vs 50.0% with standard medical treatment; p = 0.004), especially in patients with multiple organ failure (acute-on-chronic liver failure grade 2–3). Concerning the affected organ system, this effect of molecular adsorbent recirculating system on mortality was particularly evident among patients with increased kidney, brain, or coagulation Chronic Liver Failure-C-Organ Failure subscores. Subsequent reanalysis of the Recompensation of Exacerbated Liver Insufficiency with Hyperbilirubinemia and/or Encephalopathy and/or Renal Failure dataset with adoption of the Chronic Liver Failure-classification resulted in similar findings.

Conclusions:

Molecular adsorbent recirculating system treatment was associated with an improved short-term survival of patients with acute-on-chronic liver failure and multiple organ failure. Among these high-risk patients, molecular adsorbent recirculating system treatment might bridge to liver recovery or liver transplantation.

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Bonavia A, Pachuski J, Bezinover D. Perioperative Anesthetic Management of Patients Having Liver Transplantation for Uncommon Conditions. Semin Cardiothorac Vasc Anesth 2017;22:197-210. [PMID: 28922972 DOI: 10.1177/1089253217732129] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]

Karvellas CJ, Subramanian RM. Current Evidence for Extracorporeal Liver Support Systems in Acute Liver Failure and Acute-on-Chronic Liver Failure. Crit Care Clin 2017;32:439-51. [PMID: 27339682 DOI: 10.1016/j.ccc.2016.03.003] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]

Extracorporeal Liver Support Systems in Paediatric Liver Failure. J Pediatr Gastroenterol Nutr 2017;64:855-863. [PMID: 28248208 DOI: 10.1097/mpg.0000000000001500] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]

Extrakorporale Therapien bei Lebererkrankungen. Med Klin Intensivmed Notfmed 2017;112:444-453. [DOI: 10.1007/s00063-017-0289-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 03/24/2017] [Indexed: 10/19/2022]

Molecular adsorbent recirculating system (MARS) in acute liver injury and graft dysfunction: Results from a case-control study. PLoS One 2017;12:e0175529. [PMID: 28403210 PMCID: PMC5389829 DOI: 10.1371/journal.pone.0175529] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 03/27/2017] [Indexed: 12/24/2022] Open

Abstract

Background

The primary therapeutic goals in the treatment of liver injury are to support liver regeneration or bridge the gap to liver transplantation (LT). Molecular adsorbent recirculating system (MARS) therapy has shown beneficial effects for specific symptoms of liver failure; however, general survival advantages have not yet been demonstrated.

Aim

We studied the effects of MARS therapy compared to standard medical treatment (SMT) in two patient cohorts: in patients with an acute liver injury and in those with graft dysfunction (GD).

Methods

We report on our experience over a 6.5-year period with 73 patients treated with SMT or with SMT and MARS (MARS group). In total, 53 patients suffered from acute liver injury in their native liver without a preexisting liver disease (SMT: n = 31, MARS: n = 22), and 20 patients showed a severe GD after LT (SMT: n = 10, MARS: n = 10).

Results

The entire cohort was predominantly characterized by hemodynamically and respiratorily stable patients with a low hepatic encephalopathy (HE) grade and a model of end-stage liver disease (MELD) score of 20.57 (MARS) or 22.51 (SMT, p = 0.555). Within the MARS group, the median number of extracorporeal therapy sessions was four (range = 3–5 sessions). Independent of the underlying etiology, MARS improved the patients’ bilirubin values in the short term compared to SMT alone. In patients with acute liver injury, this response was sustained even after the end of MARS therapy. By contrast, the majority of patients with GD and an initial response to MARS therapy experienced worsened hyperbilirubinemia. No differences in 28-day mortality were observed with respect to acute liver injury (MARS 5.3% (95% CI: 0–15.3); SMT 3.3% (95% CI: 0–9.8), p = 0.754) or GD (MARS 20.0% (95% CI: 0–44.7), SMT 11.1% (95% CI: 0–31.7), p = 0.478).

Conclusions

Although it did not improve 28-day mortality, MARS therapy improved the short-term response in patients with acute liver injury as well as in those with GD. In cases of acute hepatic injury, the use of MARS therapy resulted in the sustained stabilization of liver function and improved liver regeneration. A short-term response to MARS may predict the future course of the disease.

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Sen S, Jalan R. The role of the Molecular Adsorbents Recirculating System (MARS) in the management of liver failure. Perfusion 2016;19 Suppl 1:S43-8. [PMID: 15161063 DOI: 10.1191/0267659104pf716oa] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]

Soo E, Sanders A, Heckert K, Vinke T, Schaefer F, Schmitt CP. Comparison of two different modes of molecular adsorbent recycling systems for liver dialysis. Pediatr Nephrol 2016;31:2171-4. [PMID: 27394132 DOI: 10.1007/s00467-016-3451-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 06/22/2016] [Accepted: 06/23/2016] [Indexed: 01/29/2023]