Evidence-Based Medicine
Copyright ©The Author(s) 2017. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 21, 2017; 23(23): 4303-4310
Published online Jun 21, 2017. doi: 10.3748/wjg.v23.i23.4303
Substantial hepatic necrosis is prognostic in fulminant liver failure
Paul Ndekwe, Marwan S Ghabril, Yong Zang, Steven A Mann, Oscar W Cummings, Jingmei Lin
Paul Ndekwe, Steven A Mann, Oscar W Cummings, Jingmei Lin, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Marwan S Ghabril, Department of Internal Medicine, Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Yong Zang, Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN 46202, United States
Author contributions: Ndekwe P and Lin J designed research/study; Ndekwe P, Ghabril MS, Mann SA and Lin J performed research/study and collected data; Ndekwe P, Ghabril MS, Zang Y, Mann SA, Cummings OW and Lin J analyzed data; Ndekwe P, Ghabril MS, Mann SA, Cummings OW and Lin J wrote paper.
Institutional review board statement: This study was reviewed and approved by the Institutional Review Board of Indiana University School of Medicine.
Conflict-of-interest statement: The authors have no conflicts of interest to disclose.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Jingmei Lin, MD, PhD, Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, 350 West 11th Street, Indianapolis, IN 46202, United States. jinglin@iupui.edu
Telephone: +1-317-4916159 Fax: +1-317-4916419
Received: October 6, 2016
Peer-review started: October 10, 2016
First decision: December 19, 2016
Revised: March 21, 2017
Accepted: May 19, 2017
Article in press: May 19, 2017
Published online: June 21, 2017
Processing time: 257 Days and 10.6 Hours
Abstract
AIM

To evaluate if any association existed between the extent of hepatic necrosis in initial liver biopsies and patient survival.

METHODS

Thirty-seven patients with fulminant liver failure, whose liver biopsy exhibited substantial necrosis, were identified and included in the study. The histological and clinical data was then analyzed in order to assess the relationship between the extent of necrosis and patient survival, with and without liver transplantation. The patients were grouped based on the etiology of hepatic necrosis. Each of the etiology groups were then further stratified according to whether or not they had received a liver transplant post-index biopsy, and whether or not the patient survived.

RESULTS

The core tissue length ranged from 5 to 44 mm with an average of 23 mm. Causes of necrosis included 14 autoimmune hepatitis, 10 drug induced liver injury (DILI), 9 hepatitis virus infection, and 4 unknown origin. Among them, 11 showed submassive (26%-75% of the parenchymal volume) and 26 massive (76%-100%) necrosis. Transplant-free survival was worse in patients with a higher extent of necrosis (40%, 71.4% and 100% in groups with necrosis of 76%-100%, 51%-75% and 26%-50%, respectively). Additionally, transplant-free survival rates were 66.7%, 57.1%, and 25.0% in groups of autoimmune hepatitis, DILI, and viral hepatitis, respectively. Even after liver transplantation, the survival rate in patients as a result of viral hepatitis remained the lowest (80%, 100%, and 40% in groups of autoimmune hepatitis, DILI, and viral hepatitis, respectively).

CONCLUSION

Adequate liver biopsy with more than 75% necrosis is associated with significant transplant-free mortality that is critical in predicting survival.

Keywords: Submassive necrosis; Massive necrosis; Fulminant liver failure; Liver transplantation; Biopsy; Histopathology

Core tip: Fulminant liver failure is clinically characterized by an abrupt onset of jaundice and liver dysfunction with subsequent development of encephalopathy and coagulopathy in patients with or without preexisting liver disease. Liver biopsy may play a role in predicting patient survival, and may also potentially play a role in optimizing the utilization of resources in the setting of fulminant liver failure.