Liver transplantation
Candidate
Acute Liver Failure and Liver Assist Devices

https://doi.org/10.1016/j.transproceed.2011.01.109Get rights and content

Abstract

Survival of patients presenting with acute liver failure (ALF) has improved over the past decades due to earlier disease recognition, advances in supportive measures, intensive care, and liver transplantation. Liver assist devices may have a role in future care of patients with ALF, bridging them to recovery or to transplantation. A multidisciplinary team approach to the care of patients with ALF is critical for achieving good patient outcomes.

Section snippets

Pathogenesis

The pathogenesis of the liver injury is largely etiology dependent.2 Hepatocellular injury causes cell damage or cell death, the latter by necrosis, apoptosis, or both.3 Cellular glutathione is reduced, increasing susceptibility to oxidative injury and impairing the cells' ability to conjugate and detoxify substances. Liver progenitor cells are present mainly in the portal regions, so injury to the portal zone severely inhibits the regenerative response. The central zone of the hepatic lobule

Etiologies and Specific Therapies

The etiologies of ALF are the single most important determinants of outcome2 and differ in frequency in different geographic locations.2, 5

Assessing the Need for Liver Transplantation

The Kings College criteria remains the standard as to whether or not a patient with ALF will die.35 Other studies have attempted to look at etiology-specific indices or have tried to use other additional serum-based tests to help predict survival.36, 37, 38 Although these may be used adjunctively with the Kings College criteria to help predict death or recovery, the best decision can be reached by the transplant team by following the patient's clinical course and disease progression. Patients

Management: Cerebral Edema and Intracranial Hypertension (ICH)

Timely detection and management of ICH is critical but challenging. Left untreated, mortality can exceed 90%, and one-third may develop brainstem herniation while awaiting transplantation. Factors associated with cerebral edema include advanced grade of hepatic encephalopathy (grades III–IV) and rapid rate of development of encephalopathy after liver injury, elevated serum ammonia (>150–200 μmmol/L), infection or systemic inflammatory syndrome, and the requirement for vasopressor support or

Liver Support Devices

Liver support devices may potentially benefit patients with ALF as a bridge to liver transplantation or liver recovery; however their utility has only been tested in nonrandomized studies to date.51 The main types of liver support devices include artificial (cell-free) systems, based on plasma filtration and removal of substances by dialysis or by exposure to an exchange medium (charcoal or other ion-exchange columns), and bioartificial systems with human or nonhuman liver cells.51, 52 Specific

Liver Transplantation

Patients with ALF not recovering from liver failure despite medical/supportive treatment are candidates for liver transplantation: deceased-donor liver transplantation, living-donor liver transplantation (LDLT), or auxiliary orthotopic liver transplantation (APOLT). LDLT in adult ALF has not been uniformly accepted, in contrast to pediatric ALF, where it is the standard. Concerns about LDLT in adult ALF include the adequacy of the graft to support the patient and problems inherent in performing

Summary

Early identification of ALF and the etiology of ALF, along with the advances in transplant and intensive care unit (ICU) management of these patients, has contributed greatly to the survival of patients with ALF. Further advances in ICU management, including the future use of liver support devices and improved organ distribution for liver transplant will permit even better future outcomes.

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