Liver transplantationCandidateAcute Liver Failure and Liver Assist Devices
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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Chapter 25 - Perioperative critical care in hepatopancreatobiliary patients
2017, Blumgart's Surgery of the Liver, Biliary Tract and Pancreas: Sixth EditionLiver renewal: Detecting misrepair and optimizing regeneration
2014, Mayo Clinic ProceedingsCitation Excerpt :The concept of manipulating regeneration to improve the outcome of acute or chronic liver injury in humans is not new, and previous attempts to optimize liver repair have generally failed to report survival benefits. Generally, these interventions were tested in patients with severe acute, or acute-on-chronic, liver failure (eg, liver assist devices, infusions of hepatocyte growth factor, and administration of bone marrow–derived mesenchymal stem cells).112-117 There are several potential explanations for the previous disappointing outcomes, including the possibility that the interventions themselves were ineffective or applied so late in the disease process that the liver damage itself was no longer reversible.
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2021, Messenger of Anesthesiology and ResuscitationSerum Metabonomics Analysis of Liver Failure Treated by Nonbioartificial Liver Support Systems
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