Hyperacute Liver Failure with Multi-organ Dysfunction Syndrome (MODS) by Leptospirosis: A Case Report

Introduction: Leptospirosis may have multi-organ involvement in its severe form with potentially life-threatening consequences. However, acute fulminant hepatic failure is very uncommonly reported. A case study is presented here with fulminant hepatic failure and a diagnostic dilemma for etiology. Case history: A 40-year-old man with no significant medical history presented with fever, muscle pain, weakness, and pain in the upper abdomen. On clinical work, he has developed multi-organ hepatic, respiratory, and renal failure. A timely workup was done, but due to the rapid progression of the disease, the patient succumbed to the disease in the intensive care unit by the time his report for positive leptospirosis test arrived. Conclusion: Leptospirosis must be considered as an important differential diagnosis of acute liver failure patients. An early suspicion for leptospirosis in patients with fulminant hepatic failure and multi-organ failure in India particularly in the rainy season is warranted owing to its high mortality rate.

Insuficiencia hepática fulminante por paracetamol / Fulminant hepatic failure due to paracetamol

Resumen: La insuficiencia hepática aguda es una enfermedad poco común pero que amenaza la vida y afecta con mayor frecuencia a pacientes que no tienen enfermedades preexistentes del hígado. El paracetamol (acetaminofén) es uno de los medicamentos analgésicos-antipiréticos prescritos con más frecuencia por los médicos y automedicados por las personas, cuyos efectos adversos son desde molestias leves hasta efectos adversos letales, que no necesariamente requieren la dosis tóxica para causar tales efectos graves. No es sorprendente que el paracetamol sigue siendo causa importante de sobredosis: desde intoxicaciones intencionadas (suicida) y no intencionadas (consumo crónico), cuyos efectos graves van desde la insuficiencia hepática fulminante relacionada con sobredosis hasta la muerte; la mitad de estos episodios se atribuyen al paracetamol y estos casos parecen estar aumentando cada vez más debido a su fácil acceso y venta libre. El objetivo de este artículo es comunicar un caso y revisar la bibliografía al respecto.

Abstract: Acute liver failure is a rare disease but life-threatening, and occurs more frequently in patients without preexisting liver disease. Paracetamol (acetaminophen) is one of the analgesic-antipyretic drugs most frequently prescribed by physicians and self- medicated by people, whose adverse effects are mild discomfort and even lethal side effects that do not necessarily require the toxic dose to cause such serious effects. Not surprisingly, acetaminophen remains a major cause of overdose: from intentional poisoning (suicide) and unintentional (chronic use), whose major effects are ranging from fulminant hepatic failure related to overdose to death; half of these episodes are attributable to paracetamol, and these cases seem to be increasing more and more, because of its easy access and free sale. The aim of this paper is to present a case report and a literature review.

A prospective study of N-acetylcysteine treatment in drug-induced fulminant hepatic failure

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, complex, multisystemic gastroenterological emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. To date, there is no established treatment for DI-ALF other than liver transplantation and little is known about the use of N-acetylcysteine (NAC) in DI-ALF. A prospective case-control study was carried with the aim to determine the effect of NAC on mortality of DI-FHF patients and also to evaluate the safety and efficacy of NAC use.Methods: A total of 18 patients with a diagnosis of DI-FHF were included in the study. 10 patients received NAC infusion for 72 hours whereas the control group received placebo. The variables evaluated were demographic, signs and symptoms, biochemical parameters, outcome and length of hospital stay.Results: Out of 18 DI-FHF patients, 13 (72.2%) had anti-tuberculosis therapy (ATT) induced FHF and 5 (27.8%) patients had ayurvedic induced FHF. The two groups were comparable for the various baseline characteristics (age, INR, alanine aminotransferase, creatinine, albumin, grade of encephalopathy, etc.). The mortality decreased to 20% with the use of NAC versus 75% in the control group (P=0.023). Use of NAC was associated with a shorter length of hospital stay of survived patients (P=0.043). Moreover, the overall survival was improved by NAC (P=0.023) in DI-FHF. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF use (P=0.019).Conclusions: Author recommended the use of NAC along with conventional treatments in patients with DI-FHF in non-transplant centers while awaiting referrals. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF with NAC administration and its use was safe.

Acute liver failure secondary to chronic lymphocytic leukemia

Chronic lymphocytic leukemia is an indolent malignancy of lymphocytes commonly seen in elderly. Dissemination of malignancy is a rare cause of acute liver failure and has rarely been reported. Here we describe the case of a sixty five year old male presenting with acute liver failure. He is a diabetic with no known history of seropositive hepatitis, drug intake or any addictions. Bone marrow and liver biopsy suggestive of chronic lymphocytic leukemia. He eventually succumbed to his illness.

Etiological profile and clinical characteristics in fulminant hepatic failure in North India

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, multisystemic medical emergency. ALF of duration <8 weeks in a patient is considered as fulminant hepatic failure (FHF). Its rapid progression and high mortality demand early diagnosis and expert management. Clinical and etiological profile varies with geographical area and time. The objective of this prospective study was to determine the clinical characteristics and etiological profile of FHF.Methods: A total of eighty consecutive patients with a diagnosis of FHF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters (bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.) and etiological profile.Results: Most of the patients were <35 years of age and males. Viral hepatitis 35 (43.8%) was the most common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Among viral causes, acute hepatitis E was most common followed by hepatitis B and A. Drug or toxic induced liver failure (18.8%) also contributed a significant proportion of cases. The three groups (viral, drug-induced and indeterminate) were comparable for the various baseline characteristics (bilirubin, alanine aminotransferase, INR, creatinine, albumin, grade of encephalopathy, MELD score etc.).Conclusions: Like the rest of India, viral hepatitis was the common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Our study highlights the differences in the profile of FHF from other earlier studies in India and the west. Each different etiology leads to a similar final common pathway. Trying to determine etiology is essential, however, as outcomes and the use of antidotes depend on the identification of the causative process.

Incidence Of Silicosis And Silicotuberculosis In Coal And Stone Industry In The State Of Chhattisgarh

Silicosis is an occupational disease reported in silica, stone & mining industry. No proper report on workers in industries using silica in stones and coal has been done from Chhattisgarh till date. Detailed history, lung functions and chest x-ray were done. Diagnosis was made on the basis of radiology & history. Data analysis was done with the help of the statistical package for social sciences software. The Chi-square test was used for determining the relationship between qualitative data and descriptive statistics was used where required. Out of the total 16 reported cases, 13 had respiratory symptoms. Radiological abnormalities were noted in all. Lung functions revealed obstruction in 25%, restriction in 12.5 %, while mixed ventilatory defects in 62.5% subjects. 16 cases of silicosis and silicotuberculosis were reported. They had high respiratory morbidity (81.25%), cough and dyspnea being predominant symptoms. Duration of exposure correlates with radiological findings and increased incidence of silicosis

Herpes Simplex Virus Hepatitis Treated with Acyclovir / 이화의대지

Herpes simplex viruses (HSVs) are the most common cause of mucocutaneous infections with dissemination to visceral organs. HSV-induced hepatitis is a rare but frequent cause of hepatitis in immunocompromised patients, pregnant women, and newborns. However, diagnosis is often difficult because the clinical features are nonspecific. In addition, the HSV-related mortality rate is high. Signs and symptoms of HSV include fever, anorexia, nausea, vomiting, abdominal pain or tenderness, leukocytopenia, coagulopathy, and an increase in serum transaminase levels without jaundice. We present a patient who did not correspond to the above symptoms, but survived following prompt intravenous high-dose acyclovir provided early in the course of the disease.

A Systematic Review on Prognostic Indicators of Acute Liver Failure and Their Predictive Value for Poor Outcome.

Aims: To systematically identify and summarize prognostic indicators in patients with acute liver failure and to evaluate their predictive value. To analyse a wide spectrum of indicators used worldwide for prediction of outcome in patients with acute liver failure as a starting point for a better prognostic index. Methodology: Online databases MEDLINE® (1950-2014) and EMBASE® (1980-2014) were searched and studies published up to 01 January 2014 were considered. Articles were included if they reported original data from a clinical trial or observational study on patients with diagnosis of acute liver failure or fulminant hepatic failure and if one of their main objectives was evaluating prognostic indicators of acute liver failure outcome. Of 1835 identified studies 119 were included for detailed analysis. Results: Based on 289 selected indicators and their effect on patient outcome following 8 categories were formed: general markers (n=32), bio-markers (n=131), hemodynamic (n=14), liver function tests (n=7), imaging/morphology (n=15), scoring systems (n=53), time intervals (n=17), and treatments (n=20). The most frequently reported indicators were: bilirubin, age creatinine, coagulopathy expressed by prothrombin time or INR and hepatic encephalopathy. Conclusion: This review provides a large amount of information, including the extensive list of worldwide used indicators to predict outcome in patients with acute liver failure. There is large heterogeneity in prognostic indicators of acute liver failure, methods of measurement, complexity of calculation and threshold values. Based on this large list of indicators we suggest that an ideal prognostic index should preferentially be based on pathophysiological aspects and has to be applied in a dynamic way. Future studies on acute liver failure can profit from this inventory.

The clinical features and outcomes of acute liver failure associated with dengue infection in adults: a case series

OBJECTIVE: To describe the clinical manifestations and outcome of acute liver failure (ALF) associated with dengue viral infection, a rare but severe complication. METHODS: One hundred and fifty five consecutive patients with ALF admitted to the national liver centre from 2001 to 2009 were reviewed retrospectively. Eight cases due to dengue infection were identified and their clinical characteristics are described. RESULTS: All patients had severe dengue with one dengue shock syndrome. The median (minimum, maximum) age was 33.5 (17, 47) years with 50% female. The median (minimum, maximum) duration from the onset of fever to development of ALF was 7.5 (5, 13) days and the maximum hepatic encephalopathy (HE) grade were III in five patients and II in three patients. Three patients had systemic inflammatory responses (SIRS) on admission and were in grade III HE. The presence of SIRS on admission was associated with higher grade of HE and its development during the course of hospitalization was associated with worsening HE grade. The hepatitis was characterized by marked elevations in: alanine transaminase [median admission 1140.5 u/L (639, 4161); median peak 2487 u/L (998, 5181)], serum bilirubin [median admission 29 µmol/L (23, 291); median peak 127 µmol/L (72, 592)], and prothrombin time [median admission 16.8 s (15.3, 26.2); median peak 22 s (15.3, 40.7)]. The survival rate with standard medical therapy alone was 100%. CONCLUSIONS: Dengue associated ALF manifest about one week after the onset of fever with severe hepatitis and encephalopathy. In our experience, the outcome with standard medical therapy alone is excellent.

A Study of Clinical Profile and Outcome in Acute Viral Hepatitis E.

Introduction: Hepatitis E is the most common cause of acute viral hepatitis in the adult population in India. Acute viral hepatitis E (HEV) is generally mild and self-limiting and resolves within six weeks, with no chronic sequelae. Pregnant women are at increased risk with the risk increasing as the pregnancy progresses near term. Methods: We performed a prospective study of 100 patients who presented to Dept. of Medicine, Civil Hospital, Ahmedabad with jaundice (IgM anti-HEV positive) during 2011-2012 and data were analyzed for the clinical profile and outcome of HEV. Results: The most common age group affected was 21-30 years with overall M:F ratio of 3.4:1. Most common presenting symptom was jaundice (100%) followed by nausea/ vomiting (87%). On presentation, serum bilirubin level was elevated in 89% patients with SGPT raised in 86%. PT was prolonged in 39% patients. Anemia (Hb < 7) was seen in 17% while 9% of patients had renal involvement. Hepatic encephalopathy was seen in 15%. In this study, 12 women were pregnant in whom IUD occurred in 66% with maternal mortality in 33%. Overall mortality was 7%. Conclusion: We found that majority of cases were cured with supportive treatment while risk of mortality and morbidity was more in pregnant women.

Encefalopatia hepática: relatório da 1ª reunião monotemática da Sociedade Brasileira de Hepatologia / Hepatic encephalopathy: report 1st monothematic meeting of the Brazilian Society

A encefalopatia hepática (EH) é um distúrbio funcional do sistema nervoso central (SNC) associado à insufi ciência hepática, de fisiopatologia multifatorial e complexa. Devido aos avanços no conhecimento sobre o manejo da EH na cirrose e na insuficiência hepática aguda (IHA), a diretoria da Sociedade Brasileira de Hepatologia (SBH) promoveu uma reunião monotemática acerca da fi siopatologia, diagnóstico e tratamento da EH, abordando aspectos controversos relacionados ao tema. Com a utilização de sistemática da medicina baseada em evidências, foram abordados o manejo da EH e da hipertensão intracraniana na IHA, o manejo da EH episódica na cirrose, as controvérsias no manejo da EH e a abordagem da EH mínima. O objetivo desta revisão é resumir os principais tópicos discutidos na reunião monotemática e apresentar recomendações sobre o manejo da síndrome votadas pelo painel de expertos da SBH.

Hepatic encephalopathy (HE) is a functional disorder of the central nervous system (CNS) associated with liver failure, either end-stage chronic liver disease or fulminant hepatic failure. Its pathogenesis remains complex and poorly understood. In view of recent advances in the management of HE, the Brazilian Society of Hepatology endorsed a monothematic meetingregarding HE in order to gather experts in the to discuss related data and to draw evidence-based recommendations concerning: management of HE and intracranial hypertension in FHF, treatment of episodic HE in cirrhosis, controversies in the management of EH including difficult to treat cases and diagnostic and treatment challenges for minimal HE. The purpose of this review is to summarize the lectures and recommendations made by the panel of experts of the Brazilian Society of Hepatology.

Reduction of the amount of intestinal secretory IgA in fulminant hepatic failure

Intestinal barrier dysfunction plays an important role in spontaneous bacterial peritonitis. In the present study, changes in the intestinal barrier with regard to levels of secretory immunoglobulin A (SIgA) and its components were studied in fulminant hepatic failure (FHF). Immunohistochemistry and double immunofluorescent staining were used to detect intestinal IgA, the secretory component (SC) and SIgA in patients with FHF (20 patients) and in an animal model with FHF (120 mice). Real-time PCR was used to detect intestinal SC mRNA in the animal model with FHF. Intestinal SIgA, IgA, and SC staining in patients with FHF was significantly weaker than in the normal control group (30 patients). Intestinal IgA and SC staining was significantly weaker in the animal model with FHF than in the control groups (normal saline: 30 mice; lipopolysaccharide: 50 mice; D-galactosamine: 50 mice; FHF: 120 mice). SC mRNA of the animal model with FHF at 2, 6, and 9 h after injection was 0.4 ± 0.02, 0.3 ± 0.01, 0.09 ± 0.01, respectively. SC mRNA of the animal model with FHF was significantly decreased compared to the normal saline group (1.0 ± 0.02) and lipopolysaccharide group (0.89 ± 0.01). The decrease in intestinal SIgA and SC induced failure of the intestinal immunologic barrier and the attenuation of gut immunity in the presence of FHF.

Effect of human umbilical cord mesenchymal stem cell-paracrine substance on liver function and hepatocytes proliferation in FHF rat / 中华肝胆外科杂志

ObjectiveTo investigate the therapeutic effect of human umbilical cord mesenchymal stem cell-paracrine substance on fulminant hepatic failure (FHF) rat, and to study the effect on liver function and hepatocyte proliferation. MethodsMesenchymal stem cells(MSCs)were separated from human umbilical cord, and surface makers of cells were detected by flow cytometry. Human umbilical cord mesenchymal stem cells-conditioned medium(MSC-CM) was prepared. FHF rat model was induced by intraperitoneal injection of D-galactosamine and they were randomly diveded into three groups: MSC-CM group, NS group, PHGF group. 24 h later, 1 ml MSC-CM, 1 ml 0. 9% NaCl solution and lml PHGF solution was injected into the tail vein of MSC-CM, NS, and PHGF rats, respectively. In each group (n=8 per group), blood samples were collected at 12, 24, 36, and 60 h after treatment from inner canthus for analysis of blood ALT and TBIL levels. We used five rats per group for tissue collection after sacrifice at 36 h after treatment and 10 animals per group for survival analysis. PCNA immunohistochemical staining was used in the sections of liver tissue to detect hepatocyte proliferation. Results24 h after treatment, the levels of ALT and TBIL in the MSC-CM and PHGF groups were lower than those in the NS group(P＜0. 05), but there was no significant difference between the MSC-CM and PHGF groups. There were more PCNA-positive hepatocytes in the MSC-CM and PHGF groups than in the NS group(P＜0.01), but there was no significant difference between MSC-CM and PHGF group. Survival analysis found that the survival rate of rats in the MSC-CM and PHGF groups was higher than that of rats in the NS group (P=0. 049), but there was no significant difference between the MSC-CM and PHGF group. ConclusionsThe paracrine substance of human umbilical cord mesenchymal stem cells can stimulate hepatocyte proliferation and improve liver function of FHF rats, potentially creating a new avenue for the treatment of FHF.

Serongative Acute Hepatic Failure-associated Aplastic Anemia in Pediatric Liver Transplantation / 대한이식학회지

Aplastic anemia (AA) is a rare complication of liver transplantation. The causes of AA have not yet been identified, and optimal treatment for AA after liver transplantation has not been firmly established. We experienced two cases of AA accompanied with fulminant hepatitis among 157 pediatric recipients (1.3%) and among 17 recipients of Korean Network of Organ Sharing (KONOS) status 1 (11.8%). The patients were a 16-year-old girl and a 3-year-old boy who had jaundice and lethargy due to non-A, non-B, non-C fulminant hepatitis. The girl underwent split liver transplantation involving the liver of a 24-year-old man, and the boy underwent an emergency living donor liver transplantation with a liver obtained from his 16-year-old cousin. Each transplantation procedure was uneventful. However, both patients were diagnosed with AA caused by thrombocytopenia and neutropenia at 140 and 26 days, respectively, after liver transplantation. The girl recovered completely after undergoing bone marrow transplantation and was followed up for 70 months. However, the boy was conservatively treated because of the development of hyperbilirubinemia and pyrexia. He died of multi-organ failure 74 days after liver transplantation. AA is not a rare complication of pediatric liver transplantation for fulminant hepatic failure. Therefore, AA must be suspected in pediatric cases of cytopenia even after liver transplantation. Our findings indicate bone marrow transplantation is the treatment of choice for AA even in cases where AA develops after liver transplantation.

Serongative Acute Hepatic Failure-associated Aplastic Anemia in Pediatric Liver Transplantation / 대한이식학회지

Aplastic anemia (AA) is a rare complication of liver transplantation. The causes of AA have not yet been identified, and optimal treatment for AA after liver transplantation has not been firmly established. We experienced two cases of AA accompanied with fulminant hepatitis among 157 pediatric recipients (1.3%) and among 17 recipients of Korean Network of Organ Sharing (KONOS) status 1 (11.8%). The patients were a 16-year-old girl and a 3-year-old boy who had jaundice and lethargy due to non-A, non-B, non-C fulminant hepatitis. The girl underwent split liver transplantation involving the liver of a 24-year-old man, and the boy underwent an emergency living donor liver transplantation with a liver obtained from his 16-year-old cousin. Each transplantation procedure was uneventful. However, both patients were diagnosed with AA caused by thrombocytopenia and neutropenia at 140 and 26 days, respectively, after liver transplantation. The girl recovered completely after undergoing bone marrow transplantation and was followed up for 70 months. However, the boy was conservatively treated because of the development of hyperbilirubinemia and pyrexia. He died of multi-organ failure 74 days after liver transplantation. AA is not a rare complication of pediatric liver transplantation for fulminant hepatic failure. Therefore, AA must be suspected in pediatric cases of cytopenia even after liver transplantation. Our findings indicate bone marrow transplantation is the treatment of choice for AA even in cases where AA develops after liver transplantation.

Acute Hepatic Failure Associated with Stevens-Johnson Syndrome Induced by Carbamazepine Treatment in a Patient with Transverse Myelitis

Carbamazepine-induced liver injury is less common, but the consequences of the side effects can be very serious leading to death or a need for liver transplantation. We report a case of a 60-year-old female transverse myelitis patient with fulminant hepatic failure and Stevens-Johnson syndrome induced by carbamazepine who successfully underwent deceased donor liver transplantation. The patient, a 60-year-old female, was admitted to our service due to acute liver insufficiency and a drowsy mental state attributable to carbamazepine. She had been treated with carbamazepine to control transverse myelitis. Fifty days after the use of carbamazepine, she developed jaundice, erythematous papules and bullae, and decreased consciousness. The diagnosis of Stevens-Johnson syndrome was considered. She underwent deceased donor liver transplantation. She was discharged with normal graft functions 5 months after transplantation. Thus, liver transplantation can be a feasible therapy for patients with carbamazepine-induced hepatic failure associated with Stevens-Johnson syndrome.

Intraparenchymal intracranial pressure monitoring in patients with acute liver failure / Monitoreo intraparenquimatoso de presión intracraneana en pacientes con falla hepática aguda

BACKGROUND: Elevated intracranial pressure (ICP) is a common cause of death in acute liver failure (ALF) and is determinant for decision-making regarding the timing of liver transplantation. The recommended type ICP monitoring device is controversial in ALF patients. Epidural devices had less risk of hemorrhagic complications, but they are less reliable than intraparenchymal ones. METHOD: Twenty-three patients with ALF were treated, and 19 of them received a liver transplant. Seventeen patients had ICP monitoring because of grade III-IV encephalopathy. All patients received fresh plasma (2-3 units) before and during placing the intraparenchymal device. RESULTS: Eleven cases (64.7 percent) had elevated ICP, and 6 patients (35.2 percent) had normal values. One patient (5.9 percent) had an asymptomatic small intraparenchymal haemorrhage <1cm³ in CTscan, which did not prevent the liver transplantation. CONCLUSION: In our experience, intraparenchymal ICP monitoring in patients with ALF seems to be an accurate method with a low risk of complications.

ANTECEDENTES: La presión intracraneana elevada (PIC) es una causa frecuente de muerte en la falla hepática aguda (FHA) y es determinante para la toma de decisiones respecto del momento del transplante hepático. El tipo de dispositivo para el monitoreo de OIC es controversial em los pacientes em FHA. Los dispositivos epidurales tienen menos riesgo de complicaciones hemorrágicas, pero son menos confiables que los intraparenquimatosos. MÉTODO: Veintitrés pacientes con FHA fueron tratados, y 19 de ellos recibieron un transplante hepático. diecisiete pacientes tuvieron monitoreo de PIC debido a encefalopatía grado III-IV. Todos los pacientes recibieron plasma fresco (2-3 unidades) antes y durante la colocación de la fibra intraparenquimatosa. RESULTADOS: Once casos (64.7 por ciento) tuvieron PIC elevada, y 6 pacientes (35.2 por ciento) tuvieron valores normales. Un paciente (5.9 por ciento) tuvo una pequeña hemorragia intraparenquimatosa asintomática <1cm³ en TAC, la cual no impidió el transplante hepático. CONCLUSIÓN: En nuestra experiencia, el monitoreo intraparenquimatoso de presión intracraneana en pacientes con FHA parece ser un método preciso y con bajo riesgo de complicaciones.

Indicaciones y oportunidad del trasplante hepático / Indications and timing of liver transplantation

El trasplante hepático (TH) está indicado en pacientes con enfermedades hepáticas agudas o crónicas severas e irreversibles para las cuales no exista un tratamiento alternativo y en ausencia de contraindicaciones. Las indicaciones de TH pueden ser agrupadas en cuatro categorías: cirrosis hepática, hepatitis fulminante, tumores hepáticos y defectos genéticos de origen hepático que producen daño en otros órganos. Deben ser derivados para TH los pacientes con cirrosis que desarrollen cualquier complicación mayor o coagulopatía. La derivación precoz es "la clave del éxito" en la hepatitis fulminante por el alto riesgo de muerte y por tener una evolución mayormente impredecible. La oportunidad del TH es el momento en la historia natural de la hepatopatía cuando la sobrevida esperada es mayor con TH que en lista de espera. Estudios recientes han sugerido que el máximo beneficio del TH se obtiene en pacientes con MELD >15. Sin embargo, en algunos casos sin riesgo de muerte inminente, el objetivo del TH es mejorar la calidad de vida o prevenir contraindicaciones como la progresión del hepatocarcinoma cuando el tiempo de espera excede los 8 meses. Actualmente existe una marcada desproporción entre el número de donantes disponibles y el número creciente de potenciales receptores, lo que ha determinado un incremento progresivo del tiempo y mortalidad en lista. La racionalidad de distribuir los órganos en base al score de MELD es otorgar prioridad en la lista a los candidatos más enfermos y a aquellos que no pueden esperar como los pacientes con hepatocarcinoma.

Liver transplantation (OLT) is indicated in patients with severe and irreversible acute or chronic liver disease without alternative therapy and in the absence of contraindications. Indications for OLT can be grouped in four categories, namely cirrhosis, fulminant hepatitis, malignant hepatic tumors and liver-based genetic defects that trigger damage of other organs. Patients with cirrhosis should be referred for OLT after the onset of any of the major complications or coagulopathy. Early referral is crucial in fulminant hepatitis due to the high mortality with medical therapy and the unpredictable nature of this condition. Ideal timing for OLT is the moment in the natural history of the disease when the expected survival of patients on the waiting list is higher with than without OLT. Recent data suggest that maximal benefit of OLT is obtained in patients with a MELD score >15. However, in some cases with no imminent risk of death, OLT is indicated to improve quality of life or to prevent contraindications such as progression of hepatocellular carcinoma. At present, there is a marked disproportion between the number of donors available and the growing number of patients listed worldwide, which in turn has resulted in prolongation of the time-interval to OLT and waitlist mortality. The rationale of allocation systems utilizing the MELD score is to prioritize on the waiting list patients with severe liver dysfunction ("the sickest first") and those with hepatocellular carcinoma who may loose the benefits of OLT when waitlist time exceeds eight months.

Continuous Peritransplant Assessment of Consciousness using Bispectral Index Monitoring for Patients with Fulminant Hepatic Failure

PURPOSE: Deterioration of consciousness is the most critical problem in patients with fulminant hepatic failure (FHF). Electroencephalography (EEG) is a standard procedure to determine the brain activity in unconscious patients. The bispectral (BIS) index derived from EEG was primarily developed to monitor the depth of unconsciousness. METHODS: A prospective study was performed to assess the clinical utility of peritransplant BIS monitoring in 11 fulminant hepatic failure (FHF) patients who were undergoing emergency living donor liver transplantation (LT) with using a right liver graft. All the patients recovered their consciousness after LT. RESULTS: There was a significant correlation between the BIS index values and the derived GCS score (r2=0.634, p <0.001). Timing of eye opening to voice command matched the BIS index value of 64+/-9.5, which was after 14+/-9.4 hours passing BIS index of 50. All the patients with endotracheal intubation during the early posttransplant period showed progressive increase of their BIS index, which appeared slightly earlier and more evident than the rise of derived GCS scores. CONCLUSION: BIS monitoring is a noninvasive, simple and easy-to-interpret method and it also appears to be a useful to assess and predict the recovery of a patient's consciousness level after LT. Therefore, we concluded that BIS monitoring can be an indispensable component of the peritransplant intensive care for patients with FHF and who require emergency LT.

A Case of Pyrazinamide Induced Fulminant Hepatic Failure / 결핵및호흡기질환

Standard antituberculous therapy, including isoniazid (INH), rifampin, ethambutol, and pyrazinamide (PZA), is widely used to treat active tuberculosis. The most important side effect is hepatotoxicity. In a standard four-drug regimen, PZA was the most common cause of drug-induced hepatitis and was dose-related. The incidence of drug-induced hepatitis is high at doses of 40~70 mg/kg per day but has fallen significantly since the recommended dose was reduced. Liver toxicity induced by PZA is rare at doses of 25 mg/kg per day or less. PZA-induced fulminant hepatic failure is also rare but fatal. We report a case of fulminant hepatic failure caused by a re-challenge of PZA.