When the heart kills the liver: acute liver failure in congestive heart failure (original) (raw)
Related papers
Frequency and Significance of Acute Heart Failure Following Liver Transplantation
The American Journal of Cardiology, 2008
Reversible cardiomyopathy has been reported in patients after liver transplantation. However, there are few data on the incidence, risk factors, and prognosis of this condition. Liver transplantation recipients who underwent preoperative right-and left-sided cardiac catheterization as well as preoperative transthoracic echocardiography from 2001 to 2005 were identified. Eighty-six patients met the outlined criteria and were included in the study. The incidence of severe heart failure (HF) after transplantation in this population was 6 of 86 (approximately 7%). Patients who developed HF were slightly older (mean age 61.2 ؎ 8.9 vs 55.4 ؎ 9.2 years, p ؍ 0.08) but had similar preoperative ejection fractions (60 ؎ 5% vs 57 ؎ 8%, p ؍ 0.22) and comparable systemic arterial blood pressure (116 ؎ 22/62 ؎ 11 vs 127 ؎ 9/66 ؎ 9, p >0.1). In addition, the severity of liver disease as measured by the model for end-stage liver disease score was not different between the 2 groups (23.9 ؎ 9.7 vs 26 ؎ 10.7, p ؍ 0.5). There was also no significant difference in the preoperative cardiac index (3.8 ؎ 1 vs 3.6 ؎ 1.5 L/min/m 2 , p ؍ 0.9) or pulmonary artery wedge pressure (13.6 ؎ 5.8 vs 15.3 ؎ 2.8 mm Hg, p ؍ 0.42). The incidence of alcohol use as the presumed cause of liver failure was equivalent in the 2 groups (33% vs 25%, p ؍ 0.65). The patients who developed HF did have significantly higher preoperative mean pulmonary arterial systolic pressures (43 ؎ 10 vs 30 ؎ 9 mm Hg, p ؍ 0.02) and right ventricular systolic pressures (44 ؎ 13 vs 34 ؎ 8 mm Hg, p ؍ 0.05). In conclusion, severe systolic HF may occur after liver transplantation in patients without traditional risk factors for HF. This study suggests that those patients with preoperative elevated right-sided cardiac pressures, as well as older patients, may be at excess risk for developing HF after transplantation.
Aetiology and outcome of acute liver failure
HPB, 2009
Background: Acute liver failure (ALF) is a clinical syndrome characterized by the sudden onset of coagulopathy and encephalopathy. The outcome is unpredictable and is associated with high morbidity and mortality. We reviewed our experience to identify the aetiology and study the outcome of acute liver failure. Methods: A total of 1237 patients who presented with acute liver failure between January 1992 and May 2008 were included in this retrospective study. Liver transplantation was undertaken based on the King's College Hospital criteria. Data were obtained from the units prospectively collected database. The following parameters were analysed: patient demographics, aetiology, operative intervention, overall outcome, 30-day mortality and regrafts. Results: There were 558 men and 679 women with a mean age of 37 years (range: 8-78 years). The most common aetiology was drug-induced liver failure (68.1%), of which 90% was as a result of a paracetamol overdose. Other causes include seronegative hepatitis (15%), hepatitis B (2.6%), hepatitis A (1.1%), acute Budd-Chiari syndrome (1.5%), acute Wilson's disease (0.6%), subacute necrosis(3.2%) and miscellaneous (7.8%). Three hundred and twenty-seven patients (26.4%) were listed for liver transplantation, of which 263 patients successfully had the procedure (80.4%). The current overall survival after transplantation was 70% with a median follow-up of 57 months. After transplantation for ALF, the 1-year, 5-year and 10-year survival were 76.7%, 66% and 47.6%, respectively. The 30-day mortality was 13.7%. Out of the 974 patients who were not transplanted, 693 patients are currently alive. Among the 281 patients who died without transplantation, 260 died within 30 days of admission (26.7%). Regrafting was performed in 31 patients (11.8%), the most common indication being hepatic artery thrombosis (11 patients). Conclusion: Paracetamol overdose was the most common cause of acute liver failure. Liver transplantation, when performed for acute liver failure, has good long-term survival.
Acute liver failure: Clinical features, outcome analysis, and applicability of prognostic criteria
Liver Transplantation, 2000
Acute liver failure(ALF)is an uncommon condition associated with high morbidity and mortality. We performed a retrospective analysis of patients evaluated for ALF. The aim of our study is to determine the clinical features and outcome of such patients and to assess the validity of King's College Hospital (KCH) prognostic criteria. One hundred seventy-seven patients were evaluated for ALF during a period of 13 years. Mean age was 39 years, and 63% were women. The causes included viral hepatitis (31%), acetaminophen toxicity (19%), idiosyncratic drug reactions (12%), miscellaneous causes (11%), and an indeterminate group (28%). Twenty-five patients (14%) recovered with medical therapy (group I), 65 patients (37%) died without orthotopic liver transplantation (OLT; group II), and 87 patients (49%) underwent OLT (group III). Patients in group II were older and often had advanced encephalopathy, whereas those in group I had less hyperbilirubinemia and often had hyperacute failure. KCH criteria had high specificity and positive predictive value but low negative predictive value for a poor outcome. We conclude that early prognostication is needed in patients with ALF to assist decision making regarding OLT. The fulfillment of KCH criteria usually predicts a poor outcome, but a lack of fulfillment does not predict survival.
Diagnostic and therapeutic challenge of heart failure after liver transplant: Case series
World journal of hepatology, 2017
Heart failure (HF) following liver transplant (LT) surgery is a distinct clinical entity with high mortality. It is known to occur in absence of obvious risk factors. No preoperative workup including electrocardiogram, echocardiography at rest and on stress, reasonably prognosticates the risk. In patients of chronic liver disease, cirrhotic cardiomyopathy, alcoholic cardiomyopathy, and stress induced cardiomyopathy have each been implicated as a cause for HF after LT. However distinguishing one etiology from another not only is difficult, several etiologies may possibly coexist in a given patient. Diagnostic dilemma is further compounded by the fact that presentation and management of HF irrespective of the possible underlying cause, remains the same. In this case series, 6 cases are presented and in the light of existing literature modification in the preoperative workup are suggested.
Risk Factors Associated With Acute Heart Failure During Liver Transplant Surgery
Transplantation, 2015
Background. Acute intraoperative heart failure (HF) is a rare but often fatal complication of liver transplant surgery. Little is known about the clinical course or predictive variables. Our aims were to provide a detailed clinical description and conduct a systematic search for characteristics associated with intraoperative HF. Methods. A matched case-control study of adults undergoing primary liver transplant from 2009 to 2011 was conducted. Cases showed new onset HF with an ejection fraction less than 50% during liver transplant surgery. Controls were recipients without signs or symptoms of HF. Matching was based on: age, sex, model for end-stage liver disease at the time of transplant, type 2 diabetes, and β-blocker use. Conditional logistic regression analyses were conducted. Results. From 2009 to 2011, seven (3%) of 256 recipients developed intraoperative HF with one resulting death. All survivors regained normal systolic function within 6 months of surgery. Decreasing preoperative serum sodium (odds ratio, 1.41; 95% confidence interval, 1.02-1.94; P = 0.039) and increasing number of units of packed red blood cells transfused intraoperatively (odds ratio=1.2, 95% confidence interval, 1.001-1.467, P = 0.048) were associated with HF. Conclusion. No preoperative echocardiographic parameter predicted HF in affected patients. Two possible explanations are: our patients suffered from stress cardiomyopathy and therefore had no evidence of impaired contraction before the event or echocardiographic predictors of HF were masked by circulatory changes in patients with cirrhosis. Lower serum sodium and more red blood cell transfusions were associated with intraoperative HF. Lower mortality of our intraoperative cases compared to others may be influenced by earlier diagnosis and intervention.
Acute liver failure: updates in pathogenesis and management
Medicine, 2019
Acute liver failure (ALF) is a life-threatening illness precipitated by an acute liver injury in patients with no pre-existing liver disease. Acute viral hepatitis and drug-induced liver injury account for the majority of cases, the clinical course characterised by the development of coagulopathy and hepatic encephalopathy (HE), often progressing to multi-organ disease which is associated with high fatality rates. The outcomes have improved significantly over time with improving standards of organ system support and access to liver transplantation for the very sick. The King's College Hospital criteria (KCH) is the most commonly used tool for determination of prognosis and consideration for transplantation. Prompt diagnosis, immediate initiation of supportive care and aetiology-specific treatment, where applicable, and early discussions and transfer to transplant centre are keys to successful outcome. KEYWORDS Acute liver failure, fulminant hepatitis, critical care, hepatic encephalopathy, multi-organ failure, intensive care, liver transplantation. DEFINITION AND CLASSIFICATION Acute liver failure (ALF) is a rare, life-threatening illness, triggered by a de novo liver injury to a previously healthy liver, frequently progressing within hours and weeks to multisystem involvement and failure. Coagulation abnormalities of liver origin (elevated prothrombin time (PT) or International Normalised Ratio (INR) above 1.5) and mental alterations due to hepatic encephalopathy (HE) are the key defining clinical criteria required to make a diagnosis. ALF is a specific clinical entity in terms of the clinical phenotype, disease course, prognosis, and eligibility for emergency liver transplantation. This must be distinguished from secondary liver injury in sepsis or congestive cardiac disease or failure following major liver resection, none of which would qualify as ALF and would not be indications for emergency liver transplantation. Conversely, acute presentations of Wilson's disease, acute Budd-Chiari syndrome and some cases of autoimmune hepatitis may have undiagnosed chronic liver involvement but are treated as ALF because of the poor prognosis without transplantation in these conditions and clinical features consisting predominantly of coagulopathy and HE.
Egyptian Liver Journal, 2022
Background: Without firm diagnostic criteria, the exact prevalence of cirrhotic cardiomyopathy still remains unknown. Its estimation is rather a difficult task as the disease is generally latent and shows itself only when the patient is subjected to overt stress such as body position changes, exercise, drugs, hemorrhage, and surgery. In this study, we aim to assess cardiac dysfunction in patients with end-stage liver disease, study the correlation between cardiac dysfunction and Child-Pugh classification of patients with liver cell failure, and study the prevalence and impact of cardiac dysfunction on the clinical outcome of patients with child B and child C liver disease. Results: Diastolic dysfunction was more prevalent among the patients' group (p < 0.001). It was absent in 28 (70%) of control group, with grade 1 diastolic dysfunction in 12 (30%). Only one patient (2.5%) had no diastolic dysfunction, 21 patients (52.5%) had grade 1 diastolic dysfunction, 12 (30%) patients had grade 2 diastolic dysfunction, and 6 patients (15%) had grade 3 diastolic dysfunction. QTc interval was significantly prolonged in the patients' group when compared to controls (p < 0.001). Echocardiographic parameters and QTc interval were comparable in child B and child C patients. All patients were followed up for a period of 3 months. Sixteen of 40 patients died in this period of time. Only child classification was found to significantly predict mortality, and patients with child C liver cirrhosis had worse survival when compared to patients with child B liver cirrhosis. Conclusion: Most of the patients had cardiac dysfunction, mainly diastolic dysfunction (87.5%). The study detected the prevalence of diastolic dysfunction among end-stage liver disease when measuring E/É using TDI which proved to be more accurate than E/A ratio. Diastolic dysfunction is proved to be the most sensitive parameter in the diagnosis of cirrhotic cardiomyopathy, being the most parameter affected early. No correlation was found between cardiac dysfunction and the severity of hepatic illness, but the severity of hepatic illness affects the outcome rather than cardiac dysfunction.
Comparative study of etiological profile and outcome in acute liver failure
International Journal of Scientific Reports
The term acute liver failure is used to describe the development of coagulopathy, usually with an international normalized ratio (INR) of greater than 1.5, and any degree of mental alteration (encephalopathy) in a patient without preexisting cirrhosis and with an illness of less than 26 weeks duration. 6 Encephalopathy may vary from only subtle changes in affect, insomnia, and ABSTRACT Background: Acute liver failure (ALF) is a clinical syndrome that is marked by the sudden loss of hepatic function in a person without chronic liver disease. Clinical and etiological profile varies with geographical area and over time. The objective of this prospective study was to determine the etiological profile and outcome of ALF and to compare it with other major studies from India and US. Methods: A total of 84 consecutive patients with a diagnosis of ALF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters, etiological profile and outcome. Results: Viral hepatitis 32 (38.1%) was the most common cause of ALF but large number of the patients 30 (35.7%) had indeterminate aetiology. Among viral causes, acute hepatitis E (19.1%) was most common followed by hepatitis B (9.5%) and A (9.5%). Drug or toxic induced liver failure (17.8%) also contributed a significant proportion. Majority of the patients were male (51.9%) and the mean age was 39.48±20.11 years. Aetiology varied with other geographical area and even over time in the same area. Overall mortality was 44 (57.1%) in ALF patients, with highest mortality in indeterminate group (60%). Conclusions: Like the rest of India, viral hepatitis was the common cause of ALF but a large number of patients 30 (35.7%) had indeterminate aetiology. Overall mortality was 57.1%. Our study highlights the differences in the profile of ALF from other earlier studies in India and the west.
Current concepts in acute liver failure
Annals of Hepatology, 2019
Acute liver failure (ALF) is a severe condition secondary to a myriad of causes associated with poor outcomes. The prompt diagnosis and identification of the aetiology allow the administration of specific treatments plus supportive strategies and to define the overall prognosis, the probability of developing complications and the need for liver transplantation. Pivotal issues are adequate monitoring and the institution of prophylactic strategies to reduce the risk of complications, such as progressive liver failure, cerebral oedema, renal failure, coagulopathies or infections. In this article, we review the main aspects of ALF, including the definition, diagnosis and complications. Also, we describe the standard-of-care strategies and recent advances in the treatment of ALF. Finally, we include our experience of care patients with ALF.