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Management and Prognosis of Acute Liver Failure in Children

  • Pediatric Gastroenterology (SR Orenstein, Section Editor)
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Abstract

Although the etiologies of pediatric acute liver failure (ALF) are diverse, ultimate pathophysiologic pathways and management challenges for these disorders, usually lethal in the pre-transplant era, are similar. This review considers particularly the mechanisms of, and monitoring for, intracranial hypertension and coagulopathy; summarizes detailed advice for management of the ALF-associated failures of multiple body systems; and reviews the variety of prognostic scores available to guide management and assist in choosing the patients most apt to benefit from liver transplantation and the optimal timing for such transplantation.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance

  1. Lee WS, McKierman P, Keely DA. Etiology, outcome, and prognostic indication of Childhood fulminant hepatic failure in United Kingdom. Pediatr Gastroenterol Nutr 2005, 575–581

  2. • Farmer DG, Venick RS, McDiarmid SV et al. Fulminant Hepatic Failure in children: Superior and durable outcome with liver transplantation over 25 years at a single center. Ann Surg 2009; 250(3) 484–493. This study, representing one of the largest published series on LT for ALF in a single center, demonstrates a long-term survival of nearly 70 %, focuses attention on morbility and prognosis, and develops a clinically applicable and readily measurable set of pretransplant factors that determine posttransplant outcome.

    PubMed  Google Scholar 

  3. Munne MS, Altabert NR, Vladimisky SN, et al. Identifications of polyhyletic variants in acute hepatitis suggest an under diagnosed circulation of hepatitis E virus in Argentina. JClin Virol. 2011;52(2):138–41.

    Article  Google Scholar 

  4. Sundaram SS, Alonso EM, Narkewicz MR, Zhang S, Squires RH. Pediatric Acute Liver Failure Study Group. Characterization and outcomes of young infants with acute liver failure. J Pediatr. 2011;159(5):813–8.

    Article  PubMed  Google Scholar 

  5. Ciocca M, Ramonet M, Cuarterolo M, Lopez S, Cernadas C, Alvarez F. Prognosis Factors in pediatric acute liver failure. Arch Dis Child. 2008;03:48–51.

    Article  Google Scholar 

  6. Bernal W, Auzinger G, Dhawan A, Wendon J. Acute liver failure. Lancet. 2010;376(9736):190–201.

    Article  PubMed  Google Scholar 

  7. Larsen FS, Wendon J. Prevention and management of brain edema in patients with Acute Liver Failure. Liver Transpl. 2008;14:90–6.

    Article  Google Scholar 

  8. Clemmensen JO, Larsen FS, Kondrup J, Hansen BA, Ott P. Cerebral herniation in patients with acute liver failure is correlated with arterial ammonia concentration. Hepatology. 1999;29:648–53.

    Article  Google Scholar 

  9. Jiang W, Desjardins P, Butterworth RF. Cerebral inflammation contributes to encephalopathy and brain edema in acute liver failure: protective effect of minocycline. J Neurochem. 2009;109:485–93.

    Article  PubMed  CAS  Google Scholar 

  10. Fiore M, Probert L, Kollia G, Akassoglou K, et al. Neurobehavioral alterations in developing transgenic mice espressing TNF-alpha in the brain. Brain Behav Immun. 1996;10:126–38.

    Article  PubMed  CAS  Google Scholar 

  11. Krueger J, Fang J, Taishi P, Chen Z, et al. Sleep A physiologic role for IL-1 beta and TNF- alpha. Ann NY Acad Sci. 1998;856:148–59.

    Article  PubMed  CAS  Google Scholar 

  12. AllanS and RothwellN. Cytokines and acute neurodegeneration. Nat. Rev. Neurosci. 2001; 2, 734–744. Petty and Lo E. Functional complexes of the blood- brain barrier: permeability changes in neuroinflammation. Prog. Neurobiol.2002; 68, 311–323.

    Google Scholar 

  13. Andersson A, Ronnback L, Hansson E. Lactate induce tumor necrosis factor- alpha, interleukin-6 and interleukin-1 beta release in microglial and astroglial—enriched primary cultures. J Neurochem. 2005;93:1327–33.

    Article  PubMed  CAS  Google Scholar 

  14. Haussinger D. Low grade cerebral edema and the pathogenesis of hepatic encephalopathy in cirrhosis. Hepatology. 2006;43:1187–90.

    Article  PubMed  Google Scholar 

  15. Vaquero J, Rose C, Butterworth R. Keeping cool in acute liver failure: Rationale for the use of mild hypothermia. Vaquero J, Rose C, Butterworth R. J Hepatol. 2005;43:1067–77.

    Article  PubMed  CAS  Google Scholar 

  16. Muñoz S, Rajender Reddy K, Lee W. The coagulopathy of acute liver failure and implications for intracranial monitoring. Neurocrit Care. 2008;9:103–7.

    Article  PubMed  Google Scholar 

  17. Mahajan A, Lat I. Correction of coagulopathy in the setting of acute liver failure. Crit Care Nurs Clin N Am. 2010;22:315–21.

    Article  Google Scholar 

  18. Stravitz R, Kramer A, Darven T, Shaikh O, et al. Intensive care of patients with acute liver failure: recommendations of the U.S. Acute Liver Failure Study Group. Crit Care Med. 2007;35:2498–508.

    Article  PubMed  Google Scholar 

  19. Bhatia V, Batra Y, Subrat Kumar A. Prophylactic phenytoin does not improve cerebral edema or survival in acute liver failure a controlled clinical trial. J Hepatol. 2004;41:89–96.

    Article  PubMed  CAS  Google Scholar 

  20. • Starvitz R, Larsen F. Therapeutic hypothermia for acute liver failure. Crit Care Med 2009; 37: S258–S264. Cerebral edema is a potentially life-threatening complication of acute liver failure. This article focused on therapeutic hypothermia with a core temperature 32[degrees]- C-35[degrees]C. It showed reduction of cerebral edema and intracranial hypertension in patients with acute liver failure and also showed it to be an effectively bridge to transplantation.

    Article  Google Scholar 

  21. Jacob S, Khan A, Jacobs E, Kandiah P, et al. Prolonged hypothermia as a bridge to recovery for cerebral edema and intracranial hypertension associated with fulminant hepatic failure. Neurocrit Care. 2009;11:242–6.

    Article  PubMed  Google Scholar 

  22. Dmello D, Cruz-Flores S, Matuschak GM. Moderate hypothermia with intracranial pressure monitoring as a therapeutic paradigm for the management of acute liver failure: A systematic review. Intensive Care Med. 2010;36:210–3.

    Article  PubMed  Google Scholar 

  23. Cochran JB, Losek JB. Acute Liver Failure in children. Pediatr Emerg Care. 2007;23(2):129–35.

    Article  PubMed  Google Scholar 

  24. Nadalin S, Heuer M, Wallot M, et al. Paediatric acute liver failure and transplantation: The University of Essen experience. Transpl Int. 2007;20(6):519–27.

    Article  PubMed  Google Scholar 

  25. Phua J, Lee KH. Liver support devices. Curr Opin Crit Care. 2008;14:208–15.

    Article  PubMed  Google Scholar 

  26. Sasbon JS, Devictor D, Tissieres P. Liver support for fulminant hepatic failure: Is it time to use the Molecular Adsorbents Recycling System in children? Pediatr Crit Care Medicine. 2005;6(5):585–91.

    Article  Google Scholar 

  27. Arora G, Keeffe EB. Management of chronic liver failure until liver transplantation. Med Clin North Am. 2008;92:839,ix–60,ix.

    Google Scholar 

  28. Tissieres P, Sasbon JS, Devictor D. Liver support for fulminant hepatic failure: is it time to use the Molecular Adsorbents Recycling System in children? Pediatr Crit Care Med. 2005;6:585–91.

    Article  PubMed  Google Scholar 

  29. Liu JP, Gluud LL, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for liver failure. Cochrane Database Syst Rev 2004;(1):CD003628

  30. Devictor D, Tissieres P, Afanetti M, Debray D. Acute liver failure in children. Clinics and Research in Hepatology and Gastroenterology. 2011;35:430–7.

    Article  PubMed  Google Scholar 

  31. • Faraj W, Dar F, Bartlet A, Vilcamelendez H, Marangoni G, Mielivergani G, Dhawan A and Rela M. Auxiliary Liver Transplantation for Acute Liver Failure in Children. Ann Surg. 2010;251(2):351–6. This study presents the largest experience of auxiliary liver transplantation for acute liver failure (ALF) in children over the past 19 years. Auxiliary partial orthotopic LT should be considered in children presenting with ALF who fulfill criteria for LT.

    Article  PubMed  Google Scholar 

  32. Dhiman R, Jain S, Masheshawri U, et al. Early indicators of prognosis in Fulminant Hepatic Failure: An assessment of the Model for End-Stage Liver Disease (MELD) and King’s College Hospital Criteria. Liver Transpl. 2007;13:814–21.

    Article  PubMed  Google Scholar 

  33. O’Grady JG. Prognostication in acute liver failure: a tool or an anchor? Liver Transpl. 2007;13:786–7.

    Article  PubMed  Google Scholar 

  34. O’Grady JG, Graeme JM, Hayllar KM, et al. Early indicators of prognosis infulminant hepatic failure. Gastroenterology. 1989;97:439–45.

    PubMed  Google Scholar 

  35. Bernuau J, Benhamou JP. Fulminant and subfulminant liver failure. In: McIntyre N, Benhamou JP, Bircher J, Rizzeto M, Rodes J, editors. Oxford Textbook of Clinical. Hepatology. Oxford: Oxford Medical Publications, 1991: 923–942.

  36. Bernuau J, Goudeau A, Poynard T, et al. Multivariate analysis of prognostic factors in fulminant hepatitis B. Hepatology. 1986;6:648–51.

    Article  PubMed  CAS  Google Scholar 

  37. Yantorno S, Kremers W, Ruf A, et al. MELD is superior to King’s College and Clichy’s Criteria to assess prognosis in fulminant hepatic failure. Transplantation. 2007;13:822–8.

    Google Scholar 

  38. • Sanchez M and D’Agostino D. Pediatric end-stage liver disease score in acute liver failure to assess poor prognosis. J Pediatr Gastroenterol Nutr. 2011 Aug 30. This is very important reference shows that PELD score used in a cohort of pediatric patients with ALF provided an accurate specificity and sensitivity to discriminate patients with poor outcome, was superior to that of the KCH and Clichy criteria, and could be helpful in establishing the optimal moment for LT evaluation and inclusion on the emergency waiting list.

  39. Squires Jr RH, Shneider BL, Bucuvalas J, et al. Acute liver failure in children: the first 348 patients in the pediatric acute liver failure study group. J Pediatr. 2006;148:652–8.

    Article  PubMed  Google Scholar 

  40. Squires RH, Sokol RJ, Schneider BL, et al. Encephalopathy at presentation predicts outcome for children with acute liver failure. Abstract Hepatology. 2002;36:167A.

    Google Scholar 

  41. Tissieres P, Prontera W, Chevret L, et al. The pediatric risk of mortality score in infants and children with fulminant liver failure. Pediatr Transplant. 2003;7:64–8.

    Article  PubMed  Google Scholar 

  42. Dhawan A, Cheeseman P, Mieli-Vergani G. Approaches to liver failure in children. Pediatr Transplant. 2004;8:584–8.

    Article  PubMed  Google Scholar 

  43. Lu B, Gralla J, Liu E, et al. Evaluation of a scoring system for assessing prognosis in pediatric acute liver failure. Clin Gastroenterol Hepatol. 2008;6:1140–5.

    Article  PubMed  Google Scholar 

  44. Bernal W, Wendon J, Rela M. Use and outcome of liver transplantation in acetaminophen-induced acute liver failure. Hepatology. 1998;27:1050–5.

    Article  PubMed  CAS  Google Scholar 

  45. Harrison PM, O’Grady JG, Keays RT, et al. Serial prothrombin time as prognostic indicator in paracetamol induced fulminant hepatic failure. Br Med J. 1990;301:964–6.

    Article  CAS  Google Scholar 

  46. Pereira LM, Langley PG, Hayllar KM, et al. Coagulation factor V and VIII/V ratio as predictors of outcome in paracetamol induced fulminant hepatic failure: relation to other prognostic indicators. Gut. 1992;33:98–102.

    Article  PubMed  CAS  Google Scholar 

  47. Hoofnagle JH, Carithers RL, Shapiro C, et al. Fulminant hepatic failure: summary of a workshop. Hepatology. 1995;21:240–52.

    PubMed  CAS  Google Scholar 

  48. Murray-Lyon IM, Orr AH, Gazzard B, et al. Prognostic value of serum alphafetoprotein in fulminant hepatic failure including patients treated by charcoal haemoperfusion. Gut. 1976;17:576–80.

    Article  PubMed  CAS  Google Scholar 

  49. Macquillan GC, Seyam MS, Nightingale P, et al. Blood lactate but not serum phosphate levels can predict patient outcome in fulminant hepatic failure. Liver Transpl. 2005;11:1073–9.

    Article  PubMed  Google Scholar 

  50. Schmidt LE, Dalhoff K. Serum phosphate is an early predictor of outcome in severe acetaminophen-induced hepatotoxicity. Hepatology. 2002;36:659–65.

    Article  PubMed  CAS  Google Scholar 

  51. Bernal W, Donaldson N, Wyncoll D, et al. Blood lactate as an early predictor of outcome in paracetamolinduced acute liver failure: a cohort study. Lancet. 2002;359:558–63.

    Article  PubMed  CAS  Google Scholar 

  52. Ranek L, Andreasen PB, Tygstrup N. Galactose elimination capacity as a prognostic index in patients with fulminant liver failure. Gut. 1976;17:959–64.

    Article  PubMed  CAS  Google Scholar 

  53. Bhatia V, Singh R, Acharya SK. Predictive value of arterial ammonia for complications and outcome in acute liver failure. Gut. 2006;55:98–104.

    Article  PubMed  CAS  Google Scholar 

  54. Lee WM, Galbraith RM, Watt GH, et al. Predicting survival in fulminant hepatic failure using serum Gc protein concentrations. Hepatology. 1995;21:101–5.

    PubMed  CAS  Google Scholar 

  55. Schiøt FV, Bangert K, Shakil AO. Predictive value of actin-free Gc-globulin in acute liver failure. Liver Transpl. 2007;13:1324–9.

    Article  Google Scholar 

  56. Donaldson BW, Gopinath R, Wanless IR, et al. The role of transjugular liver biopsy in fulminant liver failure: relation to other prognostic indicators. Hepatology. 1993;18:1370–4.

    Article  PubMed  CAS  Google Scholar 

  57. Malinchoc M, Kamath PS, Gordon FD, et al. A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts. Hepatology. 2000;3:864–71.

    Article  Google Scholar 

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D’Agostino, D., Diaz, S., Sanchez, M.C. et al. Management and Prognosis of Acute Liver Failure in Children. Curr Gastroenterol Rep 14, 262–269 (2012). https://doi.org/10.1007/s11894-012-0260-x

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  • DOI: https://doi.org/10.1007/s11894-012-0260-x

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