dutch intensive care society acute liver failure · [email protected] “liver failure ... •...
TRANSCRIPT
![Page 1: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/1.jpg)
Pulsion, Excalez MAB member
Fresenius, Ashai Kasei consultancy
“Liver Failure”
Julia WendonKings College London and Kings College Hospital
London
![Page 2: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/2.jpg)
Disclosure of speaker’s interests
(Potential) conflict of interest
Potentially relevant company
relationships in connection with
event 1
• MAB member of Pulsion and (Excalenz) : no payment
• I have undertaken consultancy work for Fresenius and AshaiKasei
• Pulsion and Baxter supported research through provision of products
![Page 3: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/3.jpg)
What is Liver Failure ?
• Cirrhosis
– Fibrosis, Portal hypertension
• Decompensated Liver Disease
– Ascites, varices, renal dysfucntion
• Acute on Chronic Liver Failure
– Acute event with worsening of liver and other organ function
• Acute Liver Failure
– Previously normal liver : acute, hyperacute, subacute
• Post surgical Liver failure
• Liver dysfunction / failure in critically ill patients
• Post trauma liver dysfunction / failure
![Page 4: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/4.jpg)
Possible points of CC referral
Is this new disease
Is this a homogoenous population
What is AoCLF ?
Asian view
minor fibrosis/ fat + viral, DILI
European / USA view
varices, sepsis, paracentesis, alcohol
Sepsis
Variceal bleed
Paracentesis
Metabolic status / drugs
Alcoholic hepatitis
Surgery
![Page 5: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/5.jpg)
Alastair J. O’Brien Intensive Care Med (2012) 38:991–1000
![Page 6: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/6.jpg)
![Page 7: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/7.jpg)
Definition of organ failureModified SOFA score for Cirrhosis (The SOFA-CLIF SCORE)
Organ/system 0 1 2 3 4
Liver (Bilirubin, mg/dL)
<1.2 ≥1.2 - ≤1.9 ≥2 - ≤5.9 ≥6 - <12 ≥12
Kidney (Creatinine (mg/dL)
<1.2 ≥1.2 - ≤ 1.9 ≥2 - <3.5 ≥3.5 - <5 ≥5
or use of renal-replacement therapy
Cerebral (HE grade)
No HE
1 2 3 4
Coagulation (INR) <1.1 ≥1.1 – <1.25 ≥1.25 - <1.5 ≥1.5 – <2.5 ≥2.5 or Platelets≤20x109/L
Circulation (MAP mm Hg)
≥70 <70 Dopamine ≤5or Dobutamine or Terlipressin
Dopamine >5 or E ≤ 0.1 or NE ≤ 0.1
Dopamine >15 or E > 0.1 or NE > 0.1
Lungs PaO/FiO2: or SpO2/FiO2
>400
>512
>300 - ≤400
>357 - ≤512
>200 - ≤300
>214 - ≤357
>100 - ≤200
>8 - ≤214
≤100
≤89
GASTROENTEROLOGY 2013;144:1426–1437
![Page 8: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/8.jpg)
Acute on chronic liver failure:
Other factors and prognosis
Levesque E et al. J Hepatology 2012, n = 377
Source :
Chest : HE
Ascites
Blood
Urine
MDR organisms / infections
18% overall BUT :
4, 18 and 35 % of community, HCA,
nosocomial
Efficacy of treatment only 40% in
nosocomial sepsis
Mortality of 25% vs 12% for MDR
![Page 9: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/9.jpg)
Multivariate analysis : predictors of mortality ignoring appropriate antiobiotic choice
diagnosis of infection, age, Bilirubin, creatinine,
Multivariate analysis : predictors of mortality considering appropriate antiobiotic choice
diagnosis of infection , appropriate antibiotic choice, age, INR
![Page 10: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/10.jpg)
Alcoholic hepatitis
Lille score
Age
Renal
INR
Bilirubin
Albumin
Delta Bilirubin
Aliment Pharmacol Ther 2014; 39: 721–732, Burroughs
Comparison of 9 scores : no difference in AUC
3.19-0.101*(age)+0.147*(alb day 0)
+0.0165*(change in Bili)-
0.206*(renal insufficiency
{0/1:creat < or > 115 µmol/L)-0.0065
(Day 0 Bili)
![Page 11: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/11.jpg)
![Page 12: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/12.jpg)
![Page 13: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/13.jpg)
Hypoxia and CLD
Common
Hydrothorax : “SBP”
Atelectasis
Sepsis
Interstitial lung disease
Intra-abdominal pressure Ascites
Hepatopulmonary syndromeO2, position
Portopulmonary hypertensionsidenafil, PGI2, bosanten
![Page 14: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/14.jpg)
![Page 15: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/15.jpg)
Aliment Pharmacol Ther 2015; 41: 189-198
Pro-coagulant
Protein C, S, FVIII
and ATIII
Thrombomodulin
resistant
Avoid FFP
Increase anticoagulation
![Page 16: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/16.jpg)
The 4 fluids of lifeJournal of Hepatology 2014 vol. 60 j 1310–1324
Journal of Hepatology 2010 vol. 53 j 397–417
![Page 17: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/17.jpg)
SBP
Endothelial markers TLR4, IL-10
Phagcytosis
Oxidative burst
![Page 18: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/18.jpg)
Albumin for bacterial infections other than
spontaneous bacterial peritonitis in cirrhosis. A
randomized, controlled study.
• J Hepatol. 2012 Oct;57(4):759-65.
• Non SBP infections 100 patients
• Antibiotics ± albumin at diagnosis and day 3
(1.5 and 1 g/kg)
• No difference in survival at 3 mnths
• Improved creatinine and circulation markers –
no difference in HRF ( 1 vs 3)
![Page 19: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/19.jpg)
Journal of Hepatology 2015
62 822–830
Thierry Thévenot
![Page 20: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/20.jpg)
![Page 21: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/21.jpg)
• Resuscitation : Airway
• Coagulation support - as per massive Tf
• Diagnostic endoscopy +
• Therapy
• Vasoactive drugs
• Endoscopic therapy
• banding and glue
• Failed drugs + OGD
• Balloon tamponade
• TIPS
Lactate
Number of endoscopies
![Page 22: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/22.jpg)
![Page 23: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/23.jpg)
CXR – that wasn’t seen before the OGD!
![Page 24: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/24.jpg)
…………….
![Page 25: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/25.jpg)
RRT/ metabolic support : yes or no
![Page 26: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/26.jpg)
Na, brain and outcome
Critical Care 2014, 18:700 Increased ITU stay and mortality
![Page 27: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/27.jpg)
Liver International (2013)
![Page 28: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/28.jpg)
Acute on chronic liver failure:
Prognostication based on scores
Levesque E et al. J Hepatology 2012, n =377
![Page 29: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/29.jpg)
A
B
C
D
The American Journal of GASTROENTEROLOGY 2014 McPhail et al
![Page 30: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/30.jpg)
• A SOFA/CLIF-SOFA score of greater than 13 on Day 1
• 90% mortality rate
• SOFA scores greater than 13 on Day 3 and 7
• 89% and 90% mortality rates respectively
• Lactate level greater than 4 mmol/L on Day 1
• 81% mortality rate
• Lactate level greater than 4 mmol/L on day 3 and 7
• 91% mortality rate and 88% mortality respectively
• The absolute SOFA score on day 3 was a better predictor of mortality than change in
score.
• Delta SOFA score changes
• Increase from day 1 : mortality 51%
• Unchanged : mortality of 42%
• Decrease after Day 1 : mortality was 28%.
Mark J. W. McPhail Clinical Gastroenterology and Hepatology 2014
![Page 31: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/31.jpg)
The Royal Free Hospital Score: A Calibrated Prognostic Model for Patients With
Cirrhosis Admitted to Intensive Care Unit. Comparison With Current Models and CLIF-
SOFA Score
Am J Gastroenterol. 2014 Feb 4.
Burroughs AK
![Page 32: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/32.jpg)
Incorporation of age and wbc : CLIFF C score
Jalan et al Journal of Hepatology
2014 vol. 61 j 1038–1047
![Page 33: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/33.jpg)
Fixing specificity at 95% and estimating sensitivity (bootstrap
method)
A cut-off value of greater than 14 for CLIF-SOFA gives a sensitivity of
32% (26%– 40%)
A cut-off of greater than 12 for SOFA gives a sensitivity of 33 % (26–
39)
Suggests neither score : SOFA or CLIFF SOFA provide an accurate
indicator of futility.
Mark J. W. McPhail Clinical Gastroenterology and Hepatology 2014
Can we predict “Futility”
![Page 34: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/34.jpg)
The right lobe is injured more commonly than the left
(>85% involve segments VI, VII, and VIII)
Deceleration injury
IVC and hepatic veins
Children at increased risk -
flexible ribs and a weaker
connective tissue framework
![Page 35: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/35.jpg)
Grade 3 – laceration >3cm deep Grade 5 – laceration >75% of lobe
juxta-hepatic venous injury
![Page 36: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/36.jpg)
Pseudo-aneurysms
Presentation 2 weeks post trauma
Haemodynamic collapse,
Malaena, Haematemesis
Obstructive liver function
Rare in
those managed with
embolization
![Page 37: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/37.jpg)
Horse kick injury
Failure of stent with ongoing
high volume drain loss
Ileus - consider nasobiliary tube
33% bile leakAll managed with ERCP
Stent placed across sphincter
Bala et al. Scandinavian
Journal of Trauma, Resuscitation
And Emergency Medicine
2012, 20:20
![Page 38: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/38.jpg)
Acute Liver Failure
Bernal et al, Lancet 2010
![Page 39: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/39.jpg)
Bone marrow stained for T cell marker
CD3
in situ hybridization for EBV
![Page 40: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/40.jpg)
Liver Int 2013
Coagulation
Journal of Hepatology
2012 vol. 57 780–786
Mallett et al
![Page 41: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/41.jpg)
![Page 42: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/42.jpg)
Larsen et al J Hepatology 2016
![Page 43: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/43.jpg)
![Page 44: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/44.jpg)
Bernal et al 2016
![Page 45: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/45.jpg)
D1: INR 6.5 rising to 8.5, CK 150K, ALT 9,000 , ARF, lactate 6 - D2 INR 5, lactate 3.0, ALT 7000
Found outside club - fitting – intubated and brought to ED : Temp 41 seizure control : D0
![Page 46: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/46.jpg)
Teams make things [email protected]
![Page 47: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/47.jpg)
Case : 50 year old man ALD, occasional drinking but remains in full employment
Presents jaundice, oedema, SoB - ?PE Rx clexane - admitted to ward
Day 2 : CT-PA negative BUT now Confused ++, malaena developed
Intubated for OGD in theatre : no bleeding point seen
Extubated - bradycardic, intubated, CPR X 1 cycle
In recovery - annuric, acidotic, adrenaline / noradrenaline infusions
pH 7.06 pO2 8.6 pCO2 8.2 HCO3 13.6 BE-14 Fi02 0.5
Lactate 2.7 mMol/l
Na 135 K 6.8
Urea 30 (N< 7) Creatinine 587 (N < 120)
Bilirubin 100 µmol/L (5.8 mg /dl)
ALP 56 AST 244 GGT 339
WBC 16.4 Hb 12.4 Plt 73
INR 2.94 APTT 2.02
CRP 190
Child Pugh 6-8 (pre)MELD 27SOFA 17CLIFF COF ACLF 3CLIFF C 70 (91% mortality)
Swollen inflammedLeg with area of necrosis
![Page 48: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/48.jpg)
Day 4
Free of pressorsPassing urine Fi02 0.4INR 1.6
Culture negative Rising ASO titre
Discharged to ward day 18
![Page 49: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/49.jpg)
*Patients who fulfil these criteria may still have structural damage such as tubular
damage. Urine biomarkers will become an important element in making a more accurate
differential diagnosis between HRS and acute tubularnecrosis.
Journal of Hepatology 2015
Rare
Most have an AKI
![Page 50: Dutch Intensive Care Society Acute Liver Failure · julia.wendon@kcl.ac.uk “Liver Failure ... • Decompensated Liver Disease – Ascites, varices, renal dysfucntion ... Intubated](https://reader035.vdocuments.us/reader035/viewer/2022071002/5fbfbc3d44972d45c947f957/html5/thumbnails/50.jpg)
Mark J. W. McPhailClinical Gastroenterology and Hepatology 2014