Etiologies and Outcomes of Acute Liver Failure in Germany

doi:10.1016/j.cgh.2012.02.016

Clinical Gastroenterology and Hepatology

Volume 10, Issue 6, June 2012, Pages 664-669.e2

https://doi.org/10.1016/j.cgh.2012.02.016 Get rights and content

Background & Aims

Acute liver failure (ALF) is a severe form of acute liver injury that can progress to multiple organ failure. We investigated causes and outcomes of ALF.

Methods

Eleven university medical centers in Germany were asked to report patients with (primary) severe acute liver injury (sALI) (international normalized ratio [INR] >1.5 but no hepatic encephalopathy) and primary ALF (INR >1.5 with overt hepatic encephalopathy) treated from 2008 to 2009. Data were analyzed from 46 patients with sALI and 109 patients with ALF.

Results

The most frequent etiologies of primary ALF were non-acetaminophen drug-induced (32%), indeterminate (24%), and viral (21%); acetaminophen ingestion was the cause of ALF in only 9% of patients. The support of a ventilator was required by 44% of patients with ALF, vasopressors by 38%, and renal replacement by 36%. Seventy-nine patients with ALF (72%) survived until hospital discharge, 38 (35%) survived without emergency liver transplantation (ELT), and 51 received ELT (47%); 80% of patients who received ELT survived until discharge from the hospital.

Conclusions

In Germany, drug toxicity, indeterminate etiology, and viral hepatitis appear to be the major causes of primary ALF, which has high mortality. Patients with ALF are at great risk of progressing to multiple organ failure, but 80% of patients who receive ELT survive until discharge from the hospital.

Section snippets

Enrollment of Patients and Definitions of Severe Acute Liver Injury and Acute Liver Failure

In 2010, all university clinics participating in the Acute Liver Failure Study Group Germany (including all major liver transplant centers) were asked to retrospectively identify patients with imminent and overt primary ALF treated at their clinics during a 2-year period (2008–2009).

Early recognition of ALF is important and has been declared as a main task of our study group. We therefore intended to include a wider range of disease severity than just those patients incurring encephalopathy,

Distribution of Etiology and Outcome in Severe Acute Liver Injury

Forty-six patients with sALI (imminent ALF) were reported by the participating centers. Seventeen patients (37.0%) developed sALI caused by non-acetaminophen drug toxicity, 8 (17.4%) had acute viral hepatitis, 7 (15.2%) had ingested acetaminophen, 6 (13.0%) were reported to have sALI of indeterminate cause, and 8 (17.4%) had other causes. Two of 4 sALI patients with phenprocoumon toxicity (50%) and 3 of 6 sALI patients with indeterminate cause (50%) died or underwent ELT in the absence of

Discussion

The main results of this multicenter retrospective analysis are (1) outcome of ALF patients is strongly associated with the underlying etiology, (2) development of HE is significantly associated with reduced chance of ELT-free survival (87% vs 35%), (3) ELT is performed in nearly half of ALF patients with an overall survival rate of 72%, and (4) KCC are widely used to predict outcome of ALF but lack sensitivity in predicting a fatal outcome that can possibly be improved by BiLE score.

The most

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Acute liver failure (ALF) is an infrequent, unpredictable, potentially fatal complication of acute liver injury (ALI) consequent to varied etiologies. Etiologies of ALF as reported in the literature have regional differences, which affects the clinical presentation and natural course. In this part of the consensus article designed to reflect the clinical practices in India, disease burden, epidemiology, clinical presentation, monitoring, and prognostication have been discussed. In India, viral hepatitis is the most frequent cause of ALF, with drug-induced hepatitis due to antituberculosis drugs being the second most frequent cause. The clinical presentation of ALF is characterized by jaundice, coagulopathy, and encephalopathy. It is important to differentiate ALF from other causes of liver failure, including acute on chronic liver failure, subacute liver failure, as well as certain tropical infections which can mimic this presentation. The disease often has a fulminant clinical course with high short-term mortality. Death is usually attributable to cerebral complications, infections, and resultant multiorgan failure. Timely liver transplantation (LT) can change the outcome, and hence, it is vital to provide intensive care to patients until LT can be arranged. It is equally important to assess prognosis to select patients who are suitable for LT. Several prognostic scores have been proposed, and their comparisons show that indigenously developed dynamic scores have an edge over scores described from the Western world. Management of ALF will be described in part 2 of this document.
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: Conflicts of interest The authors disclose no conflicts.

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Original article—liver, pancreas, and biliary tractEtiologies and Outcomes of Acute Liver Failure in Germany

Background & Aims

Methods

Results

Conclusions

Section snippets

Enrollment of Patients and Definitions of Severe Acute Liver Injury and Acute Liver Failure

Distribution of Etiology and Outcome in Severe Acute Liver Injury

Discussion

J Hepatol

Gastroenterology

Clin Gastroenterol Hepatol

Lancet

Clin Gastroenterol Hepatol

Lancet

Gastroenterology

J Hepatol

J Hepatol

The management of fulminant hepatic failure

AASLD position paper: the management of acute liver failure

Hepatology

Review of the final report of the 1998 working party on definition, nomenclature and diagnosis of hepatic encephalopathy

Aliment Pharmacol Ther

Fulminant hepatic failure

Original article—liver, pancreas, and biliary tract
Etiologies and Outcomes of Acute Liver Failure in Germany