Acute Liver Failure Anand Annamalai Incidence Etiology Lee

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Acute Liver Failure Anand Annamalai

Acute Liver Failure Anand Annamalai

Incidence & Etiology Lee et al

Incidence & Etiology Lee et al

Multi-organ Failure Nevens et al

Multi-organ Failure Nevens et al

Cerebral Edema

Cerebral Edema

Potential Predictors of Poor Prognosis in Acute Liver Failure

Potential Predictors of Poor Prognosis in Acute Liver Failure

STATUS 1 A - UNOS

STATUS 1 A - UNOS

LIVER TRANSPLANTATION AS THE GOLD STANDARD FOR ASSESSING ALTERNATE STRATEGIES TO MANAGE ACUTE LIVER

LIVER TRANSPLANTATION AS THE GOLD STANDARD FOR ASSESSING ALTERNATE STRATEGIES TO MANAGE ACUTE LIVER FAILURE

Survival • Before the option of liver transplant and advanced intensive unit care, the

Survival • Before the option of liver transplant and advanced intensive unit care, the overall survival in the US was 10 -20% • Now, with advancements in ICU management transplant-free survival is 40%

Survival • Overall survival with both transplantation and ICU management is >60%

Survival • Overall survival with both transplantation and ICU management is >60%

Cadaveric Transplantation Survival Rates

Cadaveric Transplantation Survival Rates

Similar Survival Trend in Liver Transplantation after 1 year between ALF and cirrhosis

Similar Survival Trend in Liver Transplantation after 1 year between ALF and cirrhosis

Predictors of poor prognosis No proven model exists to accurately predict who will benefit

Predictors of poor prognosis No proven model exists to accurately predict who will benefit from transplantation Inaccurate selection may have serious effects: survival without OLT? mortality without OLT? Leads to unnecessary surgery, lifelong immunosuppression, utilization of a scarce resource (hepatic graft) vs death

Factors Affecting Outcome of Emergency Transplantation • Age < 50 – Age related reduction

Factors Affecting Outcome of Emergency Transplantation • Age < 50 – Age related reduction in physiological reserve associated with extreme stress in ALF • Severity of Illness – • Acetaminophen 2 x higher mortality after OLT compared to other etiologies Graft quality – Small size, ABO-incompatibility, steatosis

Cadaveric Transplantation US Acute Liver Failure Study Group • Listing guidelines vary from institution

Cadaveric Transplantation US Acute Liver Failure Study Group • Listing guidelines vary from institution to institution • Too sick to list? • Regional differences in organ shortage? • Unclear how many listed patients would survive without OLT? • Those that died off the OLT list deemed not sick enough may benefit from OLT? Some report > 20 % of transplanted patients would have survived without OLT

“To Do” OR “To Not To Do”

“To Do” OR “To Not To Do”

Anhepatic State: Bridge to OLT Removal of “dead” liver decreases toxin load and inflammatory

Anhepatic State: Bridge to OLT Removal of “dead” liver decreases toxin load and inflammatory response transiently Improves until systemic toxins accumulate Survival of 48 -72 hours

The Tough Decision • Time is of the essence – Emergent transplantation for survival

The Tough Decision • Time is of the essence – Emergent transplantation for survival • Unpredictability of outcome – Utility of organs in limited supply – May have had better outcome in another patient – Need to consider all organs