Current guidelines recommend deferring liver transplantation (LT) in patients with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infection until clinical improvement occurs and two PCR ...tests collected at least 24 hours apart are negative. We report a case of an 18‐year‐old, previously healthy African‐American woman diagnosed with COVID‐19, who presents with acute liver failure (ALF) requiring urgent LT in the context of SARS‐CoV‐2 polymerase chain reaction (PCR) positivity. The patient was thought to have acute Wilsonian crisis on the basis of hemolytic anemia, alkaline phosphatase:bilirubin ratio <4, AST:ALT ratio >2.2, elevated serum copper, and low uric acid, although an unusual presentation of COVID‐19 causing ALF could not be excluded. After meeting criteria for status 1a listing, the patient underwent successful LT, despite ongoing SARS‐CoV‐2 PCR positivity. Remdesivir was given immediately posttransplant, and mycophenolate mofetil was withheld initially and the SARS‐CoV‐2 PCR test eventually became negative. Three months following transplantation, the patient has made a near‐complete recovery. This case highlights that COVID‐19 with SARS‐CoV‐2 PCR positivity may not be an absolute contraindication for transplantation in ALF. Criteria for patient selection and timing of LT amid the COVID‐19 pandemic need to be validated in future studies.
An 18‐year‐old, previously healthy African American woman presents with both acute COVID‐19 (known recent exposure; SARS‐CoV‐2 polymerase chain reaction positivity) and acute liver failure (previously undiagnosed Wilson's Disease), undergoes urgent liver transplantation 2 weeks after presentation and has a near‐complete recovery.
Alcohol-associated hepatitis (AH) is a severe entity associated with high mortality. Corticosteroids might be used in cases with severe disease and several dynamic models can predict mortality and ...response to corticosteroids in AH patients. However, there is no consensus on the best of them. This study aimed to evaluate dynamic models to predict response to corticosteroid treatment based on short-term mortality in patients with severe AH based on a worldwide cohort.
A retrospective cohort study of patients with severe AH (between 2009 – 2019). We included patients who received corticosteroid treatment and calculated the Lille model of day 4 (Lille-4), day 7 (Lille-7) (cut-off value ≥0.45), and the Trajectory of Serum Bilirubin (TSB)(cut-off value ≥0.8 of the ratio between bilirubin at admission and day 7) to predict mortality. We estimated up to 30-day survival using Kaplan-Meier curves, and we performed multivariable analyzes using Cox regression. Specifically, we constructed two models to compare Lille-4 vs. TSB and Lille-7 vs. TSB, adjusting by well-known clinical variables associated with higher mortality in AH (age, sex, and creatinine at admission).
1,066 patients were included (30 centers, 10 countries), age 47.7 ± 10.9 years, 30% women. The MELD score on admission was 25 21-30. Responders were considered by Lille-4 49.1%, Lille-7 46.6%, and TSB 55.4%. In the first Cox regression, we observed that Lille-4 and TSB predicted 30-day mortality (HR 3.0, 95%CI: 1.7-5.1; p<0.0001, and HR 2.1, 95%CI: 1.3-3.5; p=0.005, respectively) (Table A). In the second Cox regression, Lille-7 also predicted 30-day mortality (HR 3.7, 95%CI: 2.1-6.7; p<0.0001) but not TSB (HR 1.5, 95% CI: 0.8-2.6; p=0.180) (Table B). Creatinine at admission was also statistically significant in both Cox-regressions.
Different dynamic models can determine the response to corticosteroids in patients with severe AH. However, Lille-7 and Lille-4 have the best performance. New models are needed for better prognostication in AH.
Alcohol-associated hepatitis (AH) corresponds to a severe entity with high short-term mortality; however, few studies have been published in patients with moderate AH. This study aimed to ...characterize patients with moderate AH in a global study, identifying prognostic factors and survival at 30, 90, and 180 days.
Multi-center retrospective cohort study, which included patients with moderate AH (2009-2019). Moderate AH was defined as MELD 20 at presentation. We used competing-risk models with liver transplantation as a competing risk to assess variables associated with mortality.
We included 564 patients (24 centers, 12 countries). Median age was 48±11.6 years, 29.2% female, and 46.2.5% Caucasian. 51.7% had cirrhosis, and 1.4% underwent liver transplantation. The MELD score on admission was 17 6-20. In the entire cohort, 37.7% used corticosteroids. Survival rates at 30, 90, and 180 days were 93.7% (0.911–0.955), 89.1% (0.860–0.916), and 87% (0.836–0.898), respectively. The most frequent causes of death were multiple organ failure (30.4%) and infections (11.5%). In the univariate analysis, variables associated with mortality were age (sHR 1.035, 95%CI:1.020–1.049; p <0.001), Maddrey's discriminant function (sHR 1.013, 95%CI:1.007–1.020; p<0.001), albumin at admission (sHR 0.837, 95%CI:0.682–1.026; p 0.087), INR (sHR 1.534; 95%CI: 1.070–2.198, p=0.020), renal replacement therapy (RRT) (sHR 7.066; 95%CI:4.381–11.392; p<0.001) and infections during hospitalization (sHR 2.079; 95%CI:1.308–3.306; p=0.002)(Table). However, in the multivariate-adjusted model, only age (sHR 1.042; 95%CI:1.019–1.0656, p<0.001), RRT (sHR 7.796; 95%CI:3.993–15.218, p<0.001) and infections during hospitalization (sHR 1.666; 95%CI:0.999–2.779; p=0.050) were associated with mortality. Of note, corticosteroids did not demonstrate benefit.
Patients with moderate AH have a significant mortality at short-term. Infections are associated with higher mortality and are the most important cause of death in these patients. Better models are necessary to predict mortality in moderate AH adequately.
Alcohol-associated hepatitis (AH) is a severe entity with a mortality of up to 30–50% at 1 month. Pentoxifylline combined with steroids has not demonstrated benefits in severe AH. Some studies have ...suggested that pentoxifylline may be beneficial in the subgroup of patients with acute kidney injury (AKI) and AH. However, there is no solid evidence of its benefit in mortality in this setting. This study aimed to determine the benefit of the use of pentoxifylline in patients with severe AH and AKI.
Global retrospective cohort study, including patients with severe AH and AKI at admission (2009–2019). We used competing-risk models with liver transplantation as a competing risk to assess the potential effect of pentoxifylline.
We included 655 patients with severe AH and AKI (30 centers from 10 countries). Median age was 48±11.6 years, 26.2% were females, and 52.5% were Caucasian. Around 68.7% of the patients had a prior history of cirrhosis, and 6.6% underwent liver transplantation. The MELD score on admission was 34 15–74. 43.2% of the patients used corticosteroids, while only 6.9% used pentoxifylline during hospitalization. In the univariate analysis, the variables independently associated with mortality were the female sex (sHR 0.740; 95%IC:0.577–0.948; p=0.018), MELD (sHR 1.034; 95%IC: 1.020–1048; p<0.001), MELD 3.0 (sHR 1.034,95%IC:1.018–1.049, p<0.001), Maddrey's discriminant function (sHR 1.005, 95%IC:1.003–1.008, p<0.001), serum albumin at admission (sHR 0.756; 95%IC:0.642–0.890; p=0.001), bilirubin at admission (sHR 1.011; 95%IC:1.003–1.019, p=0.006), serum creatinine (sHR 1.083; 95%IC:1.028–1.140, p=0.002) and pentoxifylline use (sHR 1.531, 95%IC:1.107–2.119; p=0.010)(Table). In the multivariate-adjusted model, the use of pentoxifylline was associated with increased mortality (sHR 1.620, 95%IC:1.190–2.204; p=0.002).
The use of pentoxifylline has no benefit in terms of mortality and could decrease survival in patients with AH and AKI.
Liver transplantation for acute liver failure in a SARS-CoV-2 PCR-positive patient Yohanathan, Lavanya; Campioli, Cristina C; Mousa, Omar Y ...
American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons,
08/2021, Letnik:
21, Številka:
8
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