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A Journal on Internal Medicine

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Panminerva Medica 2003 June;45(2):85-94

language: English

Liver transplantation in acute liver failure

Higgins P. D. R., Fontana R. J.

From the Department of Internal Medicine Division of Gastroenterology University of Michigan Medical School Ann Arbor, MI, USA


Acetaminophen and idio­syn­cratic ­drug ­induced hepat­o­tox­icity are the ­most com­monly iden­ti­fied eti­ol­o­gies of ­acute ­liver ­failure in ­Western coun­tries. Infectious com­pli­ca­tions and cere­bral ­edema ­remain the ­leading ­causes of ­death. Moderate hypo­thermia and ­other med­ical inter­ven­tions may ­improve cere­bral ­edema in ­selected ­patients ­with ­acute ­liver ­failure. In addi­tion, ­pilot ­studies sug­gest ­that recom­bi­nant ­factor VIIa infu­sions may ­allow for the ­safe place­ment of intra­cra­nial pres­sure mon­i­toring ­devices in ­patients ­with cere­bral ­edema and ­severe coag­u­lop­athy. Auxiliary ­liver trans­plan­ta­tion and bio­ar­ti­fi­cial ­liver ­devices ­offer the ­hope of tem­po­rary ­liver sup­port for ­selected ­patients ­with a ­high like­li­hood of ­native ­liver regen­er­a­tion. Prognostic sur­vival ­models ­that ­include arte­rial lac­tate ­levels may ­improve our ­ability to iden­tify ace­tam­i­no­phen over­dose ­patients in ­urgent ­need of ­liver trans­plan­ta­tion. The ­lower 1-­year ­patient sur­vival fol­lowing ­liver trans­plan­ta­tion for ­acute ­liver ­failure com­pared to ­chronic ­liver ­failure (60 vs 80%) is in ­part due to the emer­gent ­nature of sur­gery, con­com­i­tant ­vital ­organ ­failure, and the ­higher inci­dence of immu­no­log­i­cally medi­ated ­graft dys­func­tion. Vaccination ­against hepat­o­trophic ­viruses and ­other ­public ­health meas­ures ­designed to min­i­mize the inci­dence of ­both inten­tional and non-inten­tional ace­tam­i­no­phen over­dose may ­help ­reduce the ­future inci­dence of ­acute ­liver ­failure. In the mean­while, it is rec­om­mended ­that ­acute ­liver ­failure ­patients be man­aged in expe­ri­enced cen­ters ­with ­ready ­access to ­liver trans­plan­ta­tion to opti­mize out­comes in ­this ­rare but fre­quently ­fatal ill­ness.

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