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HEPATOLOGY Vol. 34, No. 4, Pt. 2, 2001 AASLD ABSTRACTS 657A 1939 RESCUE OF A PATIENT WITH FULMINANT HEPATITIS B. Wen-Je Ko, Anne Chao, Ming-Yang Lai, National Taiwan University Hospital, Taipei Tai- wan In patients with acute liver failure, APACHE-II >18, Glasgow Coma Score (GCS)<8 and hepatic encephalopathy (HE) grade 4 are associated with high mortality. We report a case of a patient with hyperacute fulminant hepatic failure (FHF), who received liver dialysis treatment with the HemoTherapies Unit TM. The patient was a 31-yr-old Taiwanese woman, who developed fever up to 39 ° C, general malaise, nausea and vomiting four days prior to admission. She became jaundiced, developed abnormal mentation and elevated liver en- zymes, and was referred to our service. After admission to the ICU, she was diagnosed as having sudden onset FHF due to hepatitis B virus infection. Her history was negative for drug or herb use. Prior to treatment, she was in grade 4 coma with an APACHE-II score of 26 and GCS 3. On days 1 through 4 she received daily 4.5- to 6-hr liver dialysis treatments with the HemoTherapies Unit, and on day 6 she was discharged to the floor for medical observation due to an elevated bilirubin. Her APACHE-II score improved from 26 (pre) to 2 (post, days 5 to 7) to 0 (days 8 to 27); GCS, from 3 (pre) to 10T (post) to 15 (days 5 to 27); and HE decreased from grade 4 (pre) to grade 1 (post) to grade 0 (days 5 to 29). AST decreased from 4194 (pre) to 341 (post) to 56 (day 29); ALT, from 1620 (day 3) to 1140 (post) to 40 (day 29); and NH3, from 203 (pre) to 42 (post) to 33 (day 29). On day 31 she was discharged to home. More than two years later, the patient's health is normal with no evidence of liver disease. The rapid improvement in APACHE-II and GCS scores, HE grade, early dis- charge from the ICU, and avoidance of transplantation in this patient support the effectiveness of liver dialysis with the HemoTherapies Unit in patients with FHF from acute hepatitis B. Fu+minant hepatitis B: Impact of liver dialysis with the ffemoTherapies Unit DI D2 D3 I)4 Day 1 Rx I post- pest+ post- post- D6 D19 D29 D67 Rx Rx Rx Rx APACHE- 26 14 5 2 2 0 0 0 II GCS 3 4 5 9T 10T 15 15 15 15 HE 4 4 4 3 1 0 0 0 0 AST 4194 2498 1008 423 341 t25 58 56 85 ALT 1620 1t40 571 74 40 35 NHa 203 160 72 34 42 49 32 33 1 1940 ACUTE HEPATITIS AS AN INDICATION FOR LIVER BIOPSY. Susana Lopes, H S Jo~o, V.N.Gaia Portugal; Pedro Moutinho Ribeiro, Guilherme Macedo, Fatima Carneiro, Tome Ribeiro, H S Jo~o, Porto Portugal The paradigme of liver biopsy indications is the staging and histological char- acterization of chronic liver disease (viral,metabolic, autoimmune). However, not only in some acute liver failure patients but also in some acute cytolysis/ cholestasis syndromes, of unknown cause, liver biopsy may be justifiable. We have analysed 83 cases of clinical acute hepatitis syndrome that underwent liver biopsy, percutaneous or transjugular, in our Unit, and described clinical and laboratorial features, and final diagnosis.We studied 49 men and 34 women, mean age 46 (+/-14 years old). Only 11 of these patients (13%) were outpatients, and 28 (34%) were intensive care Unit patients. Transjugular biopsy was performed in 57 (68%), and in 24 patients (30%) the indication was acute liver failure. Final diagnosis were: acute alcoholic hepatitis in 23 (28%), drug induced acute hepatitis in 15 (18%), autoimmune in 14 (17%), viral in 9 (11%), Wilson's in 5 (6%), sepsisin 4 (5%), cryptogenic in 6 (7%) and miscel- laneous in 7 (8%, lymphoma, hemophagocytic syndrome, acute fatty liver of pregnancy). The coexistence of cirrhosis was observed in 37 patients (45%), belonging to the alcohol and autoimmune groups. Conclusions: Liver biopsy may have a formal indication in acute hepatitis, particularly in acute liver failure, non viral induced. It may allow liver copper assessment when suspect- ing Wilson's, and may identify cirrhosis ( in autoimmune liver disease) that should promote a special therapeutic strategy in this setting. 1941 ACUTE-ON-CHRONIC LIVER FAILURE IN TWO HIV INFECTED PA- TIENTS. All Canbay, Robert Gieseler, Klaus Radecke, Thomas Schreiter, Guido Gerken, Ulrich Treichel, University Hospital Essen, Essen Germany Background: Acute liver failure, as characterized by acute liver insufficiency, hepatorenal syn- drome, and hepatic encephalopathy, is termed acute-on-chronic liver failure (AOC) when a pre- damaged organ is affected. Indeed, >50% of all HIV+ patients present with non-specific hepatic alterations such as steatosis, siderosis, reactive hepatitis, or cholestasis which are currently attrib- uted to multifactorial causes. We here present two patients with long-lasting HIV infection under anti-retroviral therapy (ART) who developed AOC after (i) acute infection with HAV, or (ii) merhamphetamine ("Ecstasy") abuse. Case I: Approx. 1 wk. alter visiting an area endemic for HAV, a 39-yr.-old male (stage A2) became icteric, showed elevated liver enzymes, and was tested lgiVi-positive for HAV. Previous examinations had demonstrated normal transaminase activities while hepatic steatosis had been suspected. He developed liver failure-associated complications including renal failure as well as pleural and pericardial effusion. Case II: A 33-yr.-old male (stage A3), known for ethanol abuse and suspected alcoholic liver disease. Approx. 24 hrs. after Ecstasy abuse, he developed both liver failure and lactic acidosis (12 U/L). Results: Both patients suffered from fatty liver in the pre-acute stage as suspected by ultrasound assessments. After developing symptoms of liver failure, ART was discontinued. Both recovered clinically with normalized laboratory parameters in follow-up. Conclusions: Because of the high incidence of hepatic alter- ations found in HIV+ patients despite significant laboratory evidence, there appears to be high risk for developing AOC when subjected to acute risk factors such as hepatitis A or hepatotoxic drugs. Therefore, vaccination against hepatitis A and B should be strongly urged. With respect to ART, liver parameters should be closely monitored. C lin!ca!,parameters before and after liver failure Case I Virology f Clinical Chemistry Sonogr Stage aphy HN- CD4+ Total bilirubi RNA IT. ALT AST y-GT NH4+ PTT [s] [copies/ censlpl [U/L] [U/L] n [mg/dL] [U/L] [gg/dL] ml] ] Case t Pre- acute 33,200 857 14 12 0.9 18 >1 wk. after ND ND 619 520 9,5 139 HAY- inf. Casetl Pre- 304 243 46 31 1.3 87 acute >1 wk. after ND ND 460 560 12,7 107 ecstasy ND 28 FL 110 55 HSM ND 30 FL 95 69.8 HSM FL: fattyliver,HSM: hepatosplenomegaly, ND: not determined 1942 ETIOLOGY AND OUTCOME OF 83 PATIENTS WITH FULMINANT I-IE- PATIC ,,FAILURE IN ADULTS. EXPERIENCE OF AN ARGENTINEAN LIVER TRANSPLANT UNIT. Pedro L Trigo, Javier C Lendoire, Gustavo A Braslavsky, Maria C Romero, Nora G Cejas, Oscar C Imventarza, Hospital Argerich, Buenos Aires Argentina INTRODUCTION: Fulminant hepatic failure is a rare disease with a high mortality rate. The etiologies are very different around the world. Most of the series come from USA and Europe. There are only some reports from Latin America. From January 1996 to May 2001, 83 patients with fulminant hepatic failure were admitted as a candidates for liver transplantation. PURPOSE: Ana- lyze the etiology and outcome of the adult patients with fulminant hepatic failure admitted in our liver transplant unit. PATIENTSAND METHODS: All the charts of patients with fulminant hepatic failure were reviewed. The etiology, age, gender, clinical presentation (O'Grady 1993), hepatic coma grade on admission and outcome were analyzed. RESULTS: Sixty nine percent o{the patients were female, the average age was 31.94- + I3.02, at arrival 16% were in hepatic coma grade I, 24% in grade III, and 25% in grade IV. Clinic profile by etiology is described in table I. CONCLUSION: In contrast with recent report from USA and Europe no cases by acetaminophen toxicity were registered. Hepatitis A virus is an important cause of fulminant hepatic failure accounting for 8% of the cases as was demonstrated in the Western series. No patients with fulminant Wilson disease presented spontaneous recovery as were described previously. The recovery without transplant in young people with fulminant hepatitis B and hiperacute presentation were just described in the King's College criteria. It is relevant the high incidence of the fulminant presentation of autoim- mune hepatitis (18% of total) not reported in previous studies. The overall rate of spontaneous recovery is in accordancy with others centers. High mortality rate without transplantation was associated with two factors: 1)the scarce or organ donor in our country (4.3 per million popula- tion) and 2)late referral of patients that was reflected in the deep encephalopathy at arrival. Adult to adult living related liver transplantation could decrease mortality on the waiting list. ~BGI Sex Clasffication Outcome Etiology N Age Male H!pAc Acute SubAe "Ix D SR Crypto 21 33±I5 7 7 !2 2 11 9 1 HBV 18 28_+7.7 I1 9 8 1 3 9 8 AImrn 15 31_+10,2 3 1 6 8 7 5 3 Drugs 12 46_+14.2 0 4 8 0 3 6 3 HAV 7 21_+5,13 2 1 5 t 3 I 3 Wilson 3 22~7,0 1 1 1 I 1 2 0 AFL P 3 30±3.06 0 3 0 0 0 3 0 Others 4 36_+14,5 2 2 1 1 2 2 0 TOTAL 83 26 28 41 t4 30 34 t9 % 31 34 49 17 36 42 23 Hip Ac: hiperacute; SubAc:sabacule; Tx; transplanted; D: Death,SR: Spontaneus Recovery; Crypto:Cryptogenetic; HVB: Hepati{is B virus;A trnm:hepeti{is Autoimmune;HAV:hepatitis A virus; AFL: AcuteFa~yLiver of pregnancy,

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HEPATOLOGY Vol. 34 , No . 4, Pt. 2, 2001 AASLD ABSTRACTS 6 5 7 A

1939

RESCUE OF A PATIENT WITH FULMINANT HEPATITIS B. Wen-Je Ko, Anne Chao, Ming-Yang Lai, Nat ional Ta iwan Univers i ty Hospital , Taipei Tai- w a n

In pat ients w i th acute l iver failure, APACHE-I I > 1 8 , Glasgow Coma Score ( G C S ) < 8 and hepat ic encepha lopa thy (HE) grade 4 are associated w i th h igh mortal i ty. W e repor t a case of a pat ient w i th hyperacu te fu lminan t hepat ic failure (FHF) , w h o rece ived liver dialysis t r ea tmen t wi th the H e m o T h e r a p i e s Uni t TM. The pat ient was a 31-yr-o ld Ta iwanese w o m a n , w h o deve loped fever up to 39 ° C, general malaise, nausea and vomi t i ng four days pr ior to admission. She b e c a m e jaundiced , deve loped a b n o r m a l men ta t i on and e levated l iver en- zymes, and was refer red to our service. After admiss ion to the ICU, she was d iagnosed as hav ing s u d d e n onse t FHF due to hepat i t is B virus infection. Her his tory was negat ive for d rug or he rb use. Prior to t rea tment , she was in grade 4 c o m a wi th an APACHE-I I score of 26 and GCS 3. O n days 1 t h rough 4 she rece ived daily 4.5- to 6-hr l iver dialysis t rea tments w i th the H e m o T h e r a p i e s Unit , and on day 6 she was d ischarged to the floor for medica l observat ion due to an e levated bil irubin. Her APACHE-I I score i m p r o v e d f rom 26 (pre) to 2 (post, days 5 to 7) to 0 (days 8 to 27); GCS, f rom 3 (pre) to 10T (post) to 15 (days 5 to 27); and HE decreased f rom grade 4 (pre) to grade 1 (post) to grade 0 (days 5 to 29). AST decreased f rom 4194 (pre) to 341 (post) to 56 (day 29); ALT, f rom 1620 (day 3) to 1140 (post) to 40 (day 29); and NH3, f rom 203 (pre) to 42 (post) to 33 (day 29). O n day 31 she was d ischarged to home. More than two years later, the pat ient ' s hea l th is n o r m a l wi th no ev idence of l iver disease. The rap id i m p r o v e m e n t in APACHE-I I and GCS scores, HE grade, early dis- charge f rom the ICU, and avoidance of t ransplanta t ion in this pat ient suppor t the effectiveness of l iver dialysis wi th the H e m o T h e r a p i e s Uni t in pat ients wi th FHF f rom acute hepati t is B.

Fu+minant hepatitis B: Impact of liver dialysis with the ffemoTherapies Unit DI D2 D3 I)4 Day 1

Rx I post- pest+ post- post- D6 D19 D29 D67 Rx Rx Rx Rx

APACHE- 26 14 5 2 2 0 0 0 II GCS 3 4 5 9T 10T 15 15 15 15 HE 4 4 4 3 1 0 0 0 0 AST 4194 2498 1008 423 341 t25 58 56 85 ALT 1620 1t40 571 74 40 35 NHa 203 160 72 34 42 49 32 33 1

1940

ACUTE HEPATITIS AS AN INDICATION FOR LIVER BIOPSY. Susana Lopes, H S Jo~o, V.N.Gaia Portugal; Pedro Mout inho Ribeiro, Gu i lhe rme Macedo, Fa t ima Carneiro, T o m e Ribeiro, H S Jo~o, Porto Portugal

The pa rad igme of l iver b iopsy indicat ions is the s taging and histological char- acter izat ion of chronic l iver disease (viral ,metabolic, a u t o i m m u n e ) . However , no t only in s o m e acute l iver failure pat ients bu t also in some acute cytolysis/ cholestasis syndromes , of u n k n o w n cause, l iver b iopsy m a y be justifiable. W e have analysed 83 cases of clinical acute hepati t is s y n d r o m e that u n d e r w e n t l iver biopsy, pe rcu taneous or t ransjugular , in our Uni t , and descr ibed clinical and laboratorial features, and final diagnosis .We s tudied 49 m e n and 34 w o m e n , m e a n age 46 ( + / - 1 4 years old). Only 11 of these pat ients (13%) were outpat ients , and 28 (34%) were intensive care Uni t patients. Trans jugular biopsy was pe r fo rmed in 57 (68%), and in 24 pat ients (30%) the indicat ion was acute l iver failure. Final diagnosis were: acute alcoholic hepatit is in 23 (28%), d rug induced acute hepatit is in 15 (18%), a u t o i m m u n e in 14 (17%), viral in 9 (11%), Wilson 's in 5 (6%), sepsisin 4 (5%), cryptogenic in 6 (7%) and miscel- laneous in 7 (8%, l ymphoma , hemophagocy t i c syndrome , acute fatty l iver of pregnancy) . The coexistence of cirrhosis was observed in 37 pat ients (45%), be longing to the alcohol and a u t o i m m u n e groups. Conclusions: Liver biopsy m a y have a formal indicat ion in acute hepatit is, par t icular ly in acute l iver failure, non viral induced. It m a y al low liver copper assessment w h e n suspect- ing Wilson 's , and m a y identify cirrhosis ( in a u t o i m m u n e liver disease) that should p r o m o t e a special therapeut ic s t ra tegy in this setting.

1941

ACUTE-ON-CHRONIC LIVER FAILURE IN T W O H I V I N F E C T E D PA- T IE NTS . All Canbay, Robert Gieseler, Klaus Radecke, T h o m a s Schreiter, Guido Gerken , Ulr ich Treichel , Univers i ty Hospi ta l Essen, Essen G e r m a n y

Background: Acute liver failure, as characterized by acute liver insufficiency, hepatorenal syn- drome, and hepatic encephalopathy, is termed acute-on-chronic liver failure (AOC) when a pre- damaged organ is affected. Indeed, >50% of all HIV+ patients present with non-specific hepatic alterations such as steatosis, siderosis, reactive hepatitis, or cholestasis which are currently attrib- uted to multifactorial causes. We here present two patients with long-lasting HIV infection under anti-retroviral therapy (ART) who developed AOC after (i) acute infection with HAV, or (ii) merhamphetamine ("Ecstasy") abuse. Case I: Approx. 1 wk. alter visiting an area endemic for HAV, a 39-yr.-old male (stage A2) became icteric, showed elevated liver enzymes, and was tested lgiVi-positive for HAV. Previous examinations had demonstrated normal transaminase activities while hepatic steatosis had been suspected. He developed liver failure-associated complications including renal failure as well as pleural and pericardial effusion. Case II: A 33-yr.-old male (stage A3), known for ethanol abuse and suspected alcoholic liver disease. Approx. 24 hrs. after Ecstasy abuse, he developed both liver failure and lactic acidosis (12 U/L). Results: Both patients suffered from fatty liver in the pre-acute stage as suspected by ultrasound assessments. After developing symptoms of liver failure, ART was discontinued. Both recovered clinically with normalized laboratory parameters in follow-up. Conclusions: Because of the high incidence of hepatic alter- ations found in HIV+ patients despite significant laboratory evidence, there appears to be high risk for developing AOC when subjected to acute risk factors such as hepatitis A or hepatotoxic drugs. Therefore, vaccination against hepatitis A and B should be strongly urged. With respect to ART, liver parameters should be closely monitored.

C lin!ca!,parameters before and after liver failure Case I Virology f Clinical Chemistry Sonogr Stage aphy

HN- CD4+ Total bilirubi

RNA IT. ALT AST y-GT NH4+ PTT [s] [copies/ censlpl [U/L] [U/L] n [mg/dL] [U/L] [gg/dL]

ml] ]

Case t Pre- acute 33,200 857 14 12 0.9 18

>1 wk. after ND ND 619 520 9,5 139 HAY- inf. Case tl Pre-

304 243 46 31 1.3 87 acute >1 wk. after ND ND 460 560 12,7 107

ecstasy

ND 28 FL

110 55 HSM

ND 30 FL

95 69.8 HSM

FL: fatty liver, HSM: hepatosplenomegaly, ND: not determined

1942

ETIOLOGY AND OUTCOME OF 83 PATIENTS WITH FULMINANT I-IE- P A T I C ,,FAILURE IN ADULTS. EXPERIENCE OF AN ARGENTINEAN LIVER TRANSPLANT UNIT. Pedro L Trigo, Javier C Lendoire, Gustavo A Braslavsky, Maria C Romero, Nora G Cejas, Oscar C Imventa rza , Hospi ta l Argerich, Buenos Aires Argent ina

INTRODUCTION: Fulminant hepatic failure is a rare disease with a high mortality rate. The etiologies are very different around the world. Most of the series come from USA and Europe. There are only some reports from Latin America. From January 1996 to May 2001, 83 patients with fulminant hepatic failure were admitted as a candidates for liver transplantation. PURPOSE: Ana- lyze the etiology and outcome of the adult patients with fulminant hepatic failure admitted in our liver transplant unit. PATIENTS AND METHODS: All the charts of patients with fulminant hepatic failure were reviewed. The etiology, age, gender, clinical presentation (O'Grady 1993), hepatic coma grade on admission and outcome were analyzed. RESULTS: Sixty nine percent o{ the patients were female, the average age was 31.94- + I3.02, at arrival 16% were in hepatic coma grade I, 24% in grade III, and 25% in grade IV. Clinic profile by etiology is described in table I. CONCLUSION: In contrast with recent report from USA and Europe no cases by acetaminophen toxicity were registered. Hepatitis A virus is an important cause of fulminant hepatic failure accounting for 8% of the cases as was demonstrated in the Western series. No patients with fulminant Wilson disease presented spontaneous recovery as were described previously. The recovery without transplant in young people with fulminant hepatitis B and hiperacute presentation were just described in the King's College criteria. It is relevant the high incidence of the fulminant presentation of autoim- mune hepatitis (18% of total) not reported in previous studies. The overall rate of spontaneous recovery is in accordancy with others centers. High mortality rate without transplantation was associated with two factors: 1)the scarce or organ donor in our country (4.3 per million popula- tion) and 2)late referral of patients that was reflected in the deep encephalopathy at arrival. Adult to adult living related liver transplantation could decrease mortality on the waiting list.

~BGI

Sex Clasffication Outcome Etiology N Age Male H!pAc Acute SubAe "Ix D SR

Crypto 21 33±I5 7 7 !2 2 11 9 1 HBV 18 28_+7.7 I1 9 8 1 3 9 8 AImrn 15 31_+10,2 3 1 6 8 7 5 3 Drugs 12 46_+14.2 0 4 8 0 3 6 3 HAV 7 21_+5,13 2 1 5 t 3 I 3 Wilson 3 22~7,0 1 1 1 I 1 2 0 AFL P 3 30±3.06 0 3 0 0 0 3 0 Others 4 36_+14,5 2 2 1 1 2 2 0 TOTAL 83 26 28 41 t4 30 34 t9

% 31 34 49 17 36 42 23

Hip Ac: hiperacute; SubAc: sabacule; Tx; transplanted; D: Death, SR: Spontaneus Recovery; Crypto:Cryptogenetic; HVB: Hepati{is B virus; A trnm: hepeti{is Autoimmune; HAV: hepatitis A virus; AFL: Acute Fa~y Liver of pregnancy,