Liver Transplant in Acute Liver Decompensation After HBV
Liver Transplant in Acute Liver Decompensation After HBV
Non-cirrhotic patients having acute liver decompensation in flares of hepatitis B can recover spontaneously or die without liver transplantation. Criteria for identifying patients in need of liver transplantation are lacking. Fifty-one non-cirrhotic patients having acute liver decompensation in flares of hepatitis B were retrospectively reviewed. The patients were divided into three groups: group A patients (n = 18) recovered from acute liver decompensation spontaneously; group B patients (n = 22) died of acute liver failure; and group C patients (n = 11) had liver transplantation. Model of end-stage liver disease (MELD) scores were evaluated to identify the criteria for liver transplantation. The cut-off point of MELD scores for liver transplantation was evaluated by receiver operating characteristic (ROC) curve. Comparing group A and B patients, MELD score was an independent factor to predict prognosis. By analysing ROC curve, a MELD score > 30 was the most optimal cut-off point to indicate liver transplantation; however, the false positive rate was 11.1%. By weekly measurement of MELD scores, subsequent increase in MELD scores could help to avoid false positives. Moreover, a MELD score > 34 yielded 0% false positive rate and indicated the necessity of definite liver transplantation. For group C patients, ten of 11 patients were saved by liver transplantation. In conclusion, for the patients having acute liver decompensation in flares of hepatitis B, liver transplantation is definitely indicated by MELD scores > 34. Liver transplantation is also indicated if the MELD score increases in the subsequent 1–2 weeks. Liver transplantation has a good outcome if performed on time.
Hepatitis B is one of the most common infectious diseases. The natural course of hepatitis B virus (HBV) infection consists of an immune-tolerance phase, a chronic hepatitis B phase and an inactive hepatitis B phase. The chronic hepatitis B phase is the most complicated in the clinical course. During this phase, the immune-tolerance is lost for unknown reasons and immunoactivities are provoked to clear up HBV. The concentration of HBV DNA decreases and hepatitis B e antigen (HBeAg) reduction eventually leads to anti-HBe production. During this immunoactive period, hepatitis B patients may have several flares of hepatitis with repeated elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which may result in liver cirrhosis. Liver transplantation is undoubtedly needed when the liver becomes cirrhotic and decompensates. Nevertheless, a small group of chronic hepatitis B patients deal with acute liver decompensation immediately once they become aware of the flare of hepatitis. The clinical course is similar to that of fulminant liver failure. This acute liver decompensation is disastrous and life threatening. Liver transplantation is the only effective treatment for these patients if acute liver decompensation is not reversed with medical treatment.
Whether liver transplantation is crucial for acute decompensation in flares of hepatitis B, however, remains in doubt. Roughly 40% of acute liver failure patients survive with conservative treatment alone. Liver regeneration over time restores liver function; consequently, liver transplantation is unnecessary for these patients. However, differentiating between patients who require liver transplantation and those who will recover from acute liver failure spontaneously is difficult. In 1986, the Clichy criteria, based on factor V level and patient age were applied as indicators for liver transplantation of patients with fulminant hepatitis B. These criteria, focusing on fulminant hepatitis B, may not be suitable for flares of hepatitis B with acute decompensation, and measuring factor V level is not available in many centres. In 1989, the King's College criteria were developed as indicators of liver transplantation for fulminant liver failure. These criteria are valuable for acetaminophen-induced liver failure, viral fulminant liver failure or idiosyncratic drug reactions. But, these criteria are more suitable to be applied for drug-induced and non-A, non-B viral hepatitis than for hepatitis B virus-related acute liver decompensation, especially, when the patients' ages are between 10 and 40 years. The American Association for the Study of Liver Diseases published practical guidelines for liver transplantation. Nevertheless, the indications or criteria for liver transplantation for flares of hepatitis B with acute liver decompensation remain unclear.
Obviously, no simple and easy criteria can be applied to predict the prognosis for hepatitis B patients who have a flare of hepatitis B and deal with their acute liver decompensation immediately. This study attempts to find out the predictors of prognosis and indicators of liver transplantation for flares of hepatitis B with acute liver decompensation. The results of this study will help to avoid unnecessary liver transplantation and allocating donor livers to appropriate patients.
Abstract and Introduction
Abstract
Non-cirrhotic patients having acute liver decompensation in flares of hepatitis B can recover spontaneously or die without liver transplantation. Criteria for identifying patients in need of liver transplantation are lacking. Fifty-one non-cirrhotic patients having acute liver decompensation in flares of hepatitis B were retrospectively reviewed. The patients were divided into three groups: group A patients (n = 18) recovered from acute liver decompensation spontaneously; group B patients (n = 22) died of acute liver failure; and group C patients (n = 11) had liver transplantation. Model of end-stage liver disease (MELD) scores were evaluated to identify the criteria for liver transplantation. The cut-off point of MELD scores for liver transplantation was evaluated by receiver operating characteristic (ROC) curve. Comparing group A and B patients, MELD score was an independent factor to predict prognosis. By analysing ROC curve, a MELD score > 30 was the most optimal cut-off point to indicate liver transplantation; however, the false positive rate was 11.1%. By weekly measurement of MELD scores, subsequent increase in MELD scores could help to avoid false positives. Moreover, a MELD score > 34 yielded 0% false positive rate and indicated the necessity of definite liver transplantation. For group C patients, ten of 11 patients were saved by liver transplantation. In conclusion, for the patients having acute liver decompensation in flares of hepatitis B, liver transplantation is definitely indicated by MELD scores > 34. Liver transplantation is also indicated if the MELD score increases in the subsequent 1–2 weeks. Liver transplantation has a good outcome if performed on time.
Introduction
Hepatitis B is one of the most common infectious diseases. The natural course of hepatitis B virus (HBV) infection consists of an immune-tolerance phase, a chronic hepatitis B phase and an inactive hepatitis B phase. The chronic hepatitis B phase is the most complicated in the clinical course. During this phase, the immune-tolerance is lost for unknown reasons and immunoactivities are provoked to clear up HBV. The concentration of HBV DNA decreases and hepatitis B e antigen (HBeAg) reduction eventually leads to anti-HBe production. During this immunoactive period, hepatitis B patients may have several flares of hepatitis with repeated elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT), which may result in liver cirrhosis. Liver transplantation is undoubtedly needed when the liver becomes cirrhotic and decompensates. Nevertheless, a small group of chronic hepatitis B patients deal with acute liver decompensation immediately once they become aware of the flare of hepatitis. The clinical course is similar to that of fulminant liver failure. This acute liver decompensation is disastrous and life threatening. Liver transplantation is the only effective treatment for these patients if acute liver decompensation is not reversed with medical treatment.
Whether liver transplantation is crucial for acute decompensation in flares of hepatitis B, however, remains in doubt. Roughly 40% of acute liver failure patients survive with conservative treatment alone. Liver regeneration over time restores liver function; consequently, liver transplantation is unnecessary for these patients. However, differentiating between patients who require liver transplantation and those who will recover from acute liver failure spontaneously is difficult. In 1986, the Clichy criteria, based on factor V level and patient age were applied as indicators for liver transplantation of patients with fulminant hepatitis B. These criteria, focusing on fulminant hepatitis B, may not be suitable for flares of hepatitis B with acute decompensation, and measuring factor V level is not available in many centres. In 1989, the King's College criteria were developed as indicators of liver transplantation for fulminant liver failure. These criteria are valuable for acetaminophen-induced liver failure, viral fulminant liver failure or idiosyncratic drug reactions. But, these criteria are more suitable to be applied for drug-induced and non-A, non-B viral hepatitis than for hepatitis B virus-related acute liver decompensation, especially, when the patients' ages are between 10 and 40 years. The American Association for the Study of Liver Diseases published practical guidelines for liver transplantation. Nevertheless, the indications or criteria for liver transplantation for flares of hepatitis B with acute liver decompensation remain unclear.
Obviously, no simple and easy criteria can be applied to predict the prognosis for hepatitis B patients who have a flare of hepatitis B and deal with their acute liver decompensation immediately. This study attempts to find out the predictors of prognosis and indicators of liver transplantation for flares of hepatitis B with acute liver decompensation. The results of this study will help to avoid unnecessary liver transplantation and allocating donor livers to appropriate patients.
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