Short and long-term outcomes in patients with acute liver failure due to ischemic hepatitis

Abstract

Aims: The purpose of this study is to describe the incidence and presenting features of patients with acute liver failure (ALF) due to ischemic hepatitis and the prognostic factors associated with short (three-week) and long-term outcomes.

Methods: Retrospective cohort analysis of adult patients enrolled in the Acute Liver Failure Study Group between 1998 and 2008 with ALF due to ischemic hepatitis. Predictors of adverse outcomes three weeks after presentation were identified by univariate and multivariate analysis.

Results: Ischemic hepatitis accounted for 51 (4.4%) of the 1147 ALF patients enrolled. Mean age was 50 years, 63% were female, and only 31% had known heart disease before presentation. However, a cardiopulmonary precipitant of hepatic ischemia was identified in 69%. Three-week spontaneous survival was 71%, two patients (4%) underwent liver transplantation, and the remaining 13 patients (25%) died of multi-organ failure. Adverse outcomes were more frequent in subjects with higher admission phosphate levels (HR 1.3, 95% CI 1.1-1.6, P = 0.008) and in subjects with grade 3/4 encephalopathy at presentation (HR: 8.4, 95% CI 1.1-66.5, P = 0.04). Nineteen of the 28 short-term survivors (68%) were still alive at a median follow-up of 3.7 years whereas nine (32%) others had died at a median follow-up of 2 months.

Conclusions: A higher admission serum phosphate level and more advanced encephalopathy are associated with a lower likelihood of short-term survival of hospitalized patients with ALF due to ischemic hepatitis. Long-term outcomes are largely determined by underlying cardiovascular morbidity and mortality.

Figures

Fig. 1

Patients with ALF due to ischemic hepatitis. Severe hepatic ischemia accounted for 51 of the 1,147 (4.4%) ALF patients enrolled in the ALFSG between 1/98 and 10/07. At three weeks, there were 36 spontaneous survivors (71%), two patients had undergone liver transplantation (4%), and 13 had died of multi-organ failure (25%). Further follow-up of 28 initial survivors revealed that nine died of a variety of causes and the remaining 19 patients were alive at a median follow-up of 3.7 years

Fig. 2

A patient with ALF due to hepatic ischemia from an unrecognized cardiomyopathy. A 24-year-old previously healthy Caucasian male presented with a two-week history of unexplained nausea, vomiting, abdominal pain, and jaundice. At admission, his serum AST was 2,962 IU/l, ALT 2,902 IU/l, total bilirubin 15 mg/dl, and INR 4.5. In addition, he had acute kidney injury with a serum creatinine of 4.4 mg/dl and a phosphate level of 6.6 mg/dl. Evaluation for hepatitis A, B, and C, autoimmune hepatitis, and toxic liver injury was negative and a liver ultrasound demonstrated no biliary tract disease. At enrollment, he had grade 2 encephalopathy and was started on renal replacement therapy on hospital day 2. A surface echocardiogram revealed severe biventricular heart failure with an ejection fraction of