Livers – when to start, when to stop and when to transfer with Luc de Baerdemaeker
Luc de Baerdemaeker joins us from Universitair Ziekenhuis Gent to tell us about liver management
Luc starts by thanking us for the invite to “The Kingdom of Wessex”, and suggests it won’t be long until the UK is divided into it’s historical kingdoms again!!
Liver function testing
Luc points out that “classic” biomarkers are not good markers of liver function, and talks us through the usefulness of these. He stresses how important it is to interpret these in the context of a full patient history and examination.
Transaminase tests do not predict severity of liver disease. Luc suggests exploring any patient further if they have ALT above 1.5x upper limit of normal in the presence of symptomatology. He talks us through the benefit of AST/ALT ratio, but do many centres routinely test both?
Getting more complex, Luc talks about quantitative tests for liver function, such as galactose elimination capacity, indocyane green test (LIMON device), lidocaine to MEGX conversion, and radioactive label tests such as C-Aminopyrine breath test and LiMAX test. These tests are useful to assess severity, progress, and remaining function.
Child-Turcotte-Pugh is a useful predictor of mortality, including after elective abdominal surgery. Be aware the Child-Pugh B or C patient!
MELD predicts outcome after TIPS, mortality in cirrhosis, the risk of infection and subsequent death and the risk of death after surgery. 3 month mortality correlates well with increasing MELD score. MELD 40 = 100% mortality. Use the www.mayoclinic.org score to calculate this easily.
- MELD 19 refer for transplant evaluation
- MELD > 15 elective surgery should be carefully reconsidered
- MELD 12 treat with prophylaxis for SBP
- MELD 10 follow up each month
- MELD 8 follow up each 3 months
Specific for alcoholic hepatitis, the Maddrey Score can be used (>32 use corticosteroids).
Acute Liver Failure
- Hyper acute: encephalopathy within 10 days of jaundice
- Fulminant failure: within 10-30 days
- Subacute failure: within 5-24 weeks
Aetiology in Europe
- Viral – hep A, E, B (CMV, HSV, VZV, Dengue)
- Drugs/toxins – paracetamol, chemotherapy, flucloxacillin, mushrooms,
- Pregnancy – HELLP
- Congenital – Wilsons
- Malignancy – HCC
Luc stresses the importance of early referral for consideration of transplant. Clinical criteria are based upon pH, INR, AKI, encephalopathy, bilirubin.
Acute on Chronic Liver Failure
Usually triggered by an identifiable precipitant such as viral, drugs, alcohol, ischaemia or surgery. Sepsis is a common trigger. Mortality is related to the key manifestation: variceal bleed 20% for example. Outcomes are improving over time.
Scoring for Chronic Liver Failure are not applicable when patients become acutely unwell. Lucy suggests switching to classic ICU scores such as SOFA or APACHE 2. Alternatively, CLIF (Chronic Liver Failure score) is a modified SOFA score.
Managing the chronic liver failure patient
- Don’t forget the liver is a huge filter of microbes from the gut – sepsis is common.
- Cardiomyopathy is common due to the compensatory hyperdynamic circulation – beta-blockers can help.
- Maintain normovolaemia, but Luc dares to say base this on CVP as it’s linked to predicting kidney injury!
- Use balanced crystalloid, or albumen in infection/sepsis.
- Hepatorenal syndrome is rare – it’s usually AKI + chronic liver disease.
- Protect the brain and airway: actualise, rigaxamin, LOLA and LOLA-P, avoid sedation.
- Check the potency of portal vein with ultrasound.
- Treat variceal bleeds early (but avoid glue as increased embolic strokes).
- Acute Liver Failure – always refer
- Acute on Chronic – early supportive therapy
- Treat curable aetiology: vatical bleeds, spontaneous bacterial peritonitis
- Observe changes in scores such as SOFA, APACHE 2, SAPS 2 and CLIF
- Trial 2-3 days in ICU before stopping/referring if no improvement