Intensive Care Therapy for Patients with Advanced Liver Diseases

Abstract

Decompensated cirrhosis is characterized by high hospitalization rates and costs, frequent readmissions, and poor short-term survival. Patients admitted to the hospital with acute variceal bleeding and/or hepatic encephalopathy and/or renal dysfunction are at serious risk for developing infection and/or sepsis; in turn, this renders them highly susceptible to the development of multi-system organ failure. The lack of standardized intensive care unit management protocols in patients with cirrhosis along with only few data reports from longitudinal clinical trials makes it difficult for hepatologists and critical care specialists to provide uniform evidence for clinical practice that could safely consolidate favorable outcomes such as lower hospitalization rates and/or mortality. Based on a rigorous online search of the scientific literature as well as a longtime clinical experience of the authors in the field of hepatology and critical care medicine, this work represents a focused effort to elucidate the specific bio-morbidity of advanced liver diseases in relation to the aforementioned challenges in clinical management. Further meta-analyses and/or systematic reviews are needed to enable clinicians to develop more effective strategies to bridge patients with decompensated liver disease to recompensation or liver transplantation.

The risk of bleeding and encephalopathy in surgical patients with liver cirrhosis

“…The accumulation of toxins (from bacteria, inflammation and oxidative stress) is the consequence of decreased liver function on one hand, and due to development of portosystemic shunts (which diminish the liver capacity to remove toxins from the blood-stream) on 9 the other hand. All these mechanisms are responsible (at least in part) for cerebral edema, which represents the main substrate of HE (26).…”

Acute-on-chronic liver failure: Objective admission and support criteria in the intensive care unit

“…36 Depending on the amount of bleeding that occurs, haemorrhagic shock may arise necessitating ICU transfer and use of vasopressor agents to maintain a MAP of 65 mmHg. 37 Endoscopic therapy is standard treatment for variceal bleeding and should be undertaken within 12 hours of the bleeding presentation, once adequate resuscitation is achieved. 38 For oesophageal varices, the preferred endoscopic management is variceal band ligation, which has been shown to be superior to sclerotherapy in terms of rates of haemostasis, adverse events, and 6-week survival.…”

“…43 It occurs as a result of impaired hepatic metabolic function leading to reduced removal of nitrogen-based waste products such as ammonia. 37 Ammonia crosses the blood-brain-barrier and is combined with glutamate to form glutamine, which leads to cerebral oedema. 43 Most instances of HE are precipitated by reversible factors including infection, gastrointestinal bleeding, acute kidney injury (AKI), sedating medications, and constipation.…”

Paradigmenwechsel im Verständnis der akuten Nierenschädigung bei chronischer Leberinsuffizienz: Von der Pathophysiologie zur Definition von Krankheitsentitäten

“…4 Neue Klassifizierung der HRS-Subtypen. Serumkreatininanstieg um mehr als 0,3 mg/dl innerhalb von 48 Stunden oder ▪ Serumkreatininanstieg um mehr als 50 % gegenüber dem sonst bekannten Serumkreatinin innerhalb der letzten 3 Monate und/oder ▪ verminderte Urinausscheidung von weniger als 0,5 ml je kg Körpergewicht innerhalb von Patienten mit fortgeschrittener Leberzirrhose haben ein erhöhtes Risiko für die Entwicklung einer Nebenniereninsuffizienz infolge einer verringerten Cholesterinsynthese sowie anhaltender Endotoxämie und damit verbundener Hyperkoagulopathie mit Nebennierenparenchymschädigung[53]. Ein somit entstehender Cortisolmangel begünstigt zum einen über Verminderung der β-adrenergen Rezeptoren im Herzen und über Modulation der…”