The role of transjugular liver biopsy in fulminant liver failure: Relation to other prognostic indicators

Abstract

Early and accurate diagnosis and prognosis of patients with fulminant liver failure is of critical importance for optimum management. We investigated the role of transjugular liver biopsy in the management of patients with fulminant liver failure and assessed its value in comparison with the recently proposed King's College criteria. Sixty-one patients with fulminant liver failure, ages 2 to 82 yr, were retrospectively analyzed. The main outcome measures were survival vs. death or progression to orthotopic liver transplantation. Transjugular liver biopsy was successful in 60 of 61 patients, with a mean core tissue length of 2.1 cm. There were eight minor complications, all of which were managed conservatively. Biopsy specimens were evaluated for degree of fibrosis, percentage of hepatocellular necrosis and presence of bile duct proliferation, hepatocellular mitotic figures and binucleate hepatocytes for each of the 54 specimens available for analysis. In 34 of 54 patients (63%), the presumed clinical diagnosis was confirmed by transjugular liver biopsy. In 11 patients the procedure served to clarify clinical uncertainty, whereas in 9 of 54 (16.7%) the diagnosis was altered after transjugular liver biopsy. The percentage of necrosis was the only histological parameter that appeared to have significant discriminatory prognostic value, with only 2 of 19 survivors having greater than 70% necrosis. Twenty-one of these biopsy specimens were reviewed by two pathologists, and their degree of correlation for the various features was assessed. Almost perfect concordance was found between the two pathologists on the percentage of hepatocellular necrosis.(ABSTRACT TRUNCATED AT 250 WORDS)

Substantial hepatic necrosis is prognostic in fulminant liver failure

“…Studies addressing the prognostic value of liver biopsies with substantial necrosis are rare, and the conclusions are not well defined in the literature[14,15]. Hanau and colleagues questioned the value of hepatic necrosis in predicting clinical outcome, because about 50% of the biopsies in their study showed minimal bridging necrosis[7].…”

“…Additionally, Hanau and colleagues found that only one of seven (14.3%) patients whose liver biopsy demonstrated ≥ 70% necrosis survived without transplantation, keeping in line with our finding. In another study in 1993, Donaldson and colleagues found that only 2 of 19 patients (10.5%) with > 70% necrosis survived without transplantation[14]. These findings indicate that the percentage of hepatic necrosis may be an important prognosticator for patient survival.…”

“…In fulminant liver failure, the prognosis for those with significant hepatic necrosis is generally thought to be poor. And yet, the extent of necrosis in a biopsy, and its importance in predicting patient outcomes, is less well defined in the literature[7,14]. One study even casts doubt on the value of hepatic necrosis as a prognostic indicator[7].…”

Clinical management of acute liver failure: Results of an international multi-center survey

“…Although it has been suggested to be of diagnostic and prognostic value, assisting clinical decision-making and timing of LT[5,6], in our survey it was not generally considered a requirement in clinical practice and was performed only in a small minority of patients.…”

“…In clinical practice, the risk of bleeding following routine procedures such as insertion of central venous catheters or paracentesis and even for more invasive procedures such as trans-jugular LBX is considered small[5,18]. In contrast, the risk of intracranial hemorrhage following ICP monitor insertion is a major cause of concern in ALF patients with an incidence of fatal hemorrhage ranging from 1%-5%[19,20].…”