BACKGROUND/AIMS: Hepatitis-B-related acute-on-chronic liver failure has a poor prognosis. However, the advent of potent oral antiviral agents means that some patients can now recover with medical treatment. We aimed to identify the prognostic factors for hepatitis-B-related acute-on-chronic liver failure including the initial as well as the dynamically changing clinical parameters during admission. METHODS: Sixty-seven patients were retrospectively enrolled from 2003 to 2012 at Samsung Medical Center. The patients were classified into three categories: Recovery group (n=23), Liver transplantation group (n=28), and Death group (n=16). The Liver transplantation and Death groups were combined into an Unfavorable prognosis group. We analyzed the prognostic factors including the Model for End-Stage Liver Disease (MELD) scores determined at 3-day intervals. RESULTS: A multivariable analysis showed that the unfavorable prognostic factors were a high initial MELD score (> or =28) (odds ratio [OR] =6.64, p=0.015), moderate-to-severe ascites at admission (OR=6.71, P=0.012), and the aggravation of hepatic encephalopathy during hospitalization (> or =grade III) (OR=15.41, P=0.013). Compared with the baseline level, significant reductions in the MELD scores were observed on the 7th day after admission in the Recovery group (P=0.016). CONCLUSIONS: Dynamic changes in clinical parameters during admission are useful prognostic factors for hepatitis-B-related acute-on-chronic liver failure.
Acute-On-Chronic Liver Failure/*diagnosis/drug therapy/etiology ; Adult ; Aged ; Antibodies, Monoclonal, Murine-Derived/therapeutic use ; Antineoplastic Combined Chemotherapy Protocols/therapeutic use ; Antiviral Agents/therapeutic use ; Cyclophosphamide/therapeutic use ; DNA, Viral/analysis ; Doxorubicin/therapeutic use ; Female ; Hepatitis B virus/genetics ; Hepatitis B, Chronic/complications/*diagnosis/drug therapy ; Hospitalization ; Humans ; Liver Transplantation ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Prednisone/therapeutic use ; Prognosis ; Retrospective Studies ; Severity of Illness Index ; Vincristine/therapeutic use ; Young Adult

BACKGROUND/AIMS: A revised classification system for renal dysfunction in patients with cirrhosis was proposed by the Acute Dialysis Quality Initiative and the International Ascites Club Working Group in 2011. The aim of this study was to determine the prevalence of renal dysfunction according to the criteria in this proposal. METHODS: The medical records of cirrhotic patients who were admitted to Konkuk University Hospital between 2006 and 2010 were reviewed retrospectively. The data obtained at first admission were collected. Acute kidney injury (AKI) and chronic kidney disease (CKD) were defined using the proposed diagnostic criteria of kidney dysfunction in cirrhosis. RESULTS: Six hundred and forty-three patients were admitted, of whom 190 (29.5%), 273 (42.5%), and 180 (28.0%) were Child-Pugh class A, B, and C, respectively. Eighty-three patients (12.9%) were diagnosed with AKI, the most common cause for which was dehydration (30 patients). Three patients had hepatorenal syndrome type 1 and 26 patients had prerenal-type AKI caused by volume deficiency after variceal bleeding. In addition, 22 patients (3.4%) were diagnosed with CKD, 1 patient with hepatorenal syndrome type 2, and 3 patients (0.5%) with AKI on CKD. CONCLUSIONS: Both AKI and CKD are common among hospitalized cirrhotic patients, and often occur simultaneously (16.8%). The most common type of renal dysfunction was AKI (12.9%). Diagnosis of type 2 hepatorenal syndrome remains difficult. A prospective cohort study is warranted to evaluate the clinical course in cirrhotic patients with renal dysfunction.
Acute Kidney Injury/*epidemiology/etiology/mortality ; Adult ; Aged ; Cohort Studies ; Female ; Hospital Mortality ; Humans ; Kidney Failure, Chronic/*epidemiology/etiology/mortality ; Liver Cirrhosis/complications/*diagnosis ; Male ; Middle Aged ; Prevalence ; Prospective Studies ; Severity of Illness Index ; Survival Rate

The aim of this study was to investigate the clinical characteristics of acute hepatitis A during a recent outbreak in Korea. Data of patients diagnosed with acute hepatitis A from 2007 to 2009 were collected from 21 tertiary hospitals retrospectively. Their demographic, clinical, and serological characteristics and their clinical outcomes were analyzed. A total of 4,218 patients (mean age 33.3 yr) were included. The median duration of admission was 9 days. The mean of the highest ALT level was 2,963 IU/L, total bilirubin was 7.3 mg/dL, prothrombin time INR was 1.3. HBsAg was positive in 3.7%, and anti-HCV positive in 0.7%. Renal insufficiency occurred in 2.7%, hepatic failure in 0.9%, relapsing hepatitis in 0.7%, and cholestatic hepatitis in 1.9% of the patients. Nineteen patients (0.45%) died or were transplanted. Complications of renal failure or prolonged cholestasis were more frequent in patients older than 30 yr. In conclusion, most patients with acute hepatitis A recover uneventfully, however, complication rates are higher in patients older than 30 yr than younger patients. Preventive strategies including universal vaccination in infants and active immunization of hepatitis A to adult population should be considered for prevention of community-wide outbreaks of hepatitis A in Korea.
Acute Disease ; Adolescent ; Adult ; Age Factors ; Aged ; Child ; Child, Preschool ; Cholestasis/epidemiology/etiology ; Demography ; Hepatitis A/complications/*diagnosis/mortality ; Humans ; Kidney Failure, Chronic/epidemiology/etiology ; Liver Transplantation ; Middle Aged ; Morbidity ; Republic of Korea ; Retrospective Studies ; Tertiary Care Centers ; Young Adult

Trimethoprim-sulfamethoxazole (TMP-SMZ) is a commonly used antibiotic that has been associated with drug rash with eosinophilia and systemic symptoms (DRESS) syndrome. DRESS syndrome is characterised by fever, rash, lymphadenopathy, eosinophilia and one or more major organ involvement. Although rare, TMP-SMZ is a recognised cause of fulminant hepatic failure. We report a 17-year-old Chinese male adolescent who presented with fever, myalgia, generalised maculopapular rash and lymphadenopathy after taking TMP-SMZ for acne vulgaris. He subsequently developed hepatic encephalopathy and was worked up for urgent liver transplantation. He responded well to extracorporeal liver dialysis (originally intended as a bridging therapy) and subsequently recovered without the need for liver transplantation. This case report highlights the importance of early recognition of TMP-SMZ-induced DRESS syndrome and the need for early discontinuation of the drug in the affected patient. Extracorporeal liver dialysis and transplantation should be considered in the management of TMP-SMZ-induced fulminant hepatic failure.
Acne Vulgaris ; complications ; drug therapy ; Adolescent ; Anti-Infective Agents ; adverse effects ; Biopsy ; Drug Eruptions ; etiology ; Drug Hypersensitivity Syndrome ; diagnosis ; etiology ; Fever ; etiology ; Humans ; Liver Failure, Acute ; etiology ; therapy ; Lymphatic Diseases ; etiology ; Male ; Myalgia ; etiology ; Renal Dialysis ; methods ; Skin ; pathology ; Treatment Outcome ; Trimethoprim, Sulfamethoxazole Drug Combination ; adverse effects

Acute-on-chronic liver failure (ACLF) is an increasingly recognized distinct disease entity encompassing an acute deterioration of liver function in patients with chronic liver disease. Although there are no widely accepted diagnostic criteria for ACLF, the Asia.Pacific Association for the Study of the Liver (APASL) and the American Association for the Study of Liver Disease and the European Association for the Study of the Liver (AASLD/EASL) consensus definitions are commonly used. It is obvious that the APASL and the AASLD/EASL definitions are based on fundamentally different features. Two different definitions in two different parts of the world hamper the comparability of studies. Recently, the EASL-Chronic Liver Failure Consortium proposed new diagnostic criteria for ACLF based on analyses of patients with organ failure. There are areas of uncertainty in defining ACLF, such as heterogeneity of ACLF, ambiguity in qualifying underlying liver disease, argument for infection or sepsis as a precipitating event, etc. Although the exact pathogenesis of ACLF remains to be elucidated, alteration of host response to injury, infection, and unregulated inflammation play important roles. The predisposition, infection/inflammation, response, organ failure (PIRO) concept used for sepsis might be useful in describing the pathophysiology and clinical categories for ACLF. Treatment strategies are limited to organ support but better understanding of the pathophysiology is likely to lead to discovery of novel biomarkers and therapeutic strategies in the future.
Chronic Disease ; Echocardiography ; Humans ; Liver Cirrhosis/complications ; Liver Failure/diagnosis/etiology/*pathology/prevention & control ; Liver Failure, Acute/diagnosis/etiology/*pathology/prevention & control ; Liver Transplantation ; Sepsis/complications

BACKGROUND/AIMS: Most patients with acute viral hepatitis A have a favorable course, but a few of them suffer from severe forms of hepatitis such as fulminant hepatitis. This study was carried out to identify the factors influencing the severity of acute viral hepatitis A. METHODS: We retrospectively reviewed the medical records of 713 patients with acute hepatitis A, who were divided into two groups: severe hepatitis A (N=87) and non-severe hepatitis A (N=626). Severe hepatitis was defined as fulminant hepatitis or prolongation of prothrombin time (INR> or =1.5). Clinical variables were compared between the two groups. RESULTS: The incidence of fulminant hepatitis was 1.4 % (10/713) in patients with acute hepatitis A. Thirty-three (4.6 %) cases exhibited HBsAg positivity. In multivariate analyses, significant alcohol intake and the presence of HBsAg were significant predictive factors of fulminant hepatitis A, and significant alcohol intake and age were significant predictive factors of severe hepatitis A. HBeAg and HBV-DNA status did not affect the clinical course of hepatitis A in chronic hepatitis B carriers. CONCLUSIONS: While most patients with acute hepatitis A have an uncomplicated clinical course, our data suggest that a more-severe clinical course is correlated with being older, significant alcohol intake, and chronic hepatitis-B-virus infection. (
Acute Disease ; Adult ; Age Factors ; Alcohol Drinking ; Female ; Hepatitis A/complications/*diagnosis ; Hepatitis B Surface Antigens/blood ; Hepatitis B, Chronic/complications ; Humans ; Liver Failure, Acute/epidemiology/etiology ; Male ; Middle Aged ; Predictive Value of Tests ; Prothrombin Time ; Retrospective Studies ; Severity of Illness Index

Acute viral hepatitis A has recently become a major public health problem in Korea, and the incidence of symptomatic hepatitis A is growing rapidly. With improvements in socioeconomic conditions and environmental hygiene, the chances of exposure to hepatitis A virus (HAV) during childhood have decreased and, in turn, the proportion of young adults with positive anti-HAV has significantly decreased. This has led to the incidence of symptomatic acute hepatitis A increasing since the late 1990s. The incidence of serious complications including fulminant hepatic failure and acute kidney injury has also showed an increasing trend. Variation of the genotype of virus isolated from recent hepatitis A patients suggests an inflow of the hepatitis virus from other countries. In this review article, we present the situation and epidemiology of hepatitis A in Korea, and recommend further investigation and policies for vaccination on a national level.
Acute Disease ; Genotype ; Hepatitis A/complications/diagnosis/*epidemiology ; Hepatitis A Antibodies/analysis ; Humans ; Incidence ; Kidney Failure, Acute/etiology ; Liver Failure, Acute/etiology ; Vaccines, Inactivated/pharmacology

Hepatitis A is generally known as a mild, self-limiting disease of the liver, but in rare instances it can progress to fulminant hepatitis, which may require liver transplantation for recovery. Such cases are known to be related to old age and underlying liver disease. We report four cases of hepatitis A in which patients presented with fulminant hepatitis and acute renal failure and underwent liver transplantation. The following common features were observed in our cases: (1) occurrence in relatively old age (> or =39 years old), (2) association with acute renal failure, (3) presence of hepatomegaly, and (4) microscopic features of submassive hepatic necrosis.
Adult ; Age Factors ; Female ; Hepatitis/complications/*diagnosis/therapy ; Hepatitis A/complications/*diagnosis ; Hepatomegaly/diagnosis/etiology ; Humans ; Kidney Failure, Acute/complications/*diagnosis ; Liver/pathology ; Liver Cirrhosis/diagnosis/etiology ; *Liver Transplantation ; Male ; Tomography, X-Ray Computed

Carcinoma, Hepatocellular ; diagnosis ; therapy ; Gastroenterology ; trends ; Hepatitis, Viral, Human ; diagnosis ; therapy ; Humans ; Liver Cirrhosis ; diagnosis ; therapy ; Liver Diseases ; diagnosis ; therapy ; Liver Failure, Acute ; etiology ; therapy ; Liver Neoplasms ; diagnosis ; therapy ; Retrospective Studies

BACKGROUNDS/AIMS: The occurrence of acute hepatitis A is increasing and its progression to fulminant hepatic failure (FHF) is frequent. We investigated the frequency and clinical outcomes of fulminant hepatitis A and also analyzed the predictive factors of spontaneous survival. METHODS: A total of 568 patients presented with acute hepatitis A from January 2003 to June 2008, of which the 35 (6.2%) patients with FHF were divided into two groups: spontaneous survival and transplant/death. These two groups were compared according to various clinical features including the MELD score and King's College Hospital (KCH) criteria. RESULTS: The rate of FHF development increased over time among patients with acute hepatitis A: 0% in 2003, 3.4% in 2004, 3.2% in 2005, 6.0% in 2006, 7.7% in 2007, and 13.0% in 2008. Twenty patients (57.1%) showed spontaneous survival, 13 (37.1%) received liver transplantation, and 5 (14.3%) died during hospitalization. The two groups of spontaneous survival (N=20) and transplant/death (N=15) showed significant differences in prothrombin time at admission and at its worst value, albumin at its worst value, and hepatic encephalopathy grade at admission and at its worst value. The MELD score was lower in the spontaneous-survival group than in the transplant/death group (27.0+/-7.8 vs. 37.0+/-7.1, mean+/-SD; P=0.001). However, KCH criteria did not differ significantly between the two groups. On multivariate analysis, HEP grade was the only significant predictive factor, being negatively correlated with spontaneous survival (OR=0.068, P=0.025). CONCLUSIONS: FHF due to hepatitis A has increased in recent years, and in our cohort the HEP grade was closely associated with spontaneous survival.
Acute Disease ; Adult ; Female ; Hepatitis A/*complications/diagnosis ; Humans ; Liver Failure, Acute/*diagnosis/etiology/*mortality ; Liver Transplantation ; Male ; Multivariate Analysis ; Predictive Value of Tests ; Prognosis ; Retrospective Studies ; Severity of Illness Index ; Survival Analysis ; Treatment Outcome