Awareness and timely management key to bring down Acute Liver Failure mortality: Experts

HEALTH/PHARMA

by Shrutee K/DNS

Mumbai October 29, 2015: The expert team of Department of Hepatology at Global Hospitals - one of the fastest growing chains of multi-super speciality, multi-organ transplant and quaternary care hospitals in Mumbai, shared their experience in treating and managing Acute Liver Failure patients medically and through transplantation.

Acute liver failure is uncommon, life threatening, catastrophic illness which affects human beings and leads to rapid deterioration of liver function resulting in organ failure and death of a previously healthy individual. The main causes of ALF can be attributed to viral hepatitis, which is caused by contaminated drinking water and secondly it could also be drug induced.

Prof. Mohamed Rela, Director & Group Head, Institute of Liver Diseases and Transplantation, Global Hospitals Group, said, “The major cause of mortality in Acute Liver Failure (ALF) is lack of optimized care and awareness among the care givers and the medical fraternity. The key to success during ALF is timely action, optimal management and access to liver transplantation.”

Prof. Rela further added, “The initial care of patients with ALF depends on prompt recognition of the condition and early detection of etiology. Patients with irreversible ALF need Management at an advanced intensive care support unit, treatment of specific etiology and early detection of candidates for liver transplantation. The centre should be well equipped to handle all kinds of liver transplantation.”

Speaking about liver diseases and acute liver failure, Dr. Samir Shah, HOD, Hepatology, Liver Intensive Care & Transplant Hepatology, Global Hospitals, Mumbai said, "Liver diseases are amongst top ten killer diseases in India and are increasing because of lifestyle changes. Those suffering from chronic liver problems need recurrent and prolonged medical attention which can be made available at tertiary care centers. ALF, however, requires immediate decision making - referral to the right centre where facilities for optimal liver intensive care to give the best chance to the patient to have a spontaneous recovery is available.  Also, in case the patient requires a transplant then the centre should be equipped to do so. Of the ALF cases received at our unit we have been able to save 80%. Of these 50% were managed medically and 50% underwent a transplant.”

Acute liver failure (ALF) can be caused by Viruses (Hep A, Hep E, Hep B, other viruses), Drugs (anti TB drugs, painkillers, alternative medicines) , Toxins (yellow phosphorus, mushrooms), and many times the cause remains unknown. Hepatitis A and Hepatitis E are water borne illness i.e. communicable by drinking contaminated food or water. Once the liver gets affected not all patients progress to liver failure but if they do then the illness becomes life threatening unless timely action and treatment is given.

Dr. Vaishali Solao, Chief Liver Intensivist, Department of Hepatology, Liver Intensive Care and Transplant Hepatology, Global Hospitals, Mumbai said, “About 10 years ago mortality rate amongst ALF patients was as high as 80% and survival rate was a meager 20%. With advances in treatment and intensive management of ALF patients’ survival has gone up to 80% and mortality has come down to 20%. But only treatment available for ALF patients is liver transplantation and can be treated only at transplant center having specialized intensive care unit and liver surgeons. However, not all ALF require transplant. 50% survive with medical management in liver care specialized centers.”

Speaking on the occasion, Professor Julia Wendon, Clinical Director, Critical Care Division, Kings College, London, said, “With an incidence of less than 10 cases per million per year in the developed world, acute liver failure is seen most commonly in previously healthy  young adults and presents unique challenges in clinical management. The clinical presentation usually includes acute severe hepatic dysfunction with abnormal liver blood tests, and coagulopathy altered conscious level as seen by encephalopathy may develop, with progressive multi-organ failure and death until recently occurring in up to half the cases. However, rates of survival have improved substantially in recent years through advances in critical care management and the use of emergency liver transplantation.”

“Acute liver failure is much less common in the developed world than in the developing world, where viral infections (hepatitis A, B, and E) are the predominant causes. Public health measures (e.g., vaccination and improved sanitation) are among the factors resulting in the reduced incidence of these infections in the United States and much of Western Europe, where drug-induced liver injury is the most common cause of acute liver failure,” added Dr. Wendon.

Talking about ALF statistics, Dr. Ravi Mohanka, Chief Surgeon and HOD, Hepato-Pancreato-Biliary Surgery and Liver Transplantation, Global Hospitals, Mumbai, said, “As per studies 160 ALF patients were reported at PGI Chandigarh between January 1996 and June 1998, and 405 patients were reported at AIIMS, Delhi, from January 2004 to June 2011. At Global Hospitals, Mumbai, we have had 53 ALF patients beginning January 2014 till date. Drawing an inference from western data where ALF is predominantly drug induced, these numbers are not even the tip of the iceberg in Indian scenario, where we have acute viral hepatitis as an important cause for ALF and not every patient lands up in a tertiary care set-up. What further aggravates the problem is the fact that the number of cadaveric liver donation in India is far and in between. Therefore, living donor liver transplant is an important option which can now be safely performed in experienced centers of excellence.

Ø  Patient awareness and education along with good medical setup, immediate coordination and judicious transfer 

of organ should be prioritized so that 

ALF management could be optimized.

Ø  Once recognized it is important to refer the patient to a specialized centre for the only cure is transplantation. 

Not all patients require transplantation.

Ø  About 50 % recover with conservative management, 25% require transplantation and rest 25% die.

Ø  Timely referral to a specialized centre, timely transplantation in the severe failure has reduced the mortality 

in ALF considerably.

Ø  It is essential that ALF be managed in specialized ICU who has experience in treating such patients for better outcome.

Global Hospital Mumbai has already established itself in the transplant space and has handled many complex liver surgeries in the past. Global Hospitals has a dedicated Liver Intensive Care Unit. They have experience and expertise in handling serious cases and have sent many patients home without a transplant by curing them with right and timely treatment. The hospital reiterated its commitment to provide world class health care facilities to the patients.