Treatment of hepatic encephalopathy by on-line hemodiafiltration: a case series study

<p>Abstract</p> <p>Background</p> <p>It is thought that a good survival rate of patients with acute liver failure can be achieved by establishing an artificial liver support system that reliably compensates liver function until the liver regenerates or a patient undergoes transplantation. We introduced a new artificial liver support system, on-line hemodiafiltration, in patients with acute liver failure.</p> <p>Methods</p> <p>This case series study was conducted from May 2001 to October 2008 at the medical intensive care unit of a tertiary care academic medical center. Seventeen consecutive patients who admitted to our hospital presenting with acute liver failure were treated with artificial liver support including daily on-line hemodiafiltration and plasma exchange.</p> <p>Results</p> <p>After 4.9 ± 0.7 (mean ± SD) on-line hemodiafiltration sessions, 16 of 17 (94.1%) patients completely recovered from hepatic encephalopathy and maintained consciousness for 16.4 ± 3.4 (7-55) days until discontinuation of artificial liver support (a total of 14.4 ± 2.6 [6-47] on-line hemodiafiltration sessions). Significant correlation was observed between the degree of encephalopathy and number of sessions of on-line HDF required for recovery of consciousness. Of the 16 patients who recovered consciousness, 7 fully recovered and returned to society with no cognitive sequelae, 3 died of complications of acute liver failure except brain edema, and the remaining 6 were candidates for liver transplantation; 2 of them received living-related liver transplantation but 4 died without transplantation after discontinuation of therapy.</p> <p>Conclusions</p> <p>On-line hemodiafiltration was effective in patients with acute liver failure, and consciousness was maintained for the duration of artificial liver support, even in those in whom it was considered that hepatic function was completely abolished.</p

A model to estimate cost-savings in diabetic foot ulcer prevention efforts

Background: Sustained efforts at preventing diabetic foot ulcers (DFUs) and subsequent leg amputations are sporadic in most health care systems despite the high costs associated with such complications. We sought to estimate effectiveness targets at which cost-savings (i.e. improved health outcomes at decreased total costs) might occur. Methods: A Markov model with probabilistic sensitivity analyses was used to simulate the five-year survival, incidence of foot complications, and total health care costs in a hypothetical population of 100,000 people with diabetes. Clinical event and cost estimates were obtained from previously-published trials and studies. A population without previous DFU but with 17% neuropathy and 11% peripheral artery disease (PAD) prevalence was assumed. Primary prevention (PP) was defined as reducing initial DFU incidence. Results: PP was more than 90% likely to provide cost-savings when annual prevention costs are less than $50/person and/or annual DFU incidence is reduced by at least 25$150 per person per year. Conclusions: Low-cost DFU primary prevention efforts producing even small decreases in DFU incidence may provide the best opportunity for cost-savings, especially if focused on patients with neuropathy and/or PAD. Mobile phone-based reminders, self-identification of risk factors (ex. Ipswich touch test), and written brochures may be among such low-cost interventions that should be investigated for cost-savings potential

Patients With Acute on Chronic Liver Failure Grade 3 Have Greater 14‐Day Waitlist Mortality Than Status‐1a Patients

Patients listed for liver transplantation (LT) as status-1a currently receive the highest priority on the waiting list. The presence of acute on chronic liver failure with three or more organs failing (ACLF-3) portends low survival without transplantation, which may not be reflected by the model for end-stage liver disease-sodium (MELD-Na) score. We compared short-term waitlist mortality for patients listed status-1a and those with ACLF-3 at listing. Data was analyzed from the United Network for Organ Sharing (UNOS) database, years 2002-2014 for 3,377 patients listed status- 1a and 5,099 patients with ACLF-3. Candidates with ACLF were identified based on the EASLCLIF criteria. MELD-Na score was treated as a categorical variable of scores 40. We used competing risks regression to assess waitlist mortality risk. Evaluation of outcomes through 21 days after listing demonstrated a rising trend in mortality among ACLF-3 patients at 7 days (18.0%), 14 days (27.7%) and 21 days (32.7%) (p<0.001), compared to a stable trend in mortality among individuals listed as status-1a at 7 days (17.9%), 14 days (19.3%) and 21 days (19.8%), (p=0.709). Multivariable modeling with adjustment for MELD-Na category revealed that patients with ACLF-3 had significantly greater mortality (SHR=1.45, 95% CI 1.31-1.61) within 14 days of listing compared to status-1a candidates. Analysis of the interaction between MELD-Na category and ACLF-3 showed patients with ACLF-3 had greater risk of 14-day mortality than status-1a listed patients, across all three MELD-Na categories. Conclusion: Patients with ACLF-3 at the time of listing have greater 14-day mortality than those listed as status-1a, independent of MELD-Na score. These findings illustrate the importance of early transplant evaluation and consideration of transplant priority for patients with ACLF-3