1/12. Emerging indications for mars dialysis.mars stands for Molecular Adsorbent Recirculating System and represents an interesting option in treating patients with liver disease. There is still little known about the best time point of initiating this treatment and the exact selection criteria for patients who may benefit from this therapy. The list of potential applications using this procedure is expanding. We report on the experience in seven patients being treated with mars dialysis for chronic cholestatic liver disease and acute on chronic liver failure. From August 2000 to October 2001 seven patients received 27 mars treatments in our clinic, ranging from 2 to 12 treatments per subject. Presented cases were diagnosed as steatohepatitis because of alcoholism (n = 3), vanishing bile duct disease (n = 1), metabolic liver disease (n = 1), primary biliary cirrhosis (n = 1) and drug-induced hepatitis (n = 1). Based on this experience, we discuss the ongoing questions of various indications and the decision to initiate mars dialysis.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
2/12. mars therapy in critically ill patients with advanced malignancy: a clinical and technical report.BACKGROUND/methods: Molecular Adsorbent Recirculating System (mars) was used in three consecutive critically ill patients at the singapore General Hospital with advanced malignancy and acute liver failure (ALF). Case 1 was a male patient with hepatocellular carcinoma (HCC) for which initial right hepatectomy was followed by left hepatectomy 5 months later for recurrent HCC. The postoperative course following second surgery was complicated by severe methicillin-resistant staphylococcus aureus (MRSA) sepsis, mild azotaemia and subacute cholestatic liver failure. mars was used thrice in this patient. Case 2 was a female patient with advanced acute lymphoblastic leukaemia (ALL) with post bone marrow transplantation (BMT) acute haemolytic-uraemic syndrome (HUS) secondary to cyclosporin A (Cy A), cytomegalovirus (CMV) infection, severe nosocomial pneumonia, acute renal failure (ARF) treated with continuous haemofiltration and acute veno-occlusive disease resulting in budd-chiari syndrome. The latter precipitated ALF. mars was instituted twice. Case 3 was a male patient with advanced, refractory Hodgkin's disease previously treated with multiple courses of chemotherapy. ALF developed secondary to acute viral hepatitis b flare. He was given a trial of mars once in the ICU. All the three patients eventually died. RESULTS: Mean mars intradialytic systemic pressures were as follows: systolic pressure range was 95 /- 17 to 128 /- 17 mmHg and diastolic pressure range was 51 /- 5 to 67 /- 7 mmHg. pressure at albumin dialysate exit point from dialyser 1 (Ae) ranged from 253 /- 11 to 339 /- 15 mmHg and that at albumin dialysate entry point into dialyser 1 (Aa) ranged from 142 /- 11 to 210 /- 6 mmHg. ultrafiltration (UF) was 633 /- 622 mL over mean treatment duration of 6.3 /- 0.9 h with a total heparin dose of 1583 /- 817 IU. Coagulation status pre- and 6-h post-mars was similar: aPTT (P=0.116) and platelet count (P=0.753). There were no bleeding complications or circuit thromboses. mars had a significant de-uraemization effect (pre- and post-mars serum creatinine and urea: P=0.046 and 0.028, respectively) but did not significantly attenuate blood lactate, ammonia or total bilirubin levels. Albumin dialysate (Ae - Aa) urea and creatinine concentrations appeared to be sharply attenuated after 6 h of mars. In contrast, the removal of total bilirubin by albumin dialysate from the blood compartment appeared to plateau after 4 h of continuous mars operation. CONCLUSIONS: mars was well-tolerated in critically ill patients with advanced and complicated cancer. Low-dose heparin was safe and did not compromise mars circuit integrity. Although mars had a significant de-uraemization effect, this appeared to be limited by the duration of mars operation. Our data suggested that such a limit was reached earlier for total bilirubin. More data are needed to confirm the present findings and further delineate the saturation limit of mars for different toxins that accumulate in ALF. This would affect the optimal duration of mars therapy.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
3/12. Hepatic lymphoma metastasis presenting with severe acute liver failure: a rare case.Hepatic lymphoma metastasis is rare, and should always be considered in the differential diagnosis of hepatic malignancy. A 52-year-old man presented with a four-day history of fever, fatigue, yellowish skin and nausea. His past medical history was unremarkable. There was no history of alcohol intake or medications. His physical examination revealed generalized jaundice and hepatomegaly. His blood tests showed liver failure and coagulopathy. Abdominal ultrasonography illustrated hepatomegaly. A further work-up included bone marrow and liver biopsy. The pathology report was B-cell lymphoma. He was treated with chemotherapy, and his laboratory findings during follow-up showed steady improvement. In conclusion, lymphoma metastasis to liver can be a cause of liver dysfunction. A high index of suspicion is required for the diagnosis. We emphasize the importance of obtaining tissue sample in all patients with suspicious lesion in any organ to avoid missing the rare but curable pathologies.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
4/12. Hodgkin' s disease with fulminant non-alcoholic steatohepatitis.We report a woman with daily febrile episodes who developed fulminant hepatic failure. A percutaneous liver biopsy demonstrated non-alcoholic steatohepatitis, with no evidence of neoplastic infiltration. Post-mortem examination revealed stage IV Hodgkin's disease with trivial liver involvement. Rapidly progressive steatohepatitis causing acute liver failure may be a paraneoplastic presentation of Hodgkin's disease, possibly mediated by cytokines.- - - - - - - - - - ranking = 6keywords = tea (Clic here for more details about this article) |
5/12. Octogenarian livers successfully transplanted in patients with fulminant hepatic failure.Although octogenarian livers have been transplanted successfully in elective settings, their safety in the case of fulminant hepatic failure has not yet been reported. From November 1998 to June 2003, we transplanted 3 livers from 80-, 82-, and 86-year-old donors. The donors were hemodynamically stable with an intensive care unit stay ranging from 24-48 hours. cold ischemia time was from 260 minutes to 526 minutes. Mild macrosteatosis was present in 2 donors. Donor and recipient characteristics as well as posttransplantation evolution were evaluated. Two cases had uneventful courses and all recipients are well at 39, 21, and 5 months, respectively. The second recipient underwent retransplantation at 15 days due to technical complications. Livers from octogenarian donors may be safely used in an emergency to save patients. Age does not represent a limit for individually assessed and highly selected donors.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
6/12. Acute liver failure: a message found under the skin.Acute liver failure is a rare syndrome with rapid progression and high mortality. It is characterised by the onset of coma and coagulopathy usually within six weeks but can occur up to six months after the onset of illness. Viral hepatitis, idiosyncratic drug induced liver injury, and acetaminophen ingestion are common causes. This report describes the case of a 35 year old man who presented with acute liver failure shortly after binge drinking. Repeated history taking disclosed a gluteal disulfiram implant that the patient had received to treat his alcohol dependence. The patient recovered with maximum supportive care after surgical removal but without liver transplantation. This case illustrates that only meticulous history taking will disclose the sometimes bewildering causes of acute liver failure.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
7/12. Acute liver failure with renal impairment related to the abuse of senna anthraquinone glycosides.OBJECTIVE: To report a case of chronic ingestion of very large amounts of senna fruits as an herbal tea, possibly leading to severe hepatotoxicity. CASE SUMMARY: A 52-year-old woman who had ingested, for >3 years, one liter of an herbal tea each day made from a bag containing 70 g of dry senna fruits, developed acute hepatic failure and renal impairment requiring intensive care therapy. The severity of the hepatic failure was reflected by the increase in prothrombin time (international normalized ratio >7) and the development of encephalopathy. Liver transplantation was discussed, but the patient ultimately recovered with supportive therapy. Renal impairment was consistent with proximal tubular acidosis, also with marked polyuria refractory to vasopressin administration. Suprisingly, large amounts of cadmium were transiently recovered in the urine. DISCUSSION: cassia acutifolia and angustifolia plants are widely used as laxatives. Their chronic abuse may be associated with serious manifestations, including fluid and electrolyte loss, with chronic diarrhea. Severe hepatotoxicity is unusual, but could be explained by the exposure of the liver to unusual amounts of toxic metabolites of anthraquinone glycosides (sennosides). An objective causality assessment suggests that hepatotoxicity was possibly related to senna laxative abuse. Regarding nephrotoxicity, there are no available human data on sennosides, while experimental models suggest that anthraquinone derivatives may also accumulate in the kidneys. The finding of high urinary concentrations of cadmium would suggest contamination of the herbal tea by metals, but this hypothesis could not be verified. CONCLUSIONS: Ingestion of large doses of senna laxatives may expose people to the risk of hepatotoxicity.- - - - - - - - - - ranking = 3keywords = tea (Clic here for more details about this article) |
8/12. Fulminant hepatitis during self-medication with hydroalcoholic extract of green tea.Despite an ancient reputation for potential phytotherapeutic effects and innocuity, traditional herbal medicine has previously been implicated in severe adverse events. Exolise is an 80% ethanolic dry extract of green tea (camellia sinensis) standardized at 25% catechins expressed as epigallocatechin gallate, containing 5-10% caffeine. It has been available in france, belgium, spain and the United Kingdom since 1999, as an adjuvant therapy for use in weight loss programmes. In various studies, green tea has to date been considered useful for its potential hepatic protective properties. In this study, we report a case of fulminant hepatitis during self-medication with Exolise, requiring liver transplantation.- - - - - - - - - - ranking = 6keywords = tea (Clic here for more details about this article) |
9/12. Non-alcoholic fatty liver disease in hiv-positive patients predisposes for acute-on-chronic liver failure: two cases.Non-alcoholic fatty liver disease is a prominent feature in hiv-positive patients. We present two patients with long-lasting hiv-infection who suffered from this disease, as induced by highly active anti-retroviral therapy (HAART). The patients developed acute-on-chronic (AOC) liver failure after either (case 1) acute infection with hepatitis a virus (HAV) or (case 2) methamphetamine abuse ('Ecstasy'). Approximately 1 week after visiting an area endemic for HAV, case 1, a male patient, presented with icterus, elevated liver transaminases and HAV IgM. Previous examinations had demonstrated normal liver transaminase activities while hepatic steatosis had been suspected. He developed complications associated with liver failure including renal failure as well as pleural and pericardial effusions. Case 2, a second male patient, developed both liver failure and lactic acidosis 24 h after methamphetamine abuse. Both patients suffered from fatty liver in the pre-acute stage as indicated by ultrasound examination. After developing symptoms of liver failure, HAART was discontinued in both patients. Follow-up visits demonstrated that the patients recovered clinically with almost normalized laboratory parameters. In hiv infection, HAART-induced hepatopathological alterations may exist despite the absence of relevant laboratory parameters. These patients are likely to develop AOC liver failure when subjected to acute risk factors such as hepatitis viruses and narcotics or other drugs. In patients treated with HAART, we thus highly recommend hepatitis A and B virus vaccinations, and close monitoring of liver parameters.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
10/12. Surgery in patients with advanced liver cirrhosis: a Pandora's box.Advanced liver cirrhosis is a relative contraindication for abdominal surgery, as such patients are likely to develop postoperative complications and mortalities. We describe two patients with liver cirrhosis who developed postoperative decompensation and expired after undergoing non-abdominal surgery. We highlight that even non-abdominal surgery could incur high mortality in patients with child's class B or C liver cirrhosis. Surgery should be avoided in such patients unless it is absolutely necessary. If the procedure is essential and life-saving, the patient should be co-managed by a team of surgeon, anaesthesist and hepatologist. A full evaluation of the baseline liver status, preoperative optimisation, and close postoperative monitoring are required to reduce the risk of decompensation and improve survival.- - - - - - - - - - ranking = 1keywords = tea (Clic here for more details about this article) |
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