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Published on: September 13, 2014
Hepatitis A Liver Failure in Children: Native Liver Survival Despite Poor Prognosis
Vipul Gautam1, Bikrant B Lal2, Vikram Kumar1
1Department of Pediatric Hepatology, Centre for Liver and Biliary Sciences, Max Superspeciality Hospital, Saket, New Delhi, India.
Insights
Pediatric acute liver failure (PALF) due to Hepatitis A virus (HAV) can resolve with native liver support, even with severe indicators. Advanced critical care and liver assist devices improve survival in children with HAV-induced PALF.
Area of Science:
- Pediatric Hepatology
- Viral Hepatitis
- Acute Liver Failure
Background:
- Hepatitis A virus (HAV) is a leading cause of pediatric acute liver failure (PALF), particularly in developing nations.
- While HAV-induced PALF generally has better outcomes than other causes, predicting prognosis remains challenging.
- Advanced critical care, including extracorporeal liver assist devices (ELAD), has improved native liver survival in PALF.
Observation:
- This report details three children with HAV-induced PALF who presented with advanced hepatic encephalopathy (HE) and international normalized ratio (INR) > 10.
- Despite fulfilling established liver transplant criteria, all three children survived with their native livers.
- Case examples include patients with peak INR > 10.2, grade 3-4 HE, cerebral edema, acute kidney injury, and those managed with CRRT and therapeutic plasma exchange.
Findings:
- Children with HAV-induced PALF can achieve recovery with their native liver.
- Survival is possible even with extremely poor prognostic markers such as very high INR, elevated ammonia, and advanced HE.
- Effective medical management and liver support strategies are crucial for native liver recovery.
Implications:
- Current liver transplant listing criteria for PALF may need refinement to better predict outcomes.
- Dynamic clinical and biochemical monitoring is essential for timely decisions regarding liver transplantation in pediatric ALF.
- These findings highlight the potential for native liver recovery in severe HAV-induced PALF, challenging traditional prognostic assumptions.
Background:
Hepatitis A virus (HAV) infection is the commonest cause of pediatric acute liver failure (PALF) in developing countries. Literature has shown good outcomes of HAV-induced PALF as compared to other etiologies. The advanced critical care and use of extracorporeal liver assist devices (ELAD) have improved the survival with native liver in PALF and overall outcomes. Various liver transplant listing criteria have been proposed in PALF, however none of them is specific enough to predict the outcome. The timing of liver transplant in living donor setting has never been straightforward. Dynamic clinical and biochemical monitoring of the ALF child is the key to decide for LT.
Cases:
Here we report three children with HAV-induced PALF presented with advanced hepatic encephalopathy (HE) and high international normalized ratio (INR > 10). These children survived with native liver despite fulfilling the liver transplant criteria. The first child is a 14-year-old male who had peak INR of more than 10.2 and grade 3-4 HE with cerebral edema and acute kidney injury. He responded to medical management and CRRT as liver assist device. The second one is a 7-year-old male child who also recovered well with native liver despite advanced HE and INR of more than 10. Third child is a 16-year-old male who had peak INR of 12.6 and grade 2 HE. He received ELAD (Therapeutic plasma exchange and CRRT) and survived with native liver.
Conclusion:
Children with HAV-induced PALF can recover with their native liver despite extremely poor prognostic markers like very high INR, ammonia and advanced HE.
