Showing papers by "Constantine J. Karvellas published in 2021"
University of Duisburg-Essen1, Baylor University Medical Center2, Université catholique de Louvain3, University of Paris4, University of Barcelona5, Mayo Clinic6, University of Montpellier7, University of Alberta8, University of California, San Francisco9, Katholieke Universiteit Leuven10, University of Colorado Hospital11, King's College London12, University of Birmingham13, University of Kansas14, University of Pennsylvania15, University of Bologna16, Medical University of Vienna17, University Medical Center Groningen18, Université Paris-Saclay19, University of Edinburgh20, Emory University21, Charité22, Carol Davila University of Medicine and Pharmacy23, University of California, Los Angeles24, Columbia University25, French Institute of Health and Medical Research26
TL;DR: A multinational and multidisciplinary consensus is achieved on the definition of futile LT and on specific criteria for postponing or denying LT, and a framework that may facilitate the decision if a patient is too sick for transplant is presented.
Abstract: Background Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. Methods Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. Results The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or 1 μg/kg per minute and a serum lactate level >9 mmol/L. Conclusions Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.
39 citations
TL;DR: The role of LT is summarized, current prognostic scores in ACLF are highlighted, and potential opportunities to improve outcomes are explored including current care gaps and unmet research needs.
Abstract: Liver transplantation (LT) has revolutionized outcomes for cirrhotic patients. Current liver allocation policies dictate patients with highest short-term mortality receive the highest priority, thus, several patients become increasingly ill on the waitlist. Given cirrhosis is a progressive disease, it can be complicated by the occurrence of acute-on-chronic liver failure (ACLF), a syndrome defined by an acute deterioration of liver function associated with extrahepatic organ failures requiring intensive care support and a high short-term mortality. Successfully bridging to transplant includes accurate prognostication and prioritization of ACLF patients awaiting LT, optimizing intensive care support pre-LT, and tailoring immunosuppressive and anti-infective therapies post-LT. Furthermore, predicting futility (too sick to undergo LT) in ACLF is challenging. In this review, we summarize the role of LT in ACLF specifically highlighting (a) current prognostic scores in ACLF, (b) critical care management of the ACLF patient awaiting LT, (c) donor issues to consider in transplant in ACLF, and (d) exploring of recent post-LT outcomes in ACLF and potential opportunities to improve outcomes including current care gaps and unmet research needs.
24 citations
Virginia Commonwealth University1, University of Michigan2, Medical University of South Carolina3, Ohio State University4, University of Kansas5, University of California, San Francisco6, Yale University7, University of Alabama at Birmingham8, Northwestern University9, University of Washington10, University of Alberta11, University of Texas Southwestern Medical Center12, University of Groningen13
TL;DR: In this article, Rotational thromboelastometry (ROTEM) was used to determine the nature of abnormal hemostasis and whether it contributes to bleeding events, illness severity, or survival.
16 citations
TL;DR: In this article, the authors review practical considerations in critical care management, as well as discuss key knowledge gaps and areas of controversy that require further focussed research, and address the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease.
14 citations
TL;DR: In this paper, the authors proposed several strategies to improve renal function in post-Liver transplant patients with acute kidney injury (AKI) using calcineurin inhibitor tacrolimus (TAC).
10 citations
University of Cambridge1, University of Alberta2, Wake Forest University3, Université de Montréal4, University of Texas Southwestern Medical Center5, University of Washington6, Yale University7, University of Nebraska Omaha8, Mayo Clinic9, Baylor University Medical Center10, University of Pittsburgh11, Northwestern University12, University of Oregon13, University of California, Los Angeles14, University of Michigan15, University of Alabama at Birmingham16, Harvard University17, Duke University18, Columbia University19, Washington University in St. Louis20, Medical University of South Carolina21, Albert Einstein Medical Center22, University of Pennsylvania23, Virginia Commonwealth University24, University of California, Davis25, University of California, San Diego26, University of Kansas27, Emory University28, Ohio State University29, University of California, San Francisco30
TL;DR: In this article, a microRNA signature associated with successful regeneration post-auxiliary liver transplant and with recovery from acute liver failure was used to develop outcome prediction models for APAP-ALF.
9 citations
TL;DR: TFS in APAP-ALF has improved in recent years and rates of ICH/CE have declined, possibly related to increased CRRT use.
9 citations
TL;DR: FABP1 levels at late time points (days 3–5) were significantly lower in ALF patients who were alive without transplant at day 21 but not after adjusting for covariates reflecting severity of illness.
Abstract: Liver-type fatty acid binding protein (FABP1) has previously been demonstrated to improve prognostic discrimination in acetaminophen (APAP)-induced ALF but has not been investigated in other etiologies of ALF. To determine whether FABP1 levels (early: admission or late: days 3–5) are associated with 21-day transplant-free survival in non-APAP ALF. FABP1 was measured in serum samples from 384 ALF patients (n = 88 transplant-free survivors (TFS), n = 296 died/LT–NTFS) using solid-phase enzyme-linked immunosorbent assay and analyzed with US ALFSG registry data. Of 384 ALF patients (autoimmune hepatitis n = 125, drug-induced liver injury n = 141, Hepatitis B n = 118), 177 (46%) patients received LT. Early FABP1 levels were significantly higher in ALF patients requiring vasopressor support (203.4 vs. 76.3 ng/mL) and renal replacement therapy (203.4 vs. 78.8 ng/mL; p < 0.001 for both). Late FABP1 levels were significantly higher in patients requiring mechanical ventilation (77.5 vs. 53.3 ng/mL), vasopressor support (116.4 vs. 53.3 ng/mL) and in patients with grade 3/4 hepatic encephalopathy (71.4 vs. 51.4 ng/mL; p = 0.03 for all). Late FABP1 levels were significantly lower in TFS patients (TFS 54 vs. NTFS 66 ng/mL; p = 0.049) but not admission (TFS 96 vs. NTFS 87 ng/mL; p = 0.67). After adjusting for significant covariates, serum FABP1 did not discriminate significantly between TFS and patients who died/received LT at day 21 either on admission (p = 0.29) or late (days 3–5, p = 0.087) time points. In this first report of FABP1 in non-APAP ALF, FABP1 levels at late time points (days 3–5) were significantly lower in ALF patients who were alive without transplant at day 21 but not after adjusting for covariates reflecting severity of illness. Higher FABP1 levels were associated with the presence of increased organ failure.
8 citations
TL;DR: In this paper, the use of indirect calorimetry allows the determination of resting energy expenditure to serve as a guide to providing optimal nutrition intake in ICU patients, which can be used to guide optimal nutrition therapy and caloric intake in critically ill patients.
Abstract: Purpose of review Malnutrition is prevalent in critically ill patients and is linked to worse outcomes such as prolonged mechanical ventilation, length of intensive care unit (ICU) stay, and increased mortality. Therefore, nutritional therapy is important. However, it is often difficult to accurately identify those at high malnutrition risk and to optimize nutritional support. Different technological modalities have therefore been developed to identify patients at high nutritional risk and to guide nutritional support in an attempt to optimize outcomes. Recent findings Computed tomography (CT), ultrasound (US), and bioelectrical impedance analysis are tools that allow assessment of lean body mass and detection of sarcopenia, which is a significant marker of poor nutrition. The use of indirect calorimetry allows the determination of resting energy expenditure to serve as a guide to providing optimal nutrition intake in ICU patients. Summary By using CT, US, or bioelectrical impedance analysis, detection of sarcopenia can be undertaken in patients admitted to the ICU. This allows for an accurate picture of underlying nutritional status to help clinicians focus on nutritional support for these patients. Subsequently, indirect calorimetry can be used to guide optimal nutrition therapy and caloric intake in critically ill patients. However, whether these methods result in improved outcomes in critically ill patients remains to be validated.
7 citations
TL;DR: The management of patients with ALF by ICU professionals differed substantially concerning the relevant clinical measures taken, and further education and high-quality research are warranted.
2 citations
TL;DR: In patients with ALF, a higher optic nerve sheath diameter (ONSD) was associated with higher hospital mortality, and this measurement is feasible and safe and may have prognostic value.
TL;DR: The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time, and past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.
Abstract: PurposeCirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-h...