Acute severe hepatitis crisis and its application in liver transplantation in China: Clinical syndrome assessment and transplant survival status

VI. Acute Severe Hepatitis Acute severe hepatitis, also known as fulminant hepatitis, accounts for 0.2% to 0.4% of all hepatitis cases. It usually begins as acute icteric hepatitis, with jaundice rapidly deepening and the condition progressing quickly. Symptoms and signs include nausea, vomiting, and liver shrinkage, a condition known as acute yellow liver atrophy. It can quickly progress to coma with a significant bleeding tendency, ascites, oliguria or anuria, and markedly abnormal liver function. Without timely treatment, fulminant hepatic failure, cerebral depression, hypotension, arrhythmia, and cardiac arrest can occur, often leading to death. Respiratory failure or respiratory depression may also occur, as well as renal failure, oliguria or anuria. Some patients initially experience bleeding from the mouth, nose, or digestive tract, and may also have concurrent infections. This type of hepatitis is more common in pregnant women, malnourished individuals, alcoholics, those with pre-existing chronic hepatitis, or those taking hepatotoxic drugs for extended periods. The prognosis is very poor, with a mortality rate of approximately 70%. Currently, all life insurance companies in China list fulminant hepatitis as a critical illness in their critical illness insurance contracts. If the insured contracts fulminant hepatitis during the insurance period, they can receive a substantial illness insurance benefit as stipulated in the contract. Given that my country is a high-incidence area for hepatitis, this clause is very popular with customers.

VII. Liver Failure Liver failure is a clinical syndrome caused by extensive and severe damage to liver cells and serious disruption of the body's metabolic function. It is also known as liver failure. Liver failure occurs in the course of many serious liver diseases, with severe symptoms and poor prognosis. It is generally divided into two types: fulminant liver failure and chronic liver failure. (I) Etiology 1. Fulminant Liver Failure (1) Various types of viral hepatitis. Such as hepatitis A, B, C, D, and E. It can also be caused by mixed or superimposed infection of two or more hepatitis viruses. (2) Drugs. Antipyretic analgesics such as acetaminophen, aminopyrine, aspirin, etc.; anti-tuberculosis drugs such as isoniazid, rifampin, etc.; others such as halothane, methyldopa, antimony preparations, arsenic preparations, sulfonamides, etc. (3) Poisoning. Such as mushroom poisoning, rotten rice and flour poisoning, carbon tetrachloride poisoning, etc. (4) Hypoxic liver injury. Such as liver congestion and hypoxia caused by prolonged heart failure and shock. (5) Others. Such as acute Wilson's disease, etc. 2. Chronic liver failure often occurs in the course of chronic severe hepatitis, various types of cirrhosis and other diseases. (II) Clinical manifestations 1. Clinical manifestations of fulminant hepatic failure (1) Hepatic encephalopathy. Also known as hepatic coma, it is the most characteristic manifestation. In the early stage, there are changes in behavior and personality, unable to answer questions correctly, decreased orientation and calculation ability, gradually developing into excitement or drowsiness, with flutter tremor, abnormal electroencephalogram, and finally coma. (2) Jaundice. Initially, the urine color darkens, and soon the skin, mucous membranes and sclera become yellow and rapidly deepen. Due to large-scale necrosis of hepatocytes, the liver can shrink rapidly. When percussed, the liver dullness area shrinks, which can be further confirmed by B-mode ultrasound examination. The patient's breath has a musty vinegar smell, that is, liver odor, the intensity of which is consistent with the degree of hepatocyte necrosis. (3) Bleeding. Due to liver dysfunction in producing clotting factors, endotoxemia activating the clotting system, etc., skin bleeding points, ecchymosis, hematemesis, hematochezia, epistaxis, etc. may occur. (4) Cerebral edema and pulmonary edema. It may be related to inappropriate large-volume fluid replacement, hypoxia, etc., which can easily cause cerebral herniation and respiratory failure. (5) Ascites. Portal hypertension, decreased plasma albumin, etc., can cause 30% of patients to have small to moderate amounts of ascites. In addition, secondary infections, hepatorenal syndrome, shock and other serious complications may also occur. 2. Clinical manifestations of chronic liver failure Chronic liver failure occurs on the basis of chronic active liver disease. Generally, there are various manifestations of the original chronic liver disease, and liver function failure can gradually occur. Liver function failure may also occur suddenly during the course of the disease due to certain liver-damaging factors. (III) Diagnosis If there are manifestations such as rapidly deepening jaundice, shrinkage of the liver in a short period of time, neuropsychiatric symptoms, elevated transaminase or bile enzyme separation (normal or slightly elevated transaminase but significantly elevated bilirubin) on the basis of liver disease, the possibility of this disease should be considered.

VIII. Liver Transplantation (I) Current Status of Liver Transplantation in my country With the development of liver transplantation internationally, clinical liver transplantation in my country gradually resumed in the 1990s. From 1991 to 1996, 35 liver transplants were performed in Wuhan, Guangzhou, Shanghai, Tianjin, Hangzhou, Chengdu, and Nanjing, with improved quality and the emergence of long-term survivors. From 1997 onwards, liver transplantation in my country entered a new period of development, with the number of transplants increasing exponentially year by year, and clinical experience maturing, marking its entry into the clinical application stage. 1. Rapid Growth in the Number of Transplants From 1977 to the end of 2000, a total of 52 institutions in my country performed 489 liver transplants (494 times). The development momentum in 2001 was even better than in 2000. By the end of 2000, five institutions had performed more than 30 transplants: Tianjin First Central Hospital (112 cases); Tongji Medical College Organ Transplant Institute, Huazhong University of Science and Technology (84 cases); First Affiliated Hospital of Sun Yat-sen University (67 cases); First Affiliated Hospital of Zhejiang University School of Medicine (42 cases); and First Affiliated Hospital of West China University of Medical Sciences (31 cases). 2. Survival rates improved. The First Affiliated Hospital of West China University of Medical Sciences reported data from 15 cases performed between February 1999 and June 2000, with 12 surviving, including 3 surviving for more than one year. Tianjin First Central Hospital reported data from 70 cases (July 1998 to August 2000), with 38 surviving, 17 surviving for more than one year, and 3 surviving for more than two years. One patient who underwent surgery at the hospital on May 10, 1995, has survived for more than seven years, making him the longest-surviving patient in my country. 3. Reasons for the development of liver transplantation in my country in recent years (1) The clinical application of some new immunosuppressants has made anti-rejection methods more diverse and effective. (2) The advent of UW preservation solution in 1988 not only improved the preservation quality of donor livers, but also extended the preservation time. (3) The development of surgical techniques has led to an increase in surgical procedures. The procedures for harvesting, rinsing, preservation, and implantation of donor livers have become more proficient and improved. At the same time, the surgical procedures for liver transplantation have gradually increased. On the basis of the original standard procedure for orthotopic liver transplantation, piggyback liver transplantation, volume reduction and living donor partial liver transplantation, as well as liver-kidney and liver-intestine combined transplantation have been adopted. (4) The indications have been expanded. In the early stage, it was mainly for mid-to-late stage liver cancer. Now, it tends to be used for congenital and metabolic liver diseases, benign end-stage liver diseases, fulminant hepatic failure, and early malignant liver tumors. (5) The return of overseas students has also promoted the development of liver transplantation in my country. Although liver transplantation in my country has developed rapidly in recent years, the survival rate is still not ideal. In addition, there are still issues of postoperative short-term complications, long-term complications, and anesthesia management that need to be studied in depth.