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Therapeutic Hypothermia for Acute Liver Failure: Toward a Randomized, Controlled Trial in Patients with Advanced Hepatic Encephalopathy

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Abstract

Acute liver failure (ALF), the abrupt loss of liver function in a patient without previous liver disease, remains a highly mortal condition. Patients with ALF often succumb to their liver injury after the development of cerebral edema, resulting in intracranial hypertension and brain herniation. While the management of cerebral edema in ALF always includes the administration of osmotically active agents, osmotherapy often reduces intracranial pressure (ICP) insufficiently, such that herniation may be delayed but not prevented. Therapeutic hypothermia, the intentional reduction of body core temperature, has been increasingly used to treat cerebral edema in patients with traumatic and hypoxic brain injury. Data in animal models of ALF also suggest that hypothermia is effective in the prevention and treatment of cerebral edema, and case reports in humans have suggested that hypothermia is an effective bridge to orthotopic liver transplantation. A randomized, controlled trial comparing the management of ALF patients under normothermic and hypothermic conditions is a logical extension of these preliminary observations. Herein, we consider the many difficulties which will be encountered in the design of such a trial in patients with ALF at high risk of developing cerebral edema.

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Acknowledgments

This work was presented at the fifth annual meeting of the Neurocritical Care Society, Las Vegas, NV, on November 1, 2007, at a satellite symposium entitled “Management of Coagulopathy and Intracranial Hypertension in Acute Liver Failure: Is There a Role for Hypothermia?” The symposium was sponsored by the Neurocritical Care Society with generous funding from Novo Nordisk.

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Authors and Affiliations

  1. Section of Hepatology, Hume-Lee Transplant Center, Virginia Commonwealth University, Richmond, VA, 23298-0341, USA

    R. Todd Stravitz

  2. Southwestern Medical Center, University of Texas, Dallas, TX, USA

    William M. Lee & Linda Hynan

  3. University of Calgary, Calgary, AB, Canada

    Andreas H. Kramer

  4. Mayo Clinic-Jacksonville, Jacksonville, FL, USA

    David J. Kramer

  5. Northwestern University, Chicago, IL, USA

    Andres T. Blei

Authors
  1. R. Todd Stravitz
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  2. William M. Lee
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  3. Andreas H. Kramer
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  4. David J. Kramer
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  5. Linda Hynan
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  6. Andres T. Blei
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Corresponding author

Correspondence to R. Todd Stravitz.

Additional information

The authors wish to dedicate this work to our friend, teacher, and colleague, Dr. Andres Blei, who inspired the work as part of his life-long study of hepatic encephalopathy and acute liver failure. We also wish to acknowledge the thoughtful input of Drs. Fin Larsen, Julia Wendon, Nick Murphy, and William Bernal.

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Stravitz, R.T., Lee, W.M., Kramer, A.H. et al. Therapeutic Hypothermia for Acute Liver Failure: Toward a Randomized, Controlled Trial in Patients with Advanced Hepatic Encephalopathy. Neurocrit Care 9, 90–96 (2008). https://doi.org/10.1007/s12028-008-9090-y

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