Palliative care in liver disease: what does good look like?

The mortality rate from chronic liver disease in the UK is rising rapidly, and patients with advanced disease have a symptom burden comparable to or higher than that experienced in other life-limiting illnesses. While evidence is limited, there is growing recognition that care of patients with advanced disease needs to improve. Many factors limit widespread provision of good palliative care to these patients, including the unpredictable trajectory of chronic liver disease, the misconception that palliative care and end-of-life care are synonymous, lack of confidence in prescribing and lack of time and resources. Healthcare professionals managing these patients need to develop the skills to ensure effective delivery of core palliative care, with referral to specialist palliative care services reserved for those with complex needs. Core palliative care is best delivered by the hepatology team in parallel with active disease management. This includes ensuring that discussions about disease trajectory and advance care planning occur alongside active management of disease complications. Liver disease is strongly associated with significant social, psychological and financial hardships for patients and their carers; strategies that involve the wider multidisciplinary team at an early stage in the disease trajectory help ensure proactive management of such issues. This review summarises the evidence supporting palliative care for patients with advanced chronic liver disease, presents examples of current best practice and provides pragmatic suggestions for how palliative and disease-modifying care can be run in parallel, such that patients do not miss opportunities for interventions that improve their quality of life.

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Jaundice, ascites, and encephalopathy

10.1093/med/9780198821328.003.0055 ◽

2021 ◽

pp. 556-566

Author(s):

Alexandra Shingina ◽

Anne M. Larson

Keyword(s):

Palliative Care ◽

Liver Disease ◽

Chronic Liver Disease ◽

Advanced Disease ◽

Chronic Liver ◽

Liver Impairment ◽

Palliative Approach ◽

Willingness To Adopt ◽

First Admission

The development of jaundice, ascites, or encephalopathy in the context of chronic liver disease or malignancy is an ominous indicator of advanced disease. In two studies of individuals admitted to hospital with jaundice, up to 42% of patients with malignancy and up to 23% with cirrhosis died during their first admission. The necessity of a willingness to adopt a ‘palliative approach’ to the care of such individuals is obvious. This chapter discusses three features of liver impairment that may be encountered in those for whom palliative care is appropriate.

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Challenging management of severe chronic disorders in acute pandemic situation: Chronic liver disease under COVID-19 pandemic as the proof-of-principle model to orchestrate the measures in 3PM context

The EPMA Journal ◽

10.1007/s13167-021-00231-8 ◽

2021 ◽

Vol 12 (1) ◽

pp. 1-14

Author(s):

Lubomir Skladany ◽

Tomas Koller ◽

Svetlana Adamcova Selcanova ◽

Janka Vnencakova ◽

Daniela Jancekova ◽

...

Keyword(s):

Liver Disease ◽

Chronic Liver Disease ◽

Tertiary Care ◽

Chronic Liver ◽

Active Management ◽

Comprehensive Treatment ◽

List Type ◽

Individualized Care ◽

Chronic Disorder ◽

Tertiary Center

AbstractChronic liver disease management is a comprehensive approach requiring multi-professional expertise and well-orchestrated healthcare measures thoroughly organized by responsible medical units. Contextually, the corresponding multi-faceted chain of healthcare events is likely to be severely disturbed or even temporarily broken under the force majeure conditions such as global pandemics. Consequently, the chronic liver disease is highly representative for the management of any severe chronic disorder under lasting pandemics with unprecedented numbers of acutely diseased persons who, together with the chronically sick patient cohorts, have to be treated using the given capacity of healthcare systems with their limited resources. Current study aimed at exploring potentially negative impacts of the SARS CoV-2 outbreak on the quality of the advanced chronic liver disease (ACLD) management considering two well-classified parameters, namely, (1) the continuity of the patient registrations and (2) the level of mortality rates, comparing pre-COVID-19 statistics with these under the current pandemic in Slovak Republic. Altogether 1091 registrations to cirrhosis registry (with 60.8% versus 39.2% males to females ratio) were included with a median age of 57 years for patients under consideration. Already within the very first 3 months of the pandemic outbreak in Slovakia (lockdown declared from March 16, 2020, until May 20, 2020), the continuity of the patient registrations has been broken followed by significantly increased ACLD-related death rates. During this period of time, the total number of new registrations decreased by about 60% (15 registrations in 2020 versus 38 in 2018 and 38 in 2019). Corresponding mortality increased by about 52% (23 deaths in 2020 versus 10 in 2018 and 12 in 2019). Based on these results and in line with the framework of 3PM guidelines, the pandemic priority pathways (PPP) are strongly recommended for maintaining tertiary care uninterrupted. For the evidence-based implementation of PPP, creation of predictive algorithms and individualized care strategy tailored to the patient is essential. Resulting classification of measures is summarized as follows: The Green PPP Line is reserved for prioritized (urgent and comprehensive) treatment of patients at highest risk to die from ACLD (tertiary care) as compared to the risk from possible COVID-19 infection. The Orange PPP Line considers patients at middle risk of adverse outcomes from ACLD with re-addressing them to the secondary care. As further deterioration of ACLD is still probable, pro-active management is ascertained with tertiary center serving as the 24/7 telemedicine consultation hub for a secondary facility (on a physician-physician level). The Red PPP Line is related to the patients at low risk to die from ACLD, re-addressing them to the primary care. Since patients with stable chronic liver diseases without advanced fibrosis are at trivial inherent risk, they should be kept out of the healthcare setting as far as possible by the telemedical (patient-nurse or patient- physician) measurements. The assigned priority has to be monitored and re-evaluated individually—in intervals based on the baseline prognostic score such as MELD. The approach is conform with principles of predictive, preventive and personalized medicine (PPPM / 3PM) and demonstrates a potential of great clinical utility for an optimal management of any severe chronic disorder (cardiovascular, neurological and cancer) under lasting pandemics.

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Growth rate of early-stage hepatocellular carcinoma in patients with chronic liver disease

Clinical and Molecular Hepatology ◽

10.3350/cmh.2015.21.3.279 ◽

2015 ◽

Vol 21 (3) ◽

pp. 279 ◽

Cited By ~ 40

Author(s):

Chansik An ◽

Youn Ah Choi ◽

Dongil Choi ◽

Yong Han Paik ◽

Sang Hoon Ahn ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Growth Rate ◽

Liver Disease ◽

Chronic Liver Disease ◽

Early Stage ◽

Chronic Liver

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Liver resection for multifocal hepatocellular carcinoma.

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.4_suppl.355 ◽

2012 ◽

Vol 30 (4_suppl) ◽

pp. 355-355 ◽

Cited By ~ 1

Author(s):

Peter Tae Wan Kim ◽

Jihyun Jang ◽

Sandra Fischer ◽

Paul David Greig ◽

Steven Gallinger ◽

...

Keyword(s):

Hepatocellular Carcinoma ◽

Liver Disease ◽

Liver Resection ◽

Chronic Liver Disease ◽

Early Stage ◽

Chronic Liver ◽

Term Survival ◽

Liver Resections ◽

Common Etiology ◽

Multifocal Disease

355 Background: Liver resection for multifocal hepatocellular carcinoma (HCC) is controversial. This study was conducted to outline our institution’s experience with liver resection for multifocal HCC. Methods: A retrospective review of patients who underwent liver resections from 1992 to 2011 for histologically confirmed hepatocellular carcinoma was performed. Multifocal disease was defined as more than 1 histologically proven HCC found in the liver resection specimens. Results: Of the 386 liver resections performed for HCC, 47 were performed for multifocal disease. Mean age was 60+11 years, and most patients (92%) had chronic liver disease. Hepatitis B was the most common etiology (60%), followed by hepatitis C (26%), and other etiologies (15%). Most patients were Child’s class A (89%). Most patients had intermediate Barcelona Clinic Liver Cancer (BCLC) stage (stage B) tumors (81%) and a minority of patients had early stage tumors (BCLC stage A, 19%). Major hepatectomy (>2 segments) was performed in 87% with an in hospital mortality of 6.4%. Major complications (Clavien-Dindo scale >3) occurred in 4 patients (9%). Median length of stay was 7 days and the rate of liver failure was 4.3%. Mean tumor number was 3+2 and the size of the largest lesion was 5+3 cm. Cirrhosis was present in 51% of patients. Majority of tumors were moderately differentiated (60%) and vascular invasion was present in 42%. The recurrence rate was 57% and the liver was the most common site of recurrence (81%). Treatment of recurrences occurred in 74% of patients: ablation (33%), chemotherapy (11%), transarterial chemoembolization (11%), resection (7.4%), sorafenib/radiation (7.4%) and transplantation (3.7%). Median disease free interval was 8 months and the overall survival was 18 months Conclusions: Liver resection for multifocal HCC can be performed safely in patients with chronic liver disease. Long term survival can be achieved in these patients and it should be considered as an option.

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Prognostic role of lipids, apolipoproteins in patients with resectable hepatocellular carcinoma

10.21203/rs.2.23597/v1 ◽

2020 ◽

Author(s):

Xiaochun Ni ◽

Yong Yi ◽

Yipeng Fu ◽

Xiaoyan Cai ◽

Gao Liu ◽

...

Keyword(s):

Liver Disease ◽

Chronic Liver Disease ◽

Early Stage ◽

Benign Lesion ◽

Expression Patterns ◽

Multivariable Analysis ◽

Early Recurrence ◽

Chronic Liver ◽

Significant Differential Expression ◽

Prognostic Stratification

Abstract Background: To further clarify the association between abnormal levels of serum lipid components as the main features of dyslipidaemia and hepatocellular cancinima, which remains unclear.Methods: We examined the serum level of lipids and apolipoproteins pattern in 471 patients undergoing curative resection for HCC, 193 patients with chronic liver disease, and 104 patients with benign liver diseases. We performed uni- and multivariate analyses to evaluate the predictive roles of lipids and apolipoproteins for recurrence and survival of HCC in a training cohort of 242 patients and then validated in a cohort of 229 patients.Results: The majority circuling lipid and apolipoprotein levels such as ApoA1, HDL, LDL in chronic liver disease and HCC were slight to significantly decreased as compared with those in benign lesion. But no significant differential expression patterns of lipids and apolipoproteins were observed between chronic liver hepatitis and HCC. Multivariable analysis identiﬁed ApoA1 as a key parameter related to recurrence and survival in both training and validation cohorts. Moreover, we further demonstrated that low ApoA1 was an independent prognostic factor of poor early recurrence in two cohorts.Conclusions: Although the alterations of circulating lipids and apolipoproteins were observed in HCC, none of lipids and apolipoproteins could serve as a diagnostic marker. Serum ApoA1 merits consideration as a novel prognostic marker for patients with HCC undergoing surgery, since it predicts early recurrence and survival, especially for early stage patients and may improve the prognostic stratiﬁcation of patients for clinical management and promote HCC clinic outcomes.

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Plasma prolidase activity: a possible index of collagen catabolism in chronic liver disease.

Clinical Chemistry ◽

10.1093/clinchem/30.2.211 ◽

1984 ◽

Vol 30 (2) ◽

pp. 211-215 ◽

Cited By ~ 74

Author(s):

I Myara ◽

A Myara ◽

M Mangeot ◽

M Fabre ◽

C Charpentier ◽

...

Keyword(s):

Alkaline Phosphatase ◽

Liver Disease ◽

Chronic Liver Disease ◽

Total Bilirubin ◽

Early Stage ◽

Chronic Liver ◽

Easy Method ◽

Prolidase Activity ◽

Ccl4 Administration ◽

The Mean

Abstract We describe here an easy method of determining prolidase (EC 3.4.13.9) in plasma after preincubation with Mn2+ for 24 h at 37 degrees C to maximize prolidase activity. The mean activity in 338 patients who were either in hospital or outpatients was 900 U/L +/- 520 (2 SD), unrelated to sex or age. In 25 of these 338 samples tested, prolidase activity was between 1500 and 2000 U/L. It exceeded 2000 U/L in eight, all of whom were patients with chronic liver disease. Plasma prolidase activity was normal in cytolytic syndromes such as liver or heart disease. Of the 27 patients with cirrhosis, only five exhibited prolidase activity greater than 2000 U/L. Plasma prolidase activity was uncorrelated with six biochemical indexes to liver function (the aminotransferases, alkaline phosphatase, glutamyltransferase, total bilirubin, and serum albumin) or with the degree of cirrhotic fibrosis. We believe that plasma prolidase activity may be high only in the early stage of fibrosis. This hypothesis would be consistent with the data on rat-liver collagenolytic activities during CCl4 administration. Monitoring of plasma prolidase activity might be useful in evaluating fibrotic processes in chronic liver disease in the human.

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