THÁCH THỨC TRONG CHẨN ĐOÁN VÀ XỬ TRÍ SUY GAN CẤP Ở BỆNH NHÂN SỐT XUẤT HUYẾT DENGUE NGƯỜI LỚN

Abstract

Acute liver failure is a severe clinical syndrome occurring in previously healthy individuals, characterized by hepatocellular death and dysfunction. Patients with Dengue hemorrhagic fever show signs of liver damage in 60% - 90% of cases. The main clinical manifestations are hepatomegaly, jaundice, increased aminotransferase and acute liver failure. The mortality rate in patients with severe hepatitis caused by Dengue is only 0.8%, but if there are complications of acute liver failure, it is very high 58.8%. The MELD score was the only predictor of acute liver failure with aOR = 1.3 [95% CI: 1.1 - 1.5; P = < 0.001]. Initial MELD score ≥ 15 was associated with acute liver failure due to severe hepatitis with AUROC = 0.91, sensitivity 88.2% and specificity 87.3%. Hepatocellular damage during acute liver failure leads to a proinflammatory response, especially in the early stages. Recent studies in adults have shown that high-volume plasma exchange (HVPE) effectively reduces the inflammatory response of acute liver failure through the removal of cytokines and damage-associated molecules (DAMP). In 2017, the European Association for the Study of the Liver (EASL) released clinical practice guidelines for plasma exchange in the management of acute liver failure, suggesting that early plasma exchange therapy can improve survival without liver transplantation. In 2019, the American Apheresis Association recommended HVPE as first-line therapy in acute liver failure. Treatment of acute liver failure due to Dengue in countries in Southeast Asia is currently applying the methods of plasma exchange and intravenous infusion of N-acetylcysteine. At the Hospital for Tropical Diseases, plasma exchange therapy and intravenous N-acetylcysteine have been applied in the treatment of acute liver failure in adult dengue patients since June 2019. We are recommending to include a flowchart for management of the acute liver failure to update the guidelines for diagnosis and management of Dengue in adults of the Ministry of Health.