Nama : Futna Naufa

NIM : 210070600011022
Acute Liver Hepatic Failure
No Soal Pembahasan
1. A 60-year-old woman with rheumatoid arthritis was initiated NAI-ALF
on azathioprine 3 months ago and now presents with NAI-ALF - Acetylcysteine may improve oxidative stress in NAI-ALF by
secondary to DILI. On presentation, her ALT and AST acting as a free radical scavenger. In addition, acetylcysteine
concentrations are 500 IU/L and 350 IU/L, respectively. Her may improve both hepatic and systemic perfusion through its
INR is 1.7, and she is mildly confused and drowsy. Which vasodilatory effects.
intervention has been shown most effective for the treatment of - A multicenter randomized trial compared acetylcysteine with
NAI-ALF? placebo for 72 hours for treatment of NAI-ALF. Randomized
a. Intravenous acetylcysteine 21-hour regimen. patients were stratified according to coma grade, with most
b. Intravenous acetylcysteine 72-hour regimen. patients having a low-grade encephalopathy. There was no
c. Oral acetylcysteine 72-hour regimen. difference in the primary outcome of overall survival at 3
d. Oral glutamine supplementation. weeks between acetylcysteine and placebo; however, the
transplant-free survival rate significantly increased with the
use of acetylcysteine (40% vs. 27%, p=0.04).
a. The increase in transplant-free survival with acetylcysteine
was mainly confined to the subgroup of patients with
coma grade I and grade II (52% vs. 30% with placebo,
p=0.01).
b. When outcomes were compared on the basis of each
etiology of NAI-ALF, patients with DILI and hepatitis B
virus had more improvement in overall survival and
transplant-free survival from acetylcysteine compared with
placebo than with other causes of NAI-ALF.
2. A 33-year-old man presents with ALF secondary to Elevated ICPs
acetaminophen overdose. He is now 72 hours post-ingestion - ICP should be kept less than 20–25 mm Hg while preserving
and is profoundly encephalopathic and unresponsive to pain on CPP at 50–60 mm Hg.
 examination. An ICP monitor is placed, which shows acute
elevations of 30 mm Hg. Which is most appropriate for the
acute management of ICP elevations?
a. Hypertonic saline continuous infusion to maintain serum
sodium 145–155 mEq/L.
b. Mannitol 0.5 mg/kg intravenously × 1.
c. Hyperventilation to Paco2 of 25–30 mm Hg.
d. Thiopental continuous infusion.
Viral Hepatitis
No Soal
1. A 45-year-old woman with a history of intravenous drug abuse Drug therapies of chronic infection
is evaluated in the clinic for chronic HBV infection. Although
she received the HBV diagnosis 8 months ago, she has not
been treated for it. Laboratory values reported today include
HBsAg positive, HBeAg positive, AST 650 IU/mL, ALT
850IU/mL, HBV DNA 107,000 IU/mL, SCr 0.9 mg/dL, INR
1.3, and albumin 3.9 g/dL. She has no evidenceof ascites or
- Routine ICP monitoring has not been shown to reduce
mortality in patients with ALF, and routine placement of ICP
monitors is not recommended in all patients. Clinicians may
choose to place an ICP monitor in patients with high-grade
encephalopathy (grades III and IV) to provide close
monitoring of cerebral edema.
- Osmotic agents are used first line for control of ICP.
- When severe ICP elevations do not respond to other measures,
barbiturates such as thiopental or pentobarbital may be used to
control ICP.
- Hyperventilation to a Paco2 of 25–30 mm Hg can restore
cerebral autoregulation, which results in vasoconstriction and
decreased ICP.
- Hypothermia (33°C–34°C) may control ICP in patients with
ALF by lowering the production of ammonia and decreasing
the cerebral uptake of ammonia as well as decreasing cerebral
blood flow. However, hypothermia for patients with ALF has
not been compared with normothermia
in controlled trials. In addition, there are concerns about
coagulation disturbances and increased risk of infection with
hypothermia
Pembahasan
- Pegylated interferon
Best predictors of response to treatment are high pretreatment
ALT, low-serum HBV DNA, presence of active inflammation
on biopsy, and acquisition of infection; adult HBeAg-negative
disease responds less favorably to interferon
- Reverse transcriptase inhibitors
encephalopathy. A liver biopsy reveals severe a. In general, lamivudine and telbivudine are not preferred as
necroinflammation and bridging fibrosis. Resistance testing first-line therapies because of high rates of resistance.
reveals the presence of the YMDD mutation. What is the best b. Lamivudine (Epivir-HBV)
course of action? Resistance: Prolonged use is associated with the
a. Withhold drug therapy and recheck HBV DNA in 6 development of mutations in the YMDD sequence of the
months. HBV polymerase (20% at 1 year, 70% at 4 years). Risk
b. Initiate pegylated interferon alfa-2a plus ribavirin. factors for lamivudine resistance include elevated
c. Initiate lamivudine 100 mg/day. pretherapy HBV DNA or ALT, male sex, increased body
mass index, previous exposure to lamivudine or
d. Initiate tenofovir 300 mg/day.
famciclovir, and inadequate suppression on HBV DNA
after 6 months of treatment.
c. Tenofovir (Viread 300 mg, Vemlidy 25 mg)
Effective for lamivudine-resistant HBV
Dose adjustments required for renal impairment
Toxicity: Overall, well tolerated; headache, nausea, and
nasopharyngitis most commonly reported; potential renal
toxicity, so periodic monitoring of SCr recommended;
potential ALT flares on withdrawal; rare lactic acidosis.