Seminars in liver disease
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Human glutathione S-transferases (GSTs) are a functionally diverse family of soluble enzymes of detoxification that use reduced glutathione (GSH) in conjugation and reduction reactions. Toxic electrophiles, including a variety of carcinogens, are substrates for the GSTs and after conjugation or reduction they are more easily excreted into bile or urine. Many of the GSTs have been cloned, and the three-dimensional structures of GSTs from several species, including humans, have been determined. ⋯ The regulatory elements of several human GST genes have been partially characterized, and the regulation of the GSTs in humans appears to be very different from that in rodents. Several polymorphisms of GST expression occur commonly in humans and have been associated with an increased susceptibility to certain cancers, particularly when combined with other genetic and environmental factors such as smoking. The role of GSTs in protecting cells from injury by toxic electrophiles continues to be developed.
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Ascites is a common manifestation of portal hypertension in patients with cirrhosis. Approximately 5% of patients with cirrhosis may develop a pleural effusion. This is usually right sided. ⋯ Once the diagnosis of hepatic hydrothorax is established with certainty, medical therapy with salt restriction and diuretics is initiated. When these measures are ineffective the patient has refractory hepatic hydrothorax. Based on current studies, transjugular intrahepatic portal systemic shunts appear to be the most effective form of treatment for these patients.
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Seminars in liver disease · Nov 1996
ReviewLiver transplantation in Europe for patients with acute liver failure.
Approximately 11% of all liver transplants performed in Europe are for acute liver failure, with one-year patient survival rates ranging between 50% and 75%. This review summarizes the selection, perioperative management, and outcome of patients transplanted for acute liver failure, with particular reference to the experience at the Hôpital Paul Brousse in Paris and at King's College Hospital, London. ⋯ Infectious complications and cerebral edema remain the most common causes of death, and highlight the importance of intensive monitoring and early treatment of perioperative complications. In selected patients, auxiliary partial orthotopic liver transplantation may be a therapeutic option, with the potential for native liver generation and eventual immunosuppression withdrawal in approximately two-thirds of patients.
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Seminars in liver disease · Nov 1996
ReviewClassification, etiology, and considerations of outcome in acute liver failure.
Clinical descriptions of fulminant hepatic failure as originally reported, along with the subgroups of subfulminant and late onset hepatic failure identified later, are considered in relation to the proposed new classification of hyperacute, acute, and subacute liver failure. This reflects different clinical patterns of illness, etiology, and most importantly, prognosis. In addition to the defining state of encephalopathy and other manifestations directly related to the severe derangement in function and structure of the liver, the constellation of clinical symptoms and signs in acute liver failure (ALF) includes, to varying degrees, those of multiorgan failure. ⋯ Whereas hepatitis C is the major cause of ALF in Japan and the Far East, fulminant hepatitis C is seen rarely in America and European countries where most series show that in about one third of cases of presumed viral ALF, no specific agent can be identified. Over the past 10 years, the survival of those with grade 3 to 4 encephalopathy has shown a steady rise as a result of improvements in medical care, quite apart from the introduction and now widespread availability of transplantation for the treatment of this condition. As shown by a number of groups, a variety of different hematologic, biochemical, and clinical features can be used as predictive indices of the likely outcome and in determining the approach to treatment.