Liver maximum capacity (LiMAx) test as a helpful prognostic tool in acute liver failure with sepsis: a case report

Abstract

Background: Acute liver failure (ALF) is a life-threatening entity particularly when infectious complications worsen the clinical course. Urgent liver transplantation (LT) is frequently the only curative treatment. However, in some cases, recovery is observed under conservative treatment. Therefore, prognostic tools for estimating course of the disease are of great clinical interest. Since laboratory parameters sometimes lack sensitivity and specificity, enzymatic liver function measured by liver maximum capacity (LiMAx) test may offer novel and valuable additional information in this setting.

Case presentation: We here report the case of a formerly healthy 20-year old male caucasian patient who was admitted to our clinic for ALF of unknown origin in December 2017. Laboratory parameters confirmed the diagnosis with an initial MELD score of 28 points. Likewise, enzymatic liver function was significantly impaired with a value of 147 [> 315] μg/h/kg. Clinical and biochemical analyses for viral-, autoimmune-, or drug-induced hepatitis were negative. Liver synthesis parameters further deteriorated reaching a MELD score of 40 points whilst clinical course was complicated by septic pneumonia leading to severe hepatic encephalopathy grade III-IV, finally resulting in mechanical ventilation of the patient. Interestingly, although clinical course and laboratory data suggested poor outcome, serial LiMAx test revealed improvement of the enzymatic liver function at this time point increasing to 169 μg/h/kg. Clinical condition and laboratory data slowly improved likewise, however with significant time delay of 11 days. Finally, the patient could be dismissed from our clinic after 37 days.

Conclusion: Estimating prognosis in patients with ALF is challenging by use of the established scores. In our case, improvement of enzymatic liver function measured by the LiMAx test was the first parameter predicting beneficial outcome in a patient with ALF complicated by sepsis.

Keywords: Acute liver failure; King’s college criteria; LiMAx; Liver transplantation; MELD score.

Fig. 1

a-d Chest CT scans of the patient before (top row) and after (bottom row) therapy of pneumonia: top row shows ground glass opacities (a, arrow) as a sign for an atypical infection with large pleural effusions (b, *) and lung compression; lower row demonstrates resolving pulmonary infection (c) and only residual pleural effusion (d). A chest tube was inserted to reduce the effusion (c, arrow)

Fig. 2

a-b Mini-laparoscopy showing the right liver lobe with cholestatic changes of the parenchyma, regenerative nodules, and capsular fibrosis (a). Liver biopsy (HE, 200×) showing cholestasis, hepatocyte ballooning, ductular proliferation, and increasing fibrosis (b)

Fig. 3

Timespan between events and diagnostic/ therapeutic measures that were taken

Fig. 4

Course of liver function measured by MELD score with correlation to enzymatic liver function based on LiMAx test