Intensive care and transplantation

Intensive care, also called critical care, is the close monitoring and treatment given to patients with acute, life-threatening illness or injury such as shock, burns, accidents, sepsis, severe breathing problems and complex surgery as liver transplantation.

HEPATITIS B

Chronic hepatitis B (CHB) caused by hepatitis B virus (HBV) infection remains a major global health problem affecting an estimated 350 million people worldwide with more than 786000 individuals dying annually due to complications of CHB, including cirrhosis and liver cancer. CHB is the leading cause of hepatocellular carcinoma (HCC) accounting for at least 50% of newly diagnosed cases. Furthermore, HCC is the third leading cause of cancer-related mortality in the world with a dismal 5 year survival and the fastest growing rate of cancer death in North America.

Liver transplantation (LT) is the most effective treatment in patients with CHB-related liver failure, cirrhosis and HCC. However, HBV reactivation following LT emerges as a major clinical challenge. Prophylaxis with high-dose hepatitis B immunoglobulin (HBIG) and anti-viral drugs have achieved remarkable progress in LT by suppressing viral replication and improving long-term survival.

Before its introduction, reinfection with HBV after transplantation occurred in more than 80% of recipients and the 5-year graft and patient survival rates were only 50%. Now, with the use of the HBIg/nucleoside/nucleotide analogue prophylaxis, transplant programs in North America and Europe can expect prevention of HBV recurrence in greater than 90% of their patients.

Hepatitis B is contagious, but it can be transmitted from mothers to infants at the time of birth. This transmission can be markedly reduced by the immediate postpartum administration of HBIg to the infant either alone or, as currently recommended, concomitant administration of hepatitis B vaccine.

References
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Arianeb Mehrabi, “The role of HBIg as hepatitis B reinfection prophylaxis following liver transplantation” Langenbeck’s Archives of Surgery June 2012, Volume 397, Issue 5, pp 697-710
American Academy of Pediatrics. Hepatitis B. In: Peter G, editor. 1997 Red Book. Report of the Committee on Infectious Diseases. 24th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 1997. pp. 247–260

HUMAN ALBUMIN

Albumin is the most abundant circulating protein in the human body, making up about 50% of the total plasma protein content.

Albumin has been the first plasmaprotein produced from human plasma for therapeutic use. The scientific evidence of recent years has clearly shown that albumin is endowed with a long series of clinically relevant functions: alongside the well-known oncotic power, albumin performs many other activities that are grouped under the definition of non-oncotic properties. These include : Binding , Transport and detoxification, Antioxidant action, Modulation of the inflammatory and immunological response, Antithrombotic action, Capillary permeability and endothelial stabilization, Adjustment of acid-base balance.

The oncotic activity, together with the long circulating half-life and total half-life make albumin an excellent plasma expander, which is currently the main reason for its use in clinical practice expecially in critical situations. The non-oncotic activities play an important therapeutic role in many medical conditions where the condition of deficient plasma volume is associated with a pro- inflammatory state as in liver cirrhosis, sepsi/septic shock, burns .

All these properties makes albumin an important medicine for many clinical conditions for which other fluids are either contro-indicated or have no important therapeutic effect.

References
Quinlan GJ, Martin GS, Evans TW. Albumin: biochemical properties and therapeutic potential. Hepatology 2005; 41:1211–1219
Fanali G, Di Masi A, Trezza V, et al. Human serum albumin: from bench to bedside. Mol Aspects Med 2012; 33: 209-90
Vincent J-L, Russell JA, Jacob M, et al. Critical Care 2014;18:231-41
Garcia-Martinez R, Caraceni P, Bernardi M, Gines P, Arroyo V, Jalan R. Albumin: pathophysiologic basis of its role in the treatment of cirrhosis and its complications. Hepatology 2013; 58:1836-46
Taverna M, Marie AL, Mira JP, Guidet B. Specific antioxidant properties of human serum albumin. Ann Intensive Care. 2013
Schött U, Solomon C, Fries D, Bentzer P. The endothelial glycocalyx and its disruption, protection and regeneration: a narrative review. Scand J Trauma Resusc Emerg Med. 2016 Apr 12;24:48

ANTITHROMBIN

Antithrombin is a plasma protein that inactivates Thrombin, a plasma enzyme that is important in the clotting process. Antithrombin therefore acts as a powerful anticoagulant and is used to treat acquired antithrombin deficiency from Disseminated Intravascular Coagulation (DIC) as the result of sepsis, multiple trauma, severe burns, pregnancy complications, extensive surgery, etc.
Antithrombin is also used in patients with congenital antithrombin deficiency for the prophylaxis of deep vein thrombosis and thromboembolism in clinical risk situations (especially during surgery or during the peri-partum period) and for the prevention of progression of deep vein thrombosis and thromboembolism in association with heparin, when indicated.

PROTHROMBIN COMPLEX COAGULATION FACTORS (PCC)

PCC is a complex of human plasma coagulation factors for treatment of bleeding and perioperative prophylaxis of bleeding in acquired prothrombin deficiency, when rapid correction of the deficiency is required.
PCC is also used for treatment of bleeding and perioperative prophylaxis in congenital deficiency of any of the vitamin K dependent coagulation factors when purified specific coagulation factor product is not available.

References:
Rita Garcia-Martinez. Albumin: Pathophysiologic Basis of Its Role in the Treatment of Cirrhosis and Its Complications. Hepatology, Month 2013
Afshari A. Antithrombin III for critically ill patients (Review). The Cochrane Library 2009, Issue 2
Sibylle A. Management of severe perioperative bleeding. Eur J Anaesthesiol 2013; 30:270–382

RABIES

Rabies is a prolifically deadly zoonotic disease. Rabies-related human deaths are infrequent due to prophylaxis using vaccines and human rabies immunoglobulin (HRIG), providing nearly 100% success rates. Fatalities from rabies occurs when patients fail to seek medical attention. While this does not occur often, preventable deaths were reported within the last year.
Given the rarity of this disease and, therefore, the low incidence of cases reported in medical clinics, hospitals and pharmacies, it is essential for healthcare professionals to have a correct knowledge of the pathology – to immediately recognize its symptoms – and the measures to be taken to procure and administer Human Rabies Immunoglobulins based prophylaxis in combination with the rabies vaccine.

Reference
The burden of rabies. Last reviewed September 25, 2017. Accessed March 4, 2019. https://www.cdc.gov/features/dsrabies/index.html