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This study found that for pancreatic cancer and cholangiocarcinoma, CA19-9 had poor clinical utility as a tumor marker and did not change patient management. Elevations in CA19-9 were associated with biliary obstruction based on clinical history, laboratory data, and diagnoses.

Background N-acetylcysteine (NAC) improves transplant-free survival in early coma grade (I-II) patients with non-acetaminophen induced acute liver failure (ALF). We determined whether the clinical benefit was associated with improvements in hepatic function. Methods In a prospective, double blind trial, 173 ALF patients without evidence of acetaminophen overdose were stratified by coma grade (I-II vs. III-IV) and randomly assigned to receive either intravenous NAC or dextrose (placebo) for 72 hours, resulting in 4 patient groups. INR, ALT, bilirubin, creatinine, and AST obtained on admission (day 1) and subsequent days (days 2-4) were used for secondary analysis performed by fitting longitudinal logistic regression models to predict death or transplantation or transplantation alone. Results Treatment group and day of study in models including bilirubin or ALT were predictors of transplantation or death (maximum p<0.03). Those patients with early coma grade who were treated with NAC showed significant improvement in bilirubin and ALT levels when compared to the other 3 groups (maximum p <0.02 for NAC 1-2 versus the 3 other treatments) when predicting death or transplantation. Treatment group, day of study, and bilirubin were predictors of transplantation (maximum p<0.03) in ALF patients. Conclusion The decreased risk of transplantation or death or of transplantation alone with intravenous NAC in early coma grade patients with non-acetaminophen induced ALF was reflected in improvement in parameters related to hepatocyte necrosis and bile excretion: ALT and bilirubin, but not in INR, creatinine, or AST. Hepatic recovery appears hastened by NAC as measured by several important lab values.

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More than 45% of US patients develop ALF caused by acetaminophen intoxication and have a transplant-free survival (TFS, spontaneous survival without transplantation) greater than 70%, rarely requiring transplantation. In stark contrast, patients with ALF not because of acetaminophen have a TFS less than 30% and frequently require transplantation. 3 Consequently, clinicians caring for patients with non-acetaminophen-induced ALF are most pressed to determine which patients require transplantation to survive. AbstractBackground: Changes in Gc-globulin (Gc) and in alpha-foetoprotein (AFP) have been shown to be related to outcome in patients with acute liver failure (ALF). Gc is a serum protein that complexes with intravascular actin released during cellular necrosis. AFP, also made by hepatocytes, is associated with hepatocellular growth and regeneration. Previously, low absolute levels or decreases over time in either AFP or Gc portended to be a poor outcome. Methods:In a retrospective analysis of the double-blind trial of intravenous N-acetylcysteine (NAC) for ALF not because of acetaminophen, sera on days 1 and 3 or days 2 and 4 following admission were available to measure AFP in 70 patients and Gc in 66 patients. Mann-Whitney U tests were performed on the admission values, the absolute change and the fractional change of AFP and Gc to compare TFS (transplant-free survival) and non-TFS (death or transplantation). Logistic regression and receiver operating characteristic (ROC) analyses were performed to evaluate the markers in comparison and in addition to King's College Criteria (KCC).Results: Transplant-free survival patients were characterized by increases in AFP, whereas non-TFS had significantly different (negative) absolute and fractional changes (P < .01). The addition of declining AFP levels to KCC improved the area under the curve in predicting non-TFS (AUC >70%). Gc globulin values did not differ between TFS and non-TFS in the 2-day intervals studied (P> .2). Conclusion:In this comparison of two prognostic markers in patients with non-acetaminophen-induced ALF, rising AFP but not rising Gc levels was associated with TFS.Trial Registration: ClinicalTrials.gov number NCT00004467. K E Y W O R D Sacute liver failure, AFP, Gc-globulin | 2369 SINGH et al.