A Maxed-Out Liver: A Case of Acute-On-Chronic Liver Failure

Abstract

A 51-year-old man from Puerto Rico with Child-Turcotte-Pugh Class C decompensated cirrhosis due to genotype 1a chronic hepatitis C was referred for worsening jaundice and diuretic-resistant ascites. He began experiencing symptoms of hepatic decompensation 5 months prior to referral with new-onset ascites and spontaneous bacterial peritonitis, evolving into diuretic-resistant ascites, increasing jaundice, and a MELD increase from 12 to 29. During his hospitalization, his MELD score increased to >40 from a rapidly increasing international normalized ratio (INR) and evolving type 1 hepatorenal syndrome. Clinically, the patient appeared quite well despite such a high MELD score. After an extensive pretransplant evaluation and exclusion of infection, he underwent successful orthotopic liver transplantation. After histologic examination of the explanted liver, he subsequently admitted to 5 months of daily use of a detoxifying supplement known as MaxOne (®), containing D-ribose- L-cysteine, consistent with a drug-induced acute-on-chronic liver failure. The use of complementary and alternative medicines and its potential for causing drug-induced liver injury and acute-on chronic liver failure requires a high index of suspicion and increased awareness among health care providers.

Drug-Induced Liver Injury in Patients With Preexisting Chronic Liver Disease in Drug Development: How to Identify and Manage?

“…The hallmark of the hepatic manifestation in these patients is hyperbilirubinemia and coagulopathy rather than ALT elevation. [22][23][24] In extreme cases, the patient may rapidly develop a clinical picture often referred to as "acute-on-chronic liver failure," which may include jaundice, coagulopathy, hepatic encephalopathy, and ascites, and is typically associated with organ failure and a high shortterm mortality rate. 23,24 It is, therefore, critical to monitor patients who are enrolled in clinical trials with preexisting liver dysfunction closely, to enable early detection of the first signs…”

Consensus: guidelines: best practices for detection, assessment and management of suspected acute drug‐induced liver injury during clinical trials in patients with nonalcoholic steatohepatitis

“…Importantly, the AST:ALT ratio may increase to >1 in such patients, and the ratio may increase as the disease progresses . In general, DILI in patients with preexisting liver dysfunction may sometimes present with rapid deterioration of liver function (ie elevated direct bilirubin and prolonged INR), with only mild changes in ATs . Therefore, close monitoring is essential in such patients, to enable early detection of the first signs of DILI, and ensure early discontinuation of the drug.…”