Acute Liver Failure Secondary to Yellow Phosphorus Rodenticide Poisoning: Outcomes at a Center With Dedicated Liver Intensive Care and Transplant Unit

Abstract

Background: Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn 3 P 2) commonly causes acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural, and industrial rodenticides and in production of ammunitions, firecrackers, and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary-care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. Methods: Patients with YPMP-related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG), and sequential organ failure assessment (SOFA) score and managed using uniform intensive care, treatment, and transplant protocols in LICU. Sociodemographic characteristics, clinical and biochemical parameters, and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients, and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. Results: Nineteen patients with YPMP-related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0-10) days after poisoning. YPMP-related cardiotoxicity was rapidly progressive and fatal, whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower-dose ingestion (<17.5 g), absence of cardiotoxicity, < grade 3 hepatic encephalopathy (HE), lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for continuous veno-venous hemodiafiltration (CVVHDF) and King College criteria positivity on account of prothrombin time and international normalized ratio (PT-INR) > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer intensive care unit and hospital stay. At median follow-up of 3.4 (2.6-5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. Conclusions: Early transfer to a specialized center, preemptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis, and others may maximize their chances of spontaneous recovery, allowing accurate prognostication and a timely liver transplant. (J CLIN EXP HEPATOL xxxx;xxx:xxx)

Rodenticide (Yellow Phosphorus Poison)-Induced Hepatotoxicity in India: Constraints During Management

“…In a study by Sharma et al, 20 50 per cent of patients who opted out of LT, survived with PLEX and this served as a stand-alone treatment in these patients. In Mohanka's series, 7 of the 19 patients, PLEX was included as a standard of care and served as a bridge to LT and not considered as a curative modality of treatment. The number of cases reported in their study is too few to reach any conclusion on efficacy of PLEX.…”

“…6,23,24 Can avoiding/minimizing sedation in YPP-induced hepatotoxicity improve patient survival, while awaiting an urgent LT? 1,7,25,26 This has been a subject of debate. With reference to this, one must recall that most of the sedative/hypnotic drugs are metabolized in the liver, and this function is affected in ALF, thereby enhancing the risk of respiratory depression.…”

“…Although viral hepatitis (mainly hepatitis E) is a common cause of ALF in northern India, paracetamol overdose is the commonest cause in the Western world. 2 More recently, hepatotoxicity due to yellow phosphorus poison (YPP) is being increasingly recognized as a cause of ALF in some parts of the Indian subcontinent largely from southern [3][4][5][6] and western parts 7,8 of the country.…”

“…Similar observations on vWF levels have now been replicated in other causes of ALF. 13 In the aforementioned context, an article in this issue by Mohanka et al 7 discussing their experience on managing patients with YPP is timely. LT Society of India has also recently published guidelines on management of patients with YPP including indications for LT. 14 Mohanka et al 7 analyzed outcome in 19 YPPpatients with ALF managed in a center with a dedicated liver intensive care unit (ICU) and facilities for LT. Extrapolating this information to centers with massive case load as those reported from southern states of India, very few patients have an access for an urgent LT. For example, only one patient of 450 YPPinduced hepatotoxicity patients i.e.…”

“…0.2% underwent urgent LT in the multicenter study. 4 There are other similar reports from India wherein very few patients underwent supra urgent LT for YPP, even in those centers which had a provision for LT. 3,7,11 Management options for YPP induced hepatotoxicity can therefore be considered under 2 broad headings: Non-LT and LT options…”