Outcome of Acetaminophen‐Induced Acute Liver Failure Managed Without Intracranial Pressure Monitoring or Transplantation

Abstract

Acetaminophen‐induced acute liver failure (ALF) may require emergency liver transplantation (LT) in the presence of specific criteria, and its management may also include intracranial pressure (ICP) monitoring in selected patients at high risk of cerebral edema. We aimed to test the hypothesis that management of such patients without ICP monitoring or LT would yield outcomes similar to those reported with conventional management. We interrogated a database of all patients treated in an intensive care unit for acetaminophen‐induced ALF between November 2010 and October 2016 and obtained relevant information from electronic medical records. We studied 64 patients (58 females) with a median age of 38 years. Such patients had a high prevalence of depression, substance abuse, or other psychiatric disorders and had ingested a median acetaminophen dose of 25 g. No patient received ICP monitoring or LT. Overall, 51 (79.7%) patients survived. Of the 42 patients who met King’s College Hospital (KCH) criteria, 29 (69.0%) survived without transplantation. There were 45 patients who developed severe hepatic encephalopathy, and 32 (71.1%) of these survived. Finally, compared with the KCH criteria, the current UK Registration Criteria for Super‐Urgent Liver Transplantation (UKRC) for super‐urgent LT had better sensitivity (92.3%) and specificity (80.4%) for hospital mortality. In conclusion, in a center applying a no ICP monitoring and no LT approach to the management of acetaminophen‐induced ALF, during a 6‐year period, overall survival was 79.7%, and for patients fulfilling KCH criteria, it was 69.0%, which were both higher than for equivalent patients treated with conventional management as reported in the literature. Finally, the current UKRC may be a better predictor of hospital mortality in this patient population.

Metabolomics analysis reveals the protective effect of quercetin‐3‐O‐galactoside (Hyperoside) on liver injury in mice induced by acetaminophen

“…Thus, GSH in the liver played an important role in APAP's detoxify. The same conclusion was also made in recent reports where liver GSH was depleted by NAPQI and oxidative stress caused liver injury (Liu et al, 2018;Porteous et al, 2019).…”

Abdominal Organ Transplantation: Noteworthy Literature in 2019

“…They suggested that LT can be safely performed without fresh frozen plasma with substitution of PCC. � Nonsurgical management of acute liver failure: Porteous et al 55 A single-center retrospective study of 64 adult patients with ALF due to acetaminophen overdose under a conservative medical treatment protocol without use of ICP monitoring or LT showed a survival rate of 79.7%. � Liver Frailty Index score best predicts waitlist mortality: Lai et al 56 Associations were investigated between LFI scores, ascites, and HE and mortality of patients on the LT wait-list at 9 centers in the United States (n ¼ 1044); only frailty was identified as being significantly associated with wait-list mortality.…”

“…54 Porteous and associates provided highly impactful data on the treatment of acute liver failure (ALF) patients. 55 They reviewed their institutional outcomes for 64 adult patients admitted to the ICU with acetaminophen-induced ALF between November 2010 and October 2016 under a conservative medical treatment protocol without use of intracranial pressure (ICP) monitoring or LT. According to their institutional protocol, IV N-acetylcysteine was administered to all patients until discharge from the ICU.…”

“…They also suggested that the current UKRC may better predict hospital mortality in this patient population compared to KCH criteria. 55…”

Neurological Monitoring in Acute Liver Failure

“…These studies are heterogeneous; they used different strategies to reverse coagulopathy for placement and removal, attempted to correct the coagulopathy for varying periods of time, and did not consistently perform postplacement imaging to diagnose intraparenchymal hemorrhage. While patients with invasive ICP monitors have higher rates of treatment for elevated ICP and may have longer hospital survival, there has been no strong evidence showing improved overall survival to discharge . One center published much better outcomes than generally reported in acetaminophen‐induced ALF managed without invasive ICP monitoring, though their standard treatment of all high‐grade HE included aggressive maneuvers to prevent elevated ICP …”