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Fulminant Hepatic Failure Etiology of Acute Liver Failure 1998-2007

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Fulminant Hepatic Failure Etiology of Acute Liver Failure 1998-2007 Acute Liver Failure Luis S. Marsano, MD Professor of Medicine Division of Gastroenterology, Hepatology and Nutrition University of Louisville, and Louisville VAMC 2018 Definitions • Classic: Development of hepatic encephalopathy within 8 weeks of initiation of symptoms in a patient without known chronic liver disease. – Patients with Acute Onset AIH, Budd-Chiari, or Wilson disease qualify even in the presence of fibrosis. • Practical: Development of: – hepatic encephalopathy and coagulopathy (INR > 1.5) – within 26 weeks from the onset of jaundice, – in patient without known chronic liver disease. • Patients who develop coagulopathy but no hepatic encephalopathy have “Acute Liver Injury” Grades of Hepatic Encephalopathy (Porto-Systemic Encephalopathy – PSE) • Grade I: – Inverse sleep pattern, personality change, slight change in mental status. (GCS=14-15) – Normal EEG. • Grade II: – Confusion, drowsiness, asterixis. (GCS=11-13) – Abnormal EEG with generalized slowing. • Grade III: – Incoherence, stupor, agitation. (GCS=8-10) – Abnormal EEG. • Grade IV: – Unresponsiveness, coma, decerebrate posturing, seizures, areflexia. (GCS<8) – Abnormal EEG. Incidence • Incidence: – 2300-2800/ year in USA; – 6% of adult transplants; – 6% of liver-related deaths; – 0.1% of deaths in USA. Factors Affecting Survival in FHF • Acuteness of illness • Etiology • Brain Edema/ Intracranial Hypertension • Acute Kidney Injury • Superimposed Infection (bacterial or fungal) Acuteness of Illness Subtypes of Acute Hepatic Failure • Hyperacute: Clinical encephalopathy in < 8 days from jaundice (acetaminophen, mushrooms, ecstasy heat shock and ischemia). • Acute: Clinical encephalopathy 8 – 28 % days from onset of jaundice. • Subacute: Minimal encephalopathy from 29 days to 26 weeks after onset of jaundice -clinical picture may mimic cirrhosis Features of ALF by Type Gimson AE et al. Hepatol 1986:6;288-294 Hyper-Acute Acute Sub-Acute Onset of HE </= 7 8 – 56 > 56 (days) Age (years) 25 25 45 Cerebral edema % 90 67 9 Ascites % 0 7 62 HRS % 20 35 62 Recovery % 75 40 < 5 Common Etiology APAP Viral DILI Mushrooms Pregnancy Unknown Ischemia Vascular Ecstasy heat shock Etiology Brain Edema/ Intracranial Hypertension Acute Kidney Injury FHF Expected Survival by Etiology, Brain Edema & AKI 100 100 90 80 71 70 60 53 50 40 % Survival 30 20 10 0 Tylenol + Brain Tylenol + Brain Tylenol + NO edema + AKI edema Brain edema FHF Expected Survival by Etiology, Brain Edema & AKI 100 90 80 70 67 60 50 50 40 % Survival 30 30 20 10 0 Hep A/B + Brain Hep A/B + Brain Hep A/B + NO edema + AKI edema Brain edema FHF Expected Survival by Etiology 100 90 80 70 60 50 % Survival 40 30 20 20 18 18 10 0 0 Wilson's Cryptogenic Idiosyncratic Halothane Outcomes according to etiology and coma grade Best Practice & Research Clinical Gastroenterology Volume 26, Issue 1, February 2012, Pages 3–16 Overall Survival The bars for each etiology indicate the percent survival without transplantation according to coma grade (I,II vs. III,IV). The percent above each pair indicates the overall percentage of spontaneous survival Causes of Fulminant Hepatic Failure Etiology of Acute Liver Failure 1998-2007 0.8 2.721.560.9 Acetaminophen 4.37 4.86 Indeterminate Drug 5.77 HBV AIH 46.25 Other 7.5 Ischemia HAV Wilson's 11.46 Budd-Chiari Pregnancy 13.77 Best Practice & Research Clinical Gastroenterology Volume 26, Issue 1, February 2012, Pages 3–16 Best Practice & Research Clinical Gastroenterology Volume 26, Issue 1, February 2012, Pages 3–16 Causes of FHF Viral Infection • Hepatitis A • Herpes Simplex • Hepatitis B +/- HDV • Cytomegalovirus • Hepatitis E • Varicella-Zoster • Hepatitis C (very rare) • Epstein-Barr virus • Paramyxovirus • Adenovirus • Dengue • Hemorrhagic Fever – Yellow Fever, – Ebola, – Marburg, – Lassa, – Rift Valley Causes of FHF Drugs & Toxins • DOSE RELATED ISCHEMIA RELATED – Acetaminophen - Long acting Niacin – CCl4 - Cocaine – Amanita Poisoning - Methamphetamine (A. phalloides, A. ocreata, A. bisporigera, A. virosa, Galerinas, Lepiotas) – Yellow phosphorus IDIOSYNCRATIC – Bacillus cereus toxin Causes of FHF Drugs - Idiosyncratic • Amoxicillin-clavulanate • Efavirenz • Allopurinol • Etoposide • Amiodarone • Flutamide • Amphetamines • Gemtuzumab • Dapsone • Halothane • Diclofenac • Imipramine • Didanoside • Isoflurane • Disulfiram • Isoniazid • Ecstasy • Ketoconazole Causes of FHF Drugs - Idiosyncratic • Labetalol • Propylthiouracil • Lisinopril • Quetiapine • Metformin • Rifampin-INH • Methyldopa • Statins • Nefazodone • Sulfonamides • Nicotinic acid • Tolcapone • Ofloxacine • Trimethoprim-Sulfametox • Phenytoin • Troglitazone • Pirazinamide • Valproic acid Causes of FHF Herbals & Supplements • Bai-Fang herbs® • Hydroxycut ®(has green tea extract) • Chaparral (Larrea tridentata) • Impila (Callilepis laureola) • Jin Bu Huan® • Comfrey (Symphytum officinale L) • Kava kava (Piper metysticum) • Germander (Teucrium chamaedrys) • LipoKinetix® • Greater celandine (chelidonium majus) • Ma Huang (Ephedra sinica) • Green tea extract (Camellia sinensis) • Pennyroyal (Mentha pulegium) • Gum Thistle (Atractylis gummifera L) • Rattleweed (Crotalaria retusa) • He Shon Wu (Polygonum multiflorum) • Senecio (Senecio vulgaris) • Heliotrope (Heliotropium popovii and H. lasiocarpum) • Skullcap (Scutellaria lateriflora) • Herbalife ® • Sunnhemp (Crotalaria juncea) • Huamanripa (Senecio tephrosioides) Causes of FHF Metabolic & Pregnancy-related • METABOLIC • PREGNANCY- – Wilson’s Disease RELATED – Alpha-1-antitrypsin – Acute fatty liver – Galactosemia – HELLP Syndrome – Tyrosinemia (Hemolysis, Elevated Liver function, Low – Fructose Intolerance Platelets) – Neonatal Fe storage dz Causes of FHF Neoplastic & Miscellaneous • MISCELLANEOUS • NEOPLASTIC – Autoimmune hepatitis – Lymphoma – Budd-Chiari – Liver Metastasis – Veno-occlusive/ SOS (breast, small cell lung – Shock Liver & CHF cancer, melanoma) – Heat Stroke – Adult onset Still’s dz • CRYPTOGENIC – Reye’s syndrome Yamaguchi criteria for classification of adult Still's disease • Presence of 5 or more criteria, of which at least 2 are Major (96% sensitivity; 92% specificity) • Major Criteria – Temperature of > 39°C for > 1 wk – Leukocytosis > 10,000/mm3 with > 80% PMNs – Typical rash (transient, salmon color) – Arthralgias > 2 wk • Minor Criteria – Sore throat – Lymph node enlargement – Splenomegaly – Liver dysfunction (high AST/ALT) – Negative ANA, RF Primary and Secondary Causes of ALF Need for Transplantation EASL GUIDELINES; Journal of Hepatology 2017 vol. 66 j 1047–1081 Disease Group Hepatic Extrahepatic Primary ALF Secondary ALF and Liver Transplant may be option Acute on Chronic LF Liver Transplant is NOT likely option Acute Liver -DILI -Ischemic Hepatitis Failure -Viral Hepatitis -Systemic Disease: -Toxin -Hemophagocytic Syndrome -Budd-Chiari -Infiltrative Disease -Autoimmune -Metabolic Disease -Pregnancy related -Lymphoma -Infection (malaria) Chronic disease Fulminant Wilson -Liver resection for primary or metastatic Cancer. with ALF Acute onset AIH -Alcoholic Hepatitis (most cases) Phenotype Budd-Chiari HBV reactivation Selected Alcoholic Hepatitis Clinical Features Lee WM, Clin Liver Dis 2013;17:575-586 APAP Drugs Indeterm H AV HBV Other Age 37 46 39 49 43 45 % Female 76 69 59 44 44 71 PSE > 3 53 35 48 56 52 38 Mean ALT 3773 639 865 2275 1649 681 (IU/mL) Mean Bili 4 20 21 12 18 14 (mg/dL) Spontaneous 63 24 22 50 21 31 Survival % Overall 70 58 60 72 55 58 Survival % Etiologic & Management Work-Up FHF Etiologic work-up • Establish day of onset of jaundice. • Travel History (exotic viruses) • Medication (Rp & OTC), drug/alcohol, CAM therapies, environmental & food exposures. • Sexual history, piercing, tattooing, … • Family history (Wilson’s, alpha-1-antitrypsin,…) • Stigmata of chronic liver disease. • Mushroom poisoning with severe gastrointestinal symptoms (nausea, vomiting, diarrhea, abdominal cramping), which occur within hours to a day of ingestion FHF Etiologic work-up • HAV anti-HA IgM • Wilson’s 24h urine Cu > • HBV anti-HBc IgM, 100mg/dL, ceruloplasmin <20 HBV-DNA mg/dL, K-F rings, [alk.phos/bili <4 (sn 94%,sp 96%) & AST/ALT >2.2] • HCV HCV-RNA , anti-HCV (sn 100%,sp 100% if both true; Hepatology. • HDV anti-HD IgG 2008 Oct;48(4):1167-74) , low uric acid, • HEV anti-HE IgM (total & free Cu) • CMV CMV-DNA, anti CMV • Autoimmune ANA, anti-LKM, IgG & IgM, buffy coat anti-SLA, ASMA, anti-LC, QIG’s, • HSV Buffy coat, anti-HSV LIVER Bx if suspected & Ab(-) IgG & IgM, HSV PCR • AFLP Pregnancy +/- pre- • EBV acute serology, PCR eclampsia, ALT<500 • VZV Serology, PCR • Budd-Chiari U/S+doppler, angio- CT • Drug/Toxin History, toxicology drug screen • Ischemia Hx.of shock or CHF; Echocardiogram FHF Etiologic work-up in Recent Travel • West Africa, or South America’s Amazon region: – Yellow Fever capture enzyme immunoassay. • Congo, Sudan, Uganda, Côte-d’Ivoire, Liberia: – anti-Ebola virus by ELISA, • Uganda, Kenya, or Zimbabwe: – anti-Marburg fever IgM-capture by ELISA, • Guinea (Conakry), Liberia, Sierra Leone, Nigeria, or other West African countries: – anti-Lassa fever antibodies, • Senegal, Kenya, Saudi Arabia, Yemen, Egypt, Tanzania, Somalia, Jordan, and Mozambique: – Rift Valley fever antibody (ELISA). Standard Tests • CBC with diff., PT/INR • Blood type & screen done twice (two separate samples) • Pregnancy test (females) • CMP, Phosphorus, Mg, CK. • Amylase, lipase • Daily arterial ammonia • AFP on day 1, day 3, and day of 1st decrease of ALT. • Acetaminophen level; acetaminophen adducts when available. • Arterial blood gas • Arterial Lactate
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