BOSTON – Acetaminophen toxicity is the most frequent cause of acute liver failure in the United States and its usually milder presentation, along with comorbid psychosocial issues, explain why fewer patients with the etiology undergo liver transplantation, compared with other causes, according to a 10-year retrospective study of the National Institute of Diabetes and Digestive and Kidney Diseases Acute Liver Failure database.
Dr. K. Rajender Reddy and his colleagues in the National Institutes of Health Acute Liver Failure Study Group set out to determine factors that could help clinicians to improve their selection of acute liver failure patients for liver transplantation listing and their decision to proceed with transplantation.
At the annual meeting of the American Association for the Study of Liver Diseases, Dr. Reddy reported that of 1,144 patients who had at least 1 year of follow-up in the database, 491 (43%) had an acetaminophen etiology for acute liver failure, but only 26% of all patients listed for transplantation had an acetaminophen etiology and just 14% of all transplants occurred in patients with acetaminophen toxicity as the underlying cause.
In comparison, patients with other etiologies had higher listing and transplantation rates, with the highest being for autoimmune hepatitis (62% of all patients listed and 50% of all transplanted).
Overall during 2000-2010, 697 patients were not listed and not transplanted (group A), 177 were listed and not transplanted (group B), and 270 were listed and transplanted (group C). After 2 years of follow-up, patient survival was highest in group C (82%), followed by group A (47%) and group B (41%). Survival at 21 days followed the same pattern (C, 89%; A, 58%; B, 45%). Patients in groups A and B with acetaminophen etiology had greater 21-day survival than did those without an acetaminophen etiology.
Patients in group A had significantly higher rates of positive toxicology screens than did groups B and C (43% vs. 35% and 19%, respectively) and history of illicit drug use (10% vs. 4% and 2%).
Comparisons between patients who died in group B and all patients in group C could not find significant risk factors to explain the higher mortality in group B, including longer wait list times and variations in survival and transplant rates by geographic location, although greater coma severity may have contributed to the higher mortality, said Dr. Reddy, professor of medicine in the division of gastroenterology at the Hospital of the University of Pennsylvania, Philadelphia.
Dr. Reddy said that he had no relevant financial disclosures. The study was funded by a grant from the National Institute of Diabetes and Digestive and Kidney Diseases to the National Institutes of Health Acute Liver Failure Study Group.