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A5188 - Liver Transplant in Two Parts: A Possible Salvage Approach to Acute Liver Failure in the Intensive Care Unit
Author Block: C. Lampl1, G. Solomon2; 1Medicine, University of Alabama-Birmingham, Birmingham, AL, United States, 2Medicine, Univ of AL Birmingham, Birmingham, AL, United States.
Introduction: Acute liver failure (ALF) is an uncommon but devastating entity whose management in the intensive care unit is many times supportive. Of known causes, idiosyncratic drug-induced liver injury (DILI) carries a worse prognosis than most etiologies of ALF, with reported transplant-free survival around 40%. We present a case of DILI resulting in ALF and review two-stage liver transplant as a possible approach to management.
Case: A 25-year-old female presented with altered mental status, nausea, vomiting, abdominal pain, fevers, and chills. During a recent pedicure, she sustained a laceration that soon developed a superimposed soft tissue infection. On presentation, patient was several days into a prescribed course of trimethoprim/sulfamethoxazole. She had no past medical history and denied any other medications or exposures. Laboratory evaluation was significant for AST 14,900 U/L, ALT 7,800 U/L, total bilirubin (3.0 mg/dL), INR (5.2), and ammonia (458 µmol/L) with normal alkaline phosphatase levels (85 U/L). Complete laboratory and imaging evaluation otherwise excluded other causes of ALF. Over the coming days, she had worsening multi-organ failure requiring renal replacement therapy, mechanical ventilation, and multiple vasopressors. She was listed for liver transplant but deteriorated and underwent emergent hepatectomy as a bridge to transplant. Unfortunately, she passed away post-operatively. Pathology performed on the removed liver showed massive hepatocellular necrosis with portal tract inflammation and abundant eosinophils, consistent with drug-induced liver injury.
Discussion: Acute liver failure is characterized by coagulopathy and hepatic encephalopathy in the absence of chronic liver disease. Idiosyncratic DILI, defined by its unpredictable dose relationship, is the second most common cause of ALF, accounts for over 11% of cases in the United States, and carries a poor prognosis. While prognostication tools like King’s College Criteria are widely used in determining transplant candidacy, poor sensitivities (52-68% by recent metanalyses) limit their utility. Higher mortality rates in patients transplanted for ALF make appropriate selection for liver transplant paramount. In cases complicated by toxic liver syndrome—an entity described by Ringe et al as complete liver necrosis accompanied by shock and multi-organ failure—total hepatectomy with portocaval shunt has been suggested as a bridge to transplant when a graft is not readily available. Its theoretical benefit derives from the removal of necrotic liver and its inflammatory response. Limited data from case series point toward decreased vasopressor requirements in selected patients. Regardless of approach, this case highlights the need for patients with ALF to be at a center capable of liver transplant.