Elsevier

Journal of Hepatology

Volume 42, Issue 2, February 2005, Pages 202-209
Journal of Hepatology

Indication of liver transplantation following amatoxin intoxication

https://doi.org/10.1016/j.jhep.2004.10.023Get rights and content

Background/Aims

Indication of liver transplantation in acute liver failure following amatoxin intoxication is still uncertain.

Methods

One hundred and ninety-eight patients were studied retrospectively. The laboratory parameters alanineaminotransferase, serum bilirubin, serum creatinine and prothrombin index were analyzed over time. Predictors of fatal outcome and survival were determined by receiver-operating-characteristic and sensitivity–specificity analysis.

Results

Twenty-three patients died in the median 6.1 days (range, 2.7–13.9 days) after ingestion. Using a single parameter as predictor of fatal outcome the area under the receiver-operating-characteristic curve of prothrombin index (0.96) and serum creatinine (0.93) were both significantly greater (P<0.05) compared with serum bilirubin (0.82) and alanineaminotransferase (0.69). Prediction of fatal outcome had an optimum, if a prothrombin index less than 25% was combined with a serum creatinine greater than 106 μmol/l from day 3 after ingestion onwards (sensitivity 100%, 95% confidence interval 87–100; specificity 98%, 95% confidence interval 94–100). The median time period between the first occurrence of this predictor in non-survivors and death was 63 h (range, 3–230 h).

Conclusions

A decision model of liver transplantation following amatoxin intoxication using prothrombin index in combination with serum creatinine from day 3 to 10 after ingestion enables an early and reliable assessment of outcome.

Introduction

Intoxications with mushrooms containing amatoxins (Amanita, Lepiota, and Galerina species) [1] may progress into acute liver failure and finally death, if liver transplantation is not performed. The reported mortality with only conventional treatment is 1.4–16.9% [2]. The physician in charge of the patient is confronted with the problem to find the exact moment to decide in favour or against transplantation. If transplantation is done too early, the patient could have survived without impaired quality of life, whereas, if the decision of transplantation is done too late, the patient may die before a suitable donor organ is available [3], [4]. Aetiology of acute liver failure was recognized to be most important in predicting outcome [5], [6], [7]. Since amatoxin intoxication is rather rare, it is still uncertain [2], [8], [9], whether it is appropriate to apply well established prognostic schemes of other aetiologies [5]. The aim of this retrospective study was to look for criteria which may best predict fatal outcome and survival in amatoxin poisoning.

Section snippets

Subjects

Out of 265 patients with the diagnosis of amatoxin intoxication admitted to hospital between 1967 and 2002, 198 were studied retrospectively. Sixty-seven were excluded, due to an asymptomatic course (60 patients), liver transplantation (five patients) or missing data (two patients). Two hundred and seven patients were treated at the Toxicological Department of Klinikum rechts der Isar, Munich (MRI), and 58 were admitted to 29 other hospitals in nine European countries (data provided by Madaus

Characteristics of the patients

One hundred and ninety-eight patients were included in the study. Twenty-three patients had a fatal course, which results in a mortality rate of 11.6%. The mushrooms ingested were mainly Amanita phalloides followed by Amanita virosa and few Galerina marginata. Lepiota species were not involved. Therapy included decontamination, fluid resuscitation, specific treatment with benzylpenicillin or silybin and symptomatic measures. The median age was 50 years (range, 6–85 years), the median time

Discussion

Since the first report of liver transplantation in amatoxin intoxication in 1985 [13], this therapy is now a well established option in the management of these patients. However, indication of liver transplantation in this aetiology was still an element of uncertainty [2], [8], [9], since, proposed criteria refer to single cases or small series only [9], [13], [14], [15], [16], [17], [18], [19], [20]. In our study, we analyzed 198 patients retrospectively, and found that in amatoxin

Acknowledgements

We are indebted to Dr S. Wagenpfeil from Institut für Medizinische Statistik und Epidemiologie, Klinikum rechts der Isar, Technical University Munich for his advice on statistics.

References (30)

  • W. Bernal et al.

    Blood lactate as an early predictor of outcome in paracetamol-induced acute liver failure: a cohort study

    Lancet

    (2002)
  • H. Faulstich et al.

    Amatoxins

  • F. Enjalbert et al.

    Treatment of amatoxin poisoning: 20-year retrospective analysis

    J Toxicol Clin Toxicol

    (2002)
  • D.H. Thiel van

    When should a decision to proceed with transplantation actually be made in cases of fulminant or subfulminant hepatic failure: at admission to hospital or when a donor organ is made available?

    J Hepatol

    (1993)
  • W.M. Lee

    Acute liver failure

    N Engl J Med

    (1993)
  • Cited by (0)

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