Indication of liver transplantation following amatoxin intoxication
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.
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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)
- et al.
Determining prognosis in patients with fulminant hepatic failure: when you absolutely, positively have to know the answer
Hepatology
(1995) - et al.
Early indicators of prognosis in fulminant hepatic failure
Gastroenterology
(1989) - et al.
Liver transplantation in adults with acute liver failure
J Hepatol
(2004) Auxiliary liver transplantation for toxic mushroom poisoning [letter]
J Pediatr
(2001)- et al.
Amanita poisoning: treatment and the role of liver transplantation
Am J Med
(1989) - et al.
Liver transplantation for severe Amanita phalloides mushroom poisoning
Am J Surg
(1990) - et al.
Inhibition of ribonucleic acid and of protein synthesis in the organs of rats and mice poisoned with alpha-amanitin
Biochim Biophys Acta
(1973) - et al.
Emergency liver transplantation for acute liver failure. Evaluation of London and Clichy criteria
J Hepatol
(1993) - et al.
Early indicators of prognosis in fulminant hepatic failure: an assessment of the King's criteria
J Hepatol
(1997) - et al.
Acute liver failure: clinical features, outcome analysis, and applicability of prognostic criteria
Liver Transpl
(2000)