Acute liver failure secondary to toxic exposure in children

Abstract

Introduction: Acute liver failure (ALF) is a syndrome defined by jaundice, coagulopathy (INR > 1.5) and hepatic encephalopathy in patients with no evidence of prior liver disease. Toxins and drugs are a frequent cause of ALF in children. Material and methods: The aim of our study was to establish the causes of toxic ALF in children followed up in our hospital in the period of January 2000 to August 2018. We retrospectively studied all hospital records of patients who developed ALF after mushroom/drug exposure and had been admitted to our hospital, the main pediatric toxicology center in northwestern Romania. Results: In the last 18 years, 123 patients were admitted to our clinic with toxic ALF (89 patients secondary to mushroom ingestion and 34 patients after drug exposure). In the 2000-2012 period accidental mushroom poisoning was the leading cause of toxic ALF. Unfortunately, during the last years, voluntary drug ingestions have increased dramatically. The most commonly incriminated drug was acetaminophen (52.94%). Conclusions: ALF in mushroom poisoning is associated with a high mortality in children, despite optimal medical therapy. This etiology was one of the most important causes of death in our cohort. The difficulty in accessing emergency liver transplantation is an obstacle common to many Eastern European pediatric centers. Fortunately, in the last 5 years the incidence of mushroom intoxications has decreased in our area. It is worrying that over the last few years there has been an increased incidence of toxic ALF after drug exposure (for suicidal purposes or due to lenient regulations for prescribing hepatotoxic medications).

Etiology and Outcome of Acute Liver Failure in Children—The Experience of a Single Tertiary Care Hospital from Romania

“…The outcome was fatal in 22.23% of all infections despite therapeutic measures. In developing countries, there is a high prevalence of viral infections, in some regions these being the main cause of ALF in infants, with an important cause of morbidity and mortality [ 1 , 2 , 3 , 4 , 5 ]. Another important cause of severe liver injury in infants was represented by metabolic disorders.…”

“…Ingestion of wild mushrooms was the main cause of toxic hepatitis in the last 20 years in our hospital. In the last years, the number of children who developed ALF after mushroom poisoning decreased significantly, thus determining the reduction in the overall mortality [ 5 ].…”

“…Of 123 cases with toxic ALF, 89 cases were secondary to mushrooms ingestion and only 34 cases were secondary to drugs. Before 2012, the leading cause of toxic ALF was mushroom poisoning, while since 2012 most cases were due to drug ingestion [ 5 ]. The mortality due to mushroom poisoning in our previous study was 51.68%, compared to only one case in the present study (16.67%), higher that in ALF due to drugs (6.89%).…”

“…The mortality due to mushroom poisoning in our previous study was 51.68%, compared to only one case in the present study (16.67%), higher that in ALF due to drugs (6.89%). The prognostic factors for mortality in ALF due to mushroom poisoning were the presence of encephalopathy, acute kidney injury, and severity of liver injury at admission (high level of transaminases, bilirubin, and INR) [ 5 , 23 ].…”

“…Acute liver failure (ALF) is a rare condition in pediatric pathology, with increased mortality (50%) despite optimal medical therapy in the absence of emergency liver transplantation [ 1 , 2 , 3 ]. ALF is a syndrome characterized by hepatic coagulopathy not-corrected by parenteral administration of vitamin K and the value of the INR (International Normalized Ratio) of 1.5–1.9 in the presence of hepatic encephalopathy or INR > 2.0 in the absence of hepatic encephalopathy in a child without the pre-existing liver disease [ 4 , 5 , 6 ]. The causes of ALF in children are different from those of the adult and vary according to the age of the child.…”