Live donor liver transplantation for antitubercular drug-induced acute liver failure

Abstract

Antitubercular therapy (ATT)-induced hepatotoxicity is often over looked and active tuberculosis is considered a contraindication for liver transplantation, however it might be the only lifesaving option to certain patients of acute liver failure (ALF) due to ATT. We have assessed the outcome of live donor liver transplantation in ATT-induced ALF. A retrospective analysis of all the cases of ALF that underwent liver transplantation from 2006 to 2014 at the Amrita Institute of Medical Sciences was done. A total of seven (7.7%) patients with ATT-induced ALF who had underwent live donor liver transplantation were included in the study. Out of seven patients, three (42.8%) had established diagnosis of tuberculosis and the remaining (58.2%) patients were started on ATT empirically. The median duration of ATT intake was 2 months. All the patients underwent live donor liver transplant as they met King's College criteria, and their model for end-stage liver disease score was above 35 on admission, receiving graft from first degree relatives. Histopathology of explant liver showed pan acinar necrosis. Restarting of ATT after transplant was individualized. It was restarted only in two (28%) patients with prior sputum-positive pulmonary tuberculosis after a median time of 27 days after transplant. ATT was not restarted in rest of the (72%) patients. Postoperative mortality was seen in two (28%) patients due to conditions that masquerade the ATT-induced acute liver failure. The overall survival rate was 71.4% with a median follow up of 22 months. Live donor-related transplantation is feasible option in ATT-induced acute liver failure. Restarting of ATT post liver transplant is feasible and should be individualized along with frequent monitoring of immunosuppressant levels; however, if the primary diagnosis of tuberculosis was empirical, reintroduction of ATT can be omitted.

Liver transplantation for acute liver failure due to antitubercular drugs – a single-center experience

“…The 6 transplanted individuals came from a pool of 19 patients with ALF, and possibly those with better clinical parameters were given the chance of living donor transplantations, considering the risks for the donor 15 . Another recent paper described a good survival rate of 71.4% in 7 patients undergoing living donor transplantations in India, with a median follow-up of 22 months 16 . Although the authors did not mention any patient who were unfit for transplantations, patients went to the procedure very sick, with a mean MELD score greater than 35.…”

Liver Transplant Outcomes in India

“…10 Various Indian studies have shown 64%-88% survival after LT in patients with ALF. [11][12][13][14][15][16] iMMUnOlOGiCal OUTCOMes…”

Anti-tubercular drugs, predisposing factors and management of drug-induced hepatotoxicity: A concise and up-to-date

“…Nucleotide analogue ought to be administered for the patients with dynamic HBV-DNA replication before anti-TB treatment to avoid the development of hepatic failure (Li et al, 2013;Acocella, 1978;Mahmood et al, 2007). Studies have proved that patients who were co-infected with both hepatitis C and HIV infections, have a 14.4 fold relative risk of developing DIH (Jeong et al, 2015;Bavikatte et al, 2017).…”