The Outcomes of Critically Ill Patients with Combined Severe Acute Liver and Kidney Injury Secondary to Paracetamol Toxicity Requiring Renal Replacement Therapy

Abstract

There is a paucity of outcome data for critically ill patients with combined acute liver and kidney injury secondary to paracetamol overdose (POD) requiring renal replacement therapy (RRT). We retrospectively reviewed all admissions over a 6-year period to the intensive care unit (ICU) at a university teaching hospital which supports an active liver transplant program. Of the 5582 admissions over this period, 73 patients were admitted with combined liver and kidney injury requiring RRT, and of these 10 patients went on to receive a liver transplant. Overall mortality was 58%, being lower at 20% for transplant recipients. Transplant recipients were younger than non-transplanted patients with similar global disease severity scores [Model for End-Stage Liver Disease (MELD) and Acute Physiology and Chronic Health Evaluation II (APACHE II)]. Patients with a higher MELD or APACHE II score fared worse and patients fulfilling the King's College Hospital transplant criteria on admission had an odds ratio (OR) for death of 3.8 (1.3-10.6). Logistic regression modeling found that only a higher admission bilirubin OR 1.6 (1.1-2.3) mg/dL and a lower creatinine OR 0.52 (0.3-0.9) mg/dL were predictive of mortality. Of the ICU survivors, 41% remained RRT dependant at the time of ICU discharge; all regained independent renal function by 1 month. Combined severe acute liver and kidney injury secondary to POD requiring RRT is associated with a high mortality. The majority of survivors recover independent kidney function by 1 month. Standard disease severity scores appear to reflect prognosis in these patients.

Risk Factors and Outcomes of Acute Kidney Injury in Patients With Acute Liver Failure

“…Thus, there is minimal impact on long-term kidney function in patients requiring liver transplantation. 13,24 …”

Isolated paracetamol-induced acute kidney injury: a systematic review

“…27 In liver transplant unit patients with paracetamol-induced AKI, mortality ranged from 25% -58% with AKI indicating poorer prognosis. 14,28,29 However, survivors tended to regain normal renal function; patients outside of intensive care or transplant units all recovered fully.…”

Acute renal damage in Acetaminophen poisoning

“…The prognosis worsens when acute kidney injury concomitantly present with acute liver failure. 2 The mechanism of acetaminophen-induced nephrotoxicity is still not clear. However, some authors relate this with the renal metabolism of acetaminophen, similar to the liver, with the formation of a reactive metabolite (N-acetyl-p-benzoquinoneimida [NAPQI]) which cause cell destruction mainly in tubules of the renal cortex when glutathione reserves depleted.…”