The Role of Etiology in the Hyperamylasemia of Acute Liver Failure

Abstract

OBJECTIVES Hyperamylasemia (HA) is often reported in patients with acute liver failure (ALF). Direct toxic effects of acetaminophen on the pancreas have been postulated, but the occurrence of HA in other etiologies raises the question of whether multiorgan failure is part of the pathogenesis of HA in this setting. Our main aim was to describe and analyze the incidence, clinical characteristics, and outcomes of HA in ALF of different etiologies. METHODS Patients enrolled in the Acute Liver Failure Study Group registry with an admission amylase value available were included. For the purpose of this analysis, HA was defined as ≥3× upper limits of normal. Patients were classified as having acetaminophen (APAP)- or non-APAP–induced ALF, and by amylase group: normal (< 115), mildly elevated (115–345), or HA (>345). Significant variables identified by univariate analysis were added to a multiple linear regression model. The primary outcome was overall survival. RESULTS In total, 622 eligible patients were identified in the database, including 287 (46%) with APAP-induced ALF; 76 (12%) patients met the criteria for HA. Among patients with HA, 7 (9%) had documented clinical pancreatitis. The incidence of HA was similar among APAP (13%) and non-APAP (12%) patients. Although HA was associated with renal failure and greater Model for End-stage Liver Disease scores for both groups, HA was not an independent predictor of mortality in multivariate analysis. CONCLUSIONS Although not an independent predictor of mortality, HA in ALF was present in all etiologies and was associated with diminished overall survival. HA appeared to be related to renal dysfunction in both groups and multiorgan failure in non-APAP ALF.

Workup and Management of Immune-Mediated Hepatobiliary Pancreatic Toxicities That Develop During Immune Checkpoint Inhibitor Treatment

“…Challenge group one is whether routine monitoring of pancreatic enzymes is necessary and whether grade 3 or 4 elevations of amylase and lipase should be considered dose-limiting toxicities for any new immune checkpoint inhibitor tested in patients with cancer even if the diagnosis of pancreatitis is not made. The etiology of amylase and lipase elevation often remains unclear as they are nonspecific and may be elevated because of organ failure [36], bowel obstruction [37], diabetic ketoacidosis [38], or HIV infection [39]. Therefore, routine monitoring of pancreatic enzymes is not recommended, unless pancreatitis is suspected [40].…”

Liver transplantation for acute liver failure accompanied by severe acute pancreatitis

“…This condition is associated with greater renal dysfunction, higher coma grade and higher arterial lactate level among patients with ALF, and these account for higher MELD score as well as the greater proportion of patients who meet the KCH criteria 4. The mechanisms of this condition are yet to be fully elucidated.…”

“…Taking into account the time course, in which acute pancreatitis developed on 17th day of admission and only 2 days after the onset of hepatic encephalopathy, this association could occur in the context of acceleration of disease acuity, followed by worsening of overall physiological dysfunction, rather than its common aetiology with ALF 4 7…”

“…Various mechanisms behind this association, including direct injury to pancreatic acinar cells by causative agent of ALF and indirect physiological effects, have been reported 4 5. In the setting of ALF, regardless of its pathogenesis, acute pancreatitis is associated with multiple-organ system dysfunction and a significantly increased risk of mortality.…”

Acil serviste amilaz testlerinin kullanılması

“…Besides the pancreas, amylase is secreted from a variety of organs such as salivary glands, the liver, biliary ducts, the duodenum, the stomach, the esophagus, lungs, the heart, and fallopian tubes and is ectopically produced by many of the solid organs and hematological malignancies. Therefore, it is being reported that hyperamylasemia may also be detected in many extrapancreatic diseases such as mumps, parotitis, peptic ulcer perforation, perforated appendicitis, intestinal obstruction, mesenteric infarction, pulmonary embolism, pneumonia, myocardial infarction, malignancy, lymphoma and tubo-ovarian pathologies [5][6][7][8][9] . Besides the fact that amylase increases in such a variety of clinical conditions, increases related to medications are also described 10-12. However, the patient overcrowding and the inability to take adequate histories due to communication challenges in the emergency department have placed serum amylase levels among routine tests ordered in the emergency department to reduce the duration of stay under observation.…”