Management of Acute Hepatotoxicity Including Medical Agents and Liver Support Systems

Successful Treatment with Ensartinib After Alectinib-induced Hyperbilirubinemia in ALK-Positive NSCLC

Background

Alectinib is approved for the treatment of advanced non-small-cell lung cancer (NSCLC) harboring ALK rearrangements. Although generally well tolerated, alectinib can cause serious or life-threatening side effects.

Case Presentation

Here, we report a case of a patient with NSCLC with an EML4-ALK fusion and was treated with alectinib but who developed grade 4 hyperbilirubinemia after five months on therapy. Alectinib was discontinued, and an artificial liver support system (ALSS) was used with an impressive decline in bilirubin levels. After two months drug-free, the patient experienced disease progression. Ensartinib was initiated as second-line treatment with a best response of stable disease after three months of therapy with no evidence of hyperbilirubinemia.

Conclusion

This is the first report of ensartinib treatment after alectinib-induced hyperbilirubinemia which was successfully relieved by ALSS treatment and targeted drug cessation.

Flucloxacillin-Induced Hepatotoxicity - Association with HLA-B*5701

Drug-induced liver injury (DILI) to flucloxacillin is rare and is classified as idiosyncratic, as it is dependent on individual susceptibility, unpredictable, and dose-independent. The authors present the case of a 74 - year - old man with a history of monoclonal gammopathy under investigation and alcoholic habits of 24 g/day, with asthenia, anorexia, nausea, abdominal discomfort, and fever with three days of evolution. He was treated with two courses of antibiotic therapy with flucloxacillin to erysipelas previously (3 months and 2 weeks before admission). Lab tests showed serum AST levels of 349 U/L, ALT 646 U/L, alkaline phosphatase 302 U/L, GGT 652 U/L, total bilirubin 3.3 mg/dL and direct bilirubin 2.72 mg/dL. Infectious, autoimmune, and metabolic causes were ruled out. Magnetic resonance cholangiopancreatography showed normal results. Liver biopsy showed mild multifocal (predominantly microvesicular) steatosis; marked changes in the centrilobular areas (sinusoidal dilatation, marked congestion, hemorrhage, and multifocal hepatocyte collapse); expansion of the portal areas with the formation of bridges; proliferated bile ducts and inflammatory infiltrate of variable density, predominantly mononuclear type. The HLA-B*5701 screening test was positive. Hepatic biochemical tests remain abnormal with a significative increase in total bilirubin, which reached levels of 24.1 mg/dL, with the development of jaundice, pruritus, and choluria. DILI was assumed, and the patient was treated with ursodeoxycholic acid. There was favorable evolution, without evidence of blood coagulation dysfunction or encephalopathy. The analytic normalization was, however, slow, with evolution to chronicity. The authors present this case to remind the possibility of moderate/severe drug-induced liver injury to flucloxacillin, an antibiotic commonly used in clinical practice and association with the HLA-B * 5701 allele reported in the literature.

International normalized ratio and Model for End-stage Liver Disease score predict short-term outcome in cirrhotic patients after the resolution of hepatic encephalopathy

BACKGROUND

In patients with cirrhosis, hepatic encephalopathy (HE) indicates a poor prognosis despite the use of artificial liver and liver transplantation, presenting as frequent hospitalizations and increased mortality rate.

AIM

To determine predictors of early readmission and mid-term mortality in cirrhotic patients discharged after the resolution of HE.

METHODS

From January to February 2018, 213 patients were enrolled in this observational study assessing all the successive patients with cirrhosis discharged from Department of Gastroenterology and Department of Infectious and Liver Diseases, Second Affiliated Hospital of Chongqing Medical University after the resolution of HE. The patients were followed for 6 mo. For each subject, demographic, clinical, and laboratory variables were assessed at the time of diagnosis of HE, during hospital stay, at discharge, and during follow-up. The primary endpoints were incidence of early readmission and mid-term mortality.

RESULTS

During follow-up, 65 (31%) patients experienced an early readmission. International normalized ratio (INR) [odds ratio (OR) = 2.40; P = 0.003) at discharge independently predicted early readmission. The incidence of early readmission was significantly higher in patients with an INR > 1.62 at discharge than in those with an INR ≤ 1.62 (44% vs 19%; P < 0.001). Model for End-stage Liver Disease (MELD) score (OR = 1.11; P = 0.048) at discharge proved to be an independent predictor of early readmission caused by HE. Hemoglobin (OR = 0.97; P = 0.005) at discharge proved to be an independent predictor of non-early readmission. During 6 months of follow-up, 34 (16%) patients died. Artificial liver use (hazard ratio = 6.67; P = 0.021) during the first hospitalization independently predicted mid-term mortality.

CONCLUSION

INR could be applied to identify fragile cirrhotic patients, MELD score could be used to predict early relapse of HE, and anemia is a potential target for preventing early readmission.

Nonacetaminophen Drug-Induced Acute Liver Failure

Acute liver failure of all causes is diagnosed in between 2000 and 2500 patients annually in the United States. Drug-induced acute liver failure is the leading cause of acute liver failure, accounting for more than 50% of cases. Nonacetaminophen drug injury represents 11% of all cases in the latest registry from the US Acute Liver Failure Study Group. Although rare, acute liver failure is clinically dramatic when it occurs, and requires a multidisciplinary approach to management. In contrast with acetaminophen-induced acute liver failure, non-acetaminophen-induced acute liver failure has a more ominous prognosis with a lower liver transplant-free survival.

Gastrointestinal Manifestations of Autoimmune Diseases Requiring Critical Care

Proper functioning within the gastrointestinal (GI) system is essential to immune integrity. Autoimmune diseases (ADs) can disrupt GI integrity and cause serious derangements of organ function. ADs exist on a continuum of mild to severe. Life-threatening presentations of ADs can lead to rapid clinical demise. Additionally, the medications used to control ADs can precipitate gastric bleeding and predispose patients to sepsis in critical care. AD treatment focuses on diminishing symptoms through reducing autoantibody production that leads to cytokine release. This article details common and rare presentations of acute ADs associated with GI manifestations in critically ill patients.