Plasma procalcitonin may be an early predictor of liver injury in acetaminophen poisoning: A prospective cohort study

Background and Aims

Acetaminophen is a common cause of poisoning and liver injury worldwide; however, patient stratification is suboptimal. We aimed to assess the contribution of admission plasma procalcitonin concentration (PCT) to better identify acetaminophen‐poisoned patients likely to develop liver injury.

Methods

We conducted a prospective observational cohort study including all acetaminophen‐poisoned patients requiring N‐acetylcysteine admitted in a toxicological intensive care unit between 2012 and 2017. Multivariate analysis was performed using a Cox regression model to investigate factors associated with liver injury, defined as an increase in alanine aminotransferase (ALT) >100 IU/L.

Results

One hundred seventeen patients (age, 32 years (21–53), median [25th–75th percentiles]) were included after self‐ingesting 16 g (9–30) acetaminophen and received N‐acetylcysteine infusion administered within a median 6 h‐delay (4–12) from exposure. Co‐ingestions were reported in 77% of patients. Rumack–Matthew nomogram was non‐interpretable in 47% cases. Liver injury occurred in 38 patients (32%) with a median peak ALT of 2020 IU/L (577–4248). In liver injury patients, admission PCT was significantly increased in comparison to patients without liver injury (21.5 ng/ml (3.2–44.9) versus 0.1 ng/ml (0–0.4), respectively, p < 0.01). The increase in PCT preceded the increase in ALT by 33 h (10–74). In a multivariate analysis, PCT > 1 ng/ml was significantly associated with liver injury (hazard ratio, 7.2 [95% confidence interval, 2.3–22.6; p < 0.001]). PCT (area under the receiver‐operating characteristics curve, 0.91 [95%CI: 0.84–0.97]) predicted liver injury with sensitivity, specificity, negative, and positive predictive values of 0.92, 0.84, 0.96, and 0.73, respectively.

Conclusion

PCT on admission is associated with liver injury in acetaminophen poisoning. PCT might be used as a predictive tool of liver injury to improve clinical decision‐making.

Undue Elevation of Procalcitonin in Pediatric Paracetamol Intoxication is Not Explained by Liver Cell Injury Alone

INTRODUCTION AND AIM

Procalcitonin is widely used as a biomarker to distinguish bacterial infections from other etiologies of systemic inflammation. Little is known about its value in acute liver injury resulting from intoxication with paracetamol.

MATERIAL AND METHODS

We performed a single-center retrospective analysis of the procalcitonin level, liver synthesis, liver cell damage and renal function of patients admitted with paracetamol-induced liver injury to a tertiary care children's hospital. Children with acute liver failure due to other reasons without a bacterial or fungal infection served as the control group. Twelve patients with acute paracetamol intoxication and acute liver injury were compared with 29 patients with acute liver failure.

RESULTS

The procalcitonin levels were higher in children with paracetamol intoxication than in patients with acute liver failure without paracetamol intoxication (median 24.8 (0.01-55.57) ng/mL vs. 1.36 (0.1-44.18) ng/mL; p &lt; 0.005), although their liver and kidney functions were better and the liver cell injury was similar in both groups. Outcome analysis showed a trend towards better survival without transplantation in patients with paracetamol intoxication (10/12 vs. 15/29). Within each group, procalcitonin was significantly correlated with alanine aminotransferase and aspartate aminotransferase but was not correlated with the International Normalized Ratio or paracetamol blood levels in the paracetamol group. In conclusion, paracetamol intoxication leads to a marked increase in procalcitonin serum levels, which are significantly higher than those seen in acute liver failure.

CONCLUSION

The underlying mechanism is neither caused by infection nor fully explained by liver cell death alone and remains to be determined.