Acute liver injury and acute liver failure from mushroom poisoning in North America

Abstract Background & Aims Published estimates of survival associated with mushroom (amatoxin)‐induced acute liver failure ( ALF ) and injury ( ALI ) with and without liver transplant ( LT ) are highly variable. We aimed to determine the 21‐day survival associated with amatoxin‐induced ALI (A‐ ALI ) and ALF (A‐ ALF ) and review use of targeted therapies. Methods Cohort study of all A‐ ALI /A‐ ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014. Results Of the 2224 subjects in the registry, 18 (0.8%) had A‐ ALF ( n = 13) or A‐ ALI ( n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 m m , P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μ m ) and MELD scores (28 vs. 24) were similar ( P > 0.2 for all). Of the 13 patients with ALF , six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI , four (80%) recovered and one (20%) survived post‐ LT . Comparing those who died/received LT (non‐spontaneous survivors [ NSS ]) with spontaneous survivors ( SS ), N ‐acetylcysteine was used in nearly all patients ( NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently ( P > 0.15 for all therapies). Conclusion Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT . Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT .