A prospective study of N-acetylcysteine treatment in drug-induced fulminant hepatic failure

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, complex, multisystemic gastroenterological emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. To date, there is no established treatment for DI-ALF other than liver transplantation and little is known about the use of N-acetylcysteine (NAC) in DI-ALF. A prospective case-control study was carried with the aim to determine the effect of NAC on mortality of DI-FHF patients and also to evaluate the safety and efficacy of NAC use.Methods: A total of 18 patients with a diagnosis of DI-FHF were included in the study. 10 patients received NAC infusion for 72 hours whereas the control group received placebo. The variables evaluated were demographic, signs and symptoms, biochemical parameters, outcome and length of hospital stay.Results: Out of 18 DI-FHF patients, 13 (72.2%) had anti-tuberculosis therapy (ATT) induced FHF and 5 (27.8%) patients had ayurvedic induced FHF. The two groups were comparable for the various baseline characteristics (age, INR, alanine aminotransferase, creatinine, albumin, grade of encephalopathy, etc.). The mortality decreased to 20% with the use of NAC versus 75% in the control group (P=0.023). Use of NAC was associated with a shorter length of hospital stay of survived patients (P=0.043). Moreover, the overall survival was improved by NAC (P=0.023) in DI-FHF. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF use (P=0.019).Conclusions: Author recommended the use of NAC along with conventional treatments in patients with DI-FHF in non-transplant centers while awaiting referrals. ATT induced FHF showed better outcome as compared to ayurvedic induced FHF with NAC administration and its use was safe.

Comparison of cardiac autonomic response in different ABO blood groups of young adults

Background: ABO blood group has been associated with various disease phenotypes, particularly cardiovascular disease. Abnormal autonomic response also plays a role in cardiac morbidity. Increasing attention is being focused on the role of autonomic nervous system in health and disease. The literature lacks data on the association of blood groups and cardiac autonomic function. The aim of the study was to find out the association between different blood groups and cardiovascular autonomic functions in young adults.Methods: 150 healthy young students of MMU aged 18-25 years, divided into four groups based on ABO blood grouping, determined by agglutination test (group A, group B, group O and group AB). Various autonomic function tests done were lying to standing test, Valsalva maneuver, Hand grip test (HGT) and Cold pressor test (CPT).Results: The mean baseline heart rate was significantly higher in group O as compared to group A. No parasympathetic alteration between different ABO blood groups was seen. Blood pressure response to HGT and CPT was not statistically significant between different blood groups.Conclusions: Present study revealed no alteration in cardiac autonomic function with regards to ABO blood grouping in young adults.

Etiological profile and clinical characteristics in fulminant hepatic failure in North India

Background: Acute liver failure (ALF) is a rare but severe, life-threatening, multisystemic medical emergency. ALF of duration <8 weeks in a patient is considered as fulminant hepatic failure (FHF). Its rapid progression and high mortality demand early diagnosis and expert management. Clinical and etiological profile varies with geographical area and time. The objective of this prospective study was to determine the clinical characteristics and etiological profile of FHF.Methods: A total of eighty consecutive patients with a diagnosis of FHF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters (bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.) and etiological profile.Results: Most of the patients were <35 years of age and males. Viral hepatitis 35 (43.8%) was the most common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Among viral causes, acute hepatitis E was most common followed by hepatitis B and A. Drug or toxic induced liver failure (18.8%) also contributed a significant proportion of cases. The three groups (viral, drug-induced and indeterminate) were comparable for the various baseline characteristics (bilirubin, alanine aminotransferase, INR, creatinine, albumin, grade of encephalopathy, MELD score etc.).Conclusions: Like the rest of India, viral hepatitis was the common cause of FHF but the majority of the patients 25 (31.2%) had undetermined etiology. Our study highlights the differences in the profile of FHF from other earlier studies in India and the west. Each different etiology leads to a similar final common pathway. Trying to determine etiology is essential, however, as outcomes and the use of antidotes depend on the identification of the causative process.

Clinical features, laboratory characteristics and outcome of patients with drug-induced acute liver failure

Background: Acute liver failure (ALF) is a rare medical emergency. Its rapid progression and high mortality demand early diagnosis and expert management. Drug-induced ALF (DI-ALF) remains the uncommon cause of ALF in India. Clinical and etiological profile varies with geographical area and time. A prospective study of DI-ALF was carried with the aim to determine the clinical features, laboratory characteristics, outcome and hospital course.Methods: A total of 15 patients with a diagnosis of DI-ALF were included in the study. The variables evaluated were demographic, signs and symptoms, biochemical parameters [bilirubin, alanine aminotransferase (ALT), aspartate aminotransferase (AST), prothrombin time (PT), internal normalization ratio (INR) etc.], outcome and course during hospitalization.Results: Out of 15 DI-ALF patients, 12 had Anti-tuberculosis therapy (ATT) induced ALF and 3 patients had ayurvedic induced ALF. Majority of the patients were females (73.3%) and middle-aged (42.60±14.30 years). Coma grade at the time of admission showed that majority of patients (66.8%) had grade I and II encephalopathy. Depending on the pattern of liver injury, hepatocellular pattern was most common (53.3%) followed by mixed and cholestatic pattern. 40% of patients died with DI-ALF complications of which ATT induced ALF contributed 41.7%. Mean AST was more increased as compared to ALT. Development of ascites (P = 0.030) and mannitol use (P = 0.025) was significantly more common in non survived group than survived group. Length of hospital stay was significantly more in non survived group than survived group (P = 0.009).Conclusions: ATT was the class of drugs most frequently associated with DI-ALF. DI-ALF disproportionately affected middle-aged women. Most DILI ALF patients had hepatocellular injury pattern. 40% of patients died with DI-ALF complications. Development of ascites, mannitol use and length of hospital stay was significantly more in non survived group than survived group.