Consultancy Corner: Drug induced liver injury is an important cause of Acute liver failure

The presence of jaundice alone doesn’t define acute liver failure; presence of jaundice followed by disorientation (encephalopathy) over a period defines ALF. Encephalopathy can start anytime between 2 days to 4 weeks from the onset of jaundice. Most of the time jaundice resolves on its own, thanks to the powerful regenerating capacity of the liver. 

Blood tests will show deranged liver function tests such as increased bilirubin, abnormal coagulation profile (elevated Prothrombin time), high liver enzymes and high ammonia. Due to liver failure, toxic substances (lactic acid) accumulates rapidly. Often the blood sugar is low due to the depletion of liver glycogen (storage form of sugar) in the liver. 

Drug induced liver injury is an important cause of ALF. Paracetamol overdose is the most common cause of ALF in some countries. Paracetamol intake of 8 grams per day can cause severe liver injury and more than 15 grams of paracetamol will cause liver failure. Unfortunately, even some antibiotics may cause ALF. We see increasing number of patients with ALF due to yellow phosphorous (rat killer) poison. In addition to the liver injury this toxin also damages heart, pancreas, bone marrow and kidney leading to life threatening complications. In our country, patients consume alternative medicines from unauthorised pharmacies / medical shops and these substances sometimes cause liver failure because most of these drugs get metabolised in the liver and often contain heavy metals. There are other rare conditions that causes ALF like auto-immune hepatitis, Wilson’s Disease and rarely, cancers can present itself as ALF, particularly lymphomas.

If it’s due to drug induced liver injury, patient may have had antibiotic or other drugs for medical condition, which may have resolved. These patients should immediately seek medical help without delay, because one cannot predict which patients may progress to ALF. 

The cause of ALF plays a role in prognosis like the patients with acute liver hepatitis may recover with medical treatment, whereas patients with ALF due to the drug induced liver injury may not recover with medical management, and may require liver transplantation.