title: Unrecognized acetaminophen toxicity as a cause of indeterminate acute liver failure.
abstract: Despite extensive investigations, the cause of liver injury in 14% of patients with acute liver failure remains unknown (indeterminate). In a pilot study using a novel assay, highly specific acetaminophen-cysteine adducts were detected in 7 of 36 indeterminate patients (19%). To extend these observations, sera from 110 subjects enrolled in the Acute Liver Failure Study Group registry with indeterminate acute liver failure were analyzed with a similar but more efficient and sensitive adduct assay. As positive controls, another 199 patients with known or presumed acetaminophen-induced liver failure were assessed for the presence and quantity of adducts. Clinical, laboratory, and outcome data were compared for the two groups. On the basis of previous data for known therapeutic exposures and acetaminophen overdoses, an adduct concentration ≥1.0 nmol/mL of serum indicated a definite acetaminophen overdose. Among the 110 indeterminate cases, 18% had assay values ≥1.0 with a median level of 9.2 nmol/mL; 94.5% of the positive controls (known acetaminophen cases) had values ≥1.0 nmol/mL. Regardless of the initial diagnosis, subjects with elevated adduct levels demonstrated the clinical profile and hyperacute biochemical injury pattern associated with acetaminophen overdose: a predominance of female gender, very high aminotransferase levels, and low bilirubin levels.
  
  
  CONCLUSIONS
  These data confirm and extend previous observations regarding the high (18%) prevalence of unrecognized or uncertain acetaminophen toxicity among subjects with indeterminate acute liver failure. N-Acetylcysteine use was limited in this group, presumably because of the lack of a specific diagnosis of acetaminophen toxicity.
authors.affiliation: Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390-8887, USA.
authors.forename: Niraj
authors.initials: N
authors.lastname: Khandelwal
authors.forename: Laura P
authors.initials: LP
authors.lastname: James
authors.forename: Corron
authors.initials: C
authors.lastname: Sanders
authors.forename: Anne M
authors.initials: AM
authors.lastname: Larson
authors.forename: William M
authors.initials: WM
authors.lastname: Lee
mesh_terms: D000082:Acetaminophen / Q000009:adverse effects*; D000111:Acetylcysteine / Q000627:therapeutic use; D000328:Adult; D018712:Analgesics, Non-Narcotic / Q000009:adverse effects*; D001663:Bilirubin / Q000097:blood; D056486:Chemical and Drug Induced Liver Injury / Q000097:blood / Q000175:diagnosis* / Q000188:drug therapy; D062787:Drug Overdose; D005260:Female; D016166:Free Radical Scavengers / Q000627:therapeutic use; D006801:Humans; D017114:Liver Failure, Acute / Q000097:blood / Q000139:chemically induced* / Q000175:diagnosis*; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D015996:Survival Rate; D000637:Transaminases / Q000097:blood
chemical_list: D018712:Analgesics, Non-Narcotic; D016166:Free Radical Scavengers; D000082:Acetaminophen; D000637:Transaminases; D001663:Bilirubin; D000111:Acetylcysteine