title: A maxed-out liver: a case of acute-on-chronic liver failure.
abstract: A 51-year-old man from Puerto Rico with Child-Turcotte-Pugh Class C decompensated cirrhosis due to genotype 1a chronic hepatitis C was referred for worsening jaundice and diuretic-resistant ascites. He began experiencing symptoms of hepatic decompensation 5 months prior to referral with new-onset ascites and spontaneous bacterial peritonitis, evolving into diuretic-resistant ascites, increasing jaundice, and a MELD increase from 12 to 29. During his hospitalization, his MELD score increased to >40 from a rapidly increasing international normalized ratio (INR) and evolving type 1 hepatorenal syndrome. Clinically, the patient appeared quite well despite such a high MELD score. After an extensive pretransplant evaluation and exclusion of infection, he underwent successful orthotopic liver transplantation. After histologic examination of the explanted liver, he subsequently admitted to 5 months of daily use of a detoxifying supplement known as MaxOne (®), containing  D-ribose- L-cysteine, consistent with a drug-induced acute-on-chronic liver failure. The use of complementary and alternative medicines and its potential for causing drug-induced liver injury and acute-on chronic liver failure requires a high index of suspicion and increased awareness among health care providers.
authors.affiliation: Division of Liver Diseases, The Mount Sinai Medical Center, One Gustave L. Levy Place, New York, NY 10029, USA.
authors.forename: Gene Y
authors.initials: GY
authors.lastname: Im
authors.forename: Sofia
authors.initials: S
authors.lastname: Kazi
authors.forename: Swan N
authors.initials: SN
authors.lastname: Thung
authors.forename: Ponni V
authors.initials: PV
authors.lastname: Perumalswami
mesh_terms: D056486:Chemical and Drug Induced Liver Injury / Q000150:complications*; D003545:Cysteine / Q000009:adverse effects / Q000031:analogs & derivatives; D003937:Diagnosis, Differential; D058625:End Stage Liver Disease / Q000150:complications*; D016174:Hepacivirus; D019698:Hepatitis C, Chronic / Q000209:etiology*; D006530:Hepatorenal Syndrome / Q000150:complications; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications*; D017114:Liver Failure, Acute / Q000139:chemically induced / Q000150:complications* / Q000175:diagnosis; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D053778:Thiazolidines / Q000009:adverse effects
chemical_list: D053778:Thiazolidines; C070066:2-(1',2',3',4'-tetrahydroxybutyl)thiazolidine-4-carboxylic acid; D003545:Cysteine