title: Acute liver injury and acute liver failure from mushroom poisoning in North America.
abstract: 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.
  
  
  
  Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014.
  
  
  
  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 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) 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).
  
  
  
  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.
authors.affiliation: Divisions of Hepatology and Critical Care Medicine, University of Alberta, Edmonton, AB, Canada.
authors.forename: Constantine J
authors.identifier: 0000-0002-1555-1089
authors.initials: CJ
authors.lastname: Karvellas
authors.affiliation: Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA.
authors.forename: Holly
authors.initials: H
authors.lastname: Tillman
authors.affiliation: Division of Endocrinology and Metabolism, University of Calgary, Calgary, AB, Canada.
authors.forename: Alexander A
authors.initials: AA
authors.lastname: Leung
authors.affiliation: Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA.
authors.forename: William M
authors.initials: WM
authors.lastname: Lee
authors.affiliation: Division of Digestive Diseases and Transplant and Immunology, Yale University School of Medicine, New Haven, CT, USA.
authors.forename: Michael L
authors.initials: ML
authors.lastname: Schilsky
authors.affiliation: Division of Gastroenterology and Hepatology, University of California San Francisco, San Francisco, CA, USA.
authors.forename: Bilal
authors.initials: B
authors.lastname: Hameed
authors.affiliation: Division of Gastroenterology and Hepatology, Virginia Commonwealth University, Richmond, VA, USA.
authors.forename: R Todd
authors.initials: RT
authors.lastname: Stravitz
authors.affiliation: Division of Gastroenterology and Hepatology, University of Alabama, Birmingham, AL, USA.
authors.forename: Brendan M
authors.initials: BM
authors.lastname: McGuire
authors.affiliation: Organ Transplant Program, Swedish Medical Center, Seattle, WA, USA.
authors.forename: Oren K
authors.initials: OK
authors.lastname: Fix
mesh_terms: D000111:Acetylcysteine / Q000627:therapeutic use; D000328:Adult; D000546:Amanitins / Q000633:toxicity*; D056486:Chemical and Drug Induced Liver Injury / Q000209:etiology* / Q000628:therapy; D015331:Cohort Studies; D005260:Female; D006801:Humans; D017114:Liver Failure, Acute / Q000209:etiology* / Q000401:mortality / Q000628:therapy; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009145:Mushroom Poisoning / Q000453:epidemiology* / Q000628:therapy; D009656:North America / Q000453:epidemiology; D010406:Penicillins / Q000627:therapeutic use; D012042:Registries; D000077385:Silybin; D012838:Silymarin / Q000627:therapeutic use
chemical_list: D000546:Amanitins; D010406:Penicillins; D012838:Silymarin; D000077385:Silybin; C018207:amatoxin; D000111:Acetylcysteine
keywords: Amanita phalloides; acute liver failure; acute liver injury; fulminant hepatic failure; liver transplantation; mushroom toxicity