title: Urgent Liver Transplantation for Dietary Supplements: An Under-Recognized Problem.
abstract: BACKGROUND
  The recent outbreak of acute liver failure caused by herbal/dietary supplements (HDS) in Hawaii prompted evaluation of those patients who underwent emergency liver transplantation (LT) for HDS in the United States.
  
  
  METHODS
  We queried the Scientific Registry of Transplant Recipients (2003-2015) to identify patients who underwent urgent LT for acute hepatic necrosis (AHN) and identified those with HDS use. This group of patients was then characterized.
  
  
  RESULTS
  Of 2408 adult cases, 625 were characterized as a drug-induced liver injury. The majority of cases (n = 300) were due to acetaminophen toxicity, but the fourth highest category was due to HDS (n = 21). Of these 21 cases caused by HDS, 13 did not list the specific agent responsible, mean age was 36 years, and all cases occurred after 2007. There probably are more cases because 25% of all LT cases in the study did not list a specific reason for liver failure and 20% of all drug-induced liver failure did not list a specific drug.
  
  
  CONCLUSIONS
  Herbal/supplement use is the fourth most common cause of drug-induced AHN requiring LT, albeit an underestimation of the problem. Detailed questioning of patients and their support systems regarding herbal/supplement use and better reporting are imperative to further define this problem and identify products that have the potential to lead to liver failure.
authors.affiliation: Department of Surgery, University of Hawaii, John A. Burns School of Medicine, Honolulu, Hawaii. Electronic address: hepatoma@aol.com.
authors.forename: L L
authors.initials: LL
authors.lastname: Wong
authors.affiliation: University of Hawaii, Honolulu, Hawaii.
authors.forename: L
authors.initials: L
authors.lastname: Lacar
authors.affiliation: Liver Center, Queens Medical Center, Honolulu, Hawaii.
authors.forename: M
authors.initials: M
authors.lastname: Roytman
authors.affiliation: Division of Abdominal Organ Transplantation/Hepatobiliary Surgery, Oregon Health and Sciences University, Portland VA Medical Center, Portland, Oregon.
authors.forename: S L
authors.initials: SL
authors.lastname: Orloff
mesh_terms: D000328:Adult; D000894:Anti-Inflammatory Agents, Non-Steroidal / Q000009:adverse effects; D056487:Chemical and Drug Induced Liver Injury, Chronic / Q000209:etiology / Q000601:surgery*; D019587:Dietary Supplements / Q000009:adverse effects*; D004638:Emergency Treatment; D005260:Female; D006801:Humans; D017114:Liver Failure, Acute / Q000139:chemically induced; D016031:Liver Transplantation / Q000379:methods*; D008297:Male; D008875:Middle Aged; D028321:Plant Preparations / Q000009:adverse effects*; D012042:Registries; D014481:United States; D055815:Young Adult
chemical_list: D000894:Anti-Inflammatory Agents, Non-Steroidal; D028321:Plant Preparations