Abstract
Acute liver failure is a rare, life-threatening illness accounting for about 7% of all liver-related deaths. Patients with acute liver failure are managed with supportive care initially, and if supportive care fails, liver transplantation is the definitive option for eligible candidates in liver failure. N-acetyl cysteine (NAC) has a well-established role in acetaminophen-induced liver failure and has been reported to reduce mortality in these patients. It has also been reported to provide benefit in non-acetaminophen-induced liver failure secondary to infection, drugs, and toxins. Here we report an interesting case of NAC use in an elderly patient with shock liver secondary to severe sepsis in whom liver transplantation was not an option.
Highlights
N-acetyl cysteine (NAC) is the acetylated form of the amino acid L- cysteine
Some case reports and studies have described the use of NAC in alcoholic hepatitis, infective hepatitis, and contrast-induced nephropathy, but knowledge of its effects and relevant treatment guidelines for shock liver secondary to severe sepsis are limited
The patient was started on an IV Cardizem drip, IV fluids and a 72-hour IV NAC protocol in addition to antibiotics. His blood pressure (BP) and lactic acidosis improved over a 48-hour period with fluids and antibiotics, and his heart rate (HR) improved and was well controlled
Summary
N-acetyl cysteine (NAC) is the acetylated form of the amino acid L- cysteine. Its role in acetaminopheninduced liver failure has been well established, and the use of NAC in non-acetaminophen-induced liver failure has been reported, relatively few randomized trials and prospective studies have been published [1,2,3]. His liver enzymes were elevated at aspartate aminotransferase (AST) 1,216, alanine aminotransferase (ALT) 736, lactic acid 9.4, and international normalized ratio (INR) = 1.93. His BP and lactic acidosis improved over a 48-hour period with fluids and antibiotics, and his HR improved and was well controlled His liver enzymes trended downwards: AST 5,028 > 2,445 > 1,515 > 730 > 54 and ALT 2,328 > 2,359 > 2,278 > 1,790 > 217 over 72 hour period. His acetaminophen levels were below 5, the hepatitis panel was negative, urine drug screen was negative, and ultrasound of the abdomen and computed tomography (CT) of the abdomen and pelvis were normal. The patient’s mental status improved over the 48-72 hour period, his vitals stabilized, and he was transferred to a step-down unit and eventually discharged on PO antibiotics with outpatient follow-up
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