Prolonged Anhepatic State After Rescue Hepatectomy of a Transplanted Liver

Abstract

Introduction: Lamotrigine is an antiepileptic drug that has been associated with hepatocellular injury and only a few cases of fulminant hepatic failure. We present a rare case of Lamotrigine-induced liver failure requiring liver transplantation, which was complicated by severe acute rejection and recurrent liver failure requiring a complete hepatectomy with a 29-hour anhepatic course before undergoing a second transplant. Case: A 44 year-old female with a history of gastroparesis, Meniere's disease, migraines, depression, anxiety, chronic back pain, and alcohol abuse presented as a transfer from an outside hospital for altered mental status and presumed severe alcoholic hepatitis. Labs revealed AST and ALT elevated to 1271 and 1379 respectively, total bilirubin of 11.6, PT of 23.8, ammonia of 100, and otherwise normal serum chemistries. She was initially treated with prednisolone. Due to concerns for acute liver failure, she underwent liver biopsy which showed active hepatitis with extensive parenchymal necrosis consistent with drug-induced liver injury. After further investigation, it appeared that patient was taking Lamotrigine for a mood disorder and possibly migraines. Transplant surgery was quickly consulted and patient received an orthotopic liver transplant. Within one week, her transaminases and lactic acid began to rise and abdominal distention worsened. Given recurrent acute liver failure and abdominal compartment syndrome, hepatectomy with portocaval anastomosis was performed. Intraoperatively, the liver appeared ischemic and explant pathology showed evidence of acute humoral-mediated rejection with extensive necrosis. Fulminant hepatic failure protocol activated and she remained anhepatic for about 29 hours until receiving a re-transplantation. She eventually recovered after an extended hospital stay and was discharged to a skilled nursing facility. Discussion: Prolonged anhepatic states after hepatectomy are associated with poor clinical outcomes with an increased risk of multiple organ failure, metabolic disturbances, and accumulation of toxic metabolites. Oftentimes, a temporary portocaval shunt is used as bridge therapy to re-transplantation as in our case. There are limited reports of anhepatic patients, with 67 hours being one of the longest reported durations. Our case demonstrates the rare instance of a successful rescue hepatectomy leaving our patient anhepatic for greater than a day.