S2739 Successful Use of Plasmapheresis in Concurrent Fulminant Acute Fatty Liver of Pregnancy and COVID-19 Infection

Abstract

Introduction: Acute fatty liver of pregnancy (AFLP) is a rare condition characterized by maternal liver dysfunction and/or failure during the third trimester or early postpartum period, thought to be caused by defects in fatty acid metabolism during pregnancy. Management includes prompt delivery and supportive care. In the following case, we describe a patient found to have fulminant liver failure after delivery but was unable to undergo liver transplantation due to Coronavirus Disease 2019 (COVID-19) infection. Fortunately, with plasmapheresis, the patient recovered from both fulminant liver failure and COVID-19. Case Description/Methods: A 26-year-old female 38 weeks pregnant with recent diagnosis of COVID-19 infection presented with 3 days of nausea, vomiting, abdominal pain, and polydipsia. Due to non-reassuring fetal heart rate tracings, emergency cesarean section was performed. On post-partum day one, she was noted to be somnolent and jaundiced. Laboratory testing revealed a leukocytosis of 17,800, platelets 168,000, creatinine 3.95 mg/dL, glucose 26 mg/dL, uric acid 8.4 mg/dL, total bilirubin 8.5 mg/dL, AST 234 U/L, ALT 224 U/L, ALP 466 U/L, PT 57.3 s, and ammonia 69 µmol/L. A chest x-ray showed bibasilar opacities; abdominal ultrasound revealed a mildly fatty liver and ascites. Viral, autoimmune hepatitis, hemochromatosis, alpha-1 antitrypsin deficiency, and Wilson’s serologies were unremarkable. Thirteen Swansea criteria were met, thus a diagnosis of AFLP was made. Liver transplantation was initially considered but was high risk due to active COVID-19 infection resulting in respiratory failure requiring intubation. After multidisciplinary discussion, she was started on plasmapheresis. After 6 days of plasmapheresis, liver and renal function improved. She was discharged home on post-partum day 19. Discussion: In the above case, we describe a patient with COVID-19 infection with fulminant liver failure from AFLP. The patient needed a liver transplant due to rapidly worsening liver function. However, due to limited data on the safety of liver transplantation in active COVID-19 infection, it was deemed high-risk. Fortunately, the patient’s condition improved with plasmapheresis, and liver transplant was not needed. Plasmapheresis removes toxins, ammonia, and inflammatory cytokines while replacing coagulation factors, albumin, and biologically active substances that are typically produced by liver cells. The therapy has also been reported to be an effective salvage treatment for severe cases of COVID-19.