Amanita Phalloides Intoxication Research Articles

α-amanitin induces autophagy through AMPK-mTOR-ULK1 signaling pathway in hepatocytes

Amanitin poisoning is one of the most life-threatening mushroom poisonings. α-Amanitin plays a key role in Amanita phalloides intoxication. α-Amanitin shows toxic effects on the liver. However, the mechanism by which α-amanitin induces liver injury has not been elucidated. Autophagy plays a crucial role in maintaining cellular homeostasis and is closely related to the occurrence of a variety of diseases. Studies have shown that autophagy may play an important role in the process of α-amanitin-induced liver injury. However, the mechanism of α-amanitin-induced autophagy remains unclear. Thus, this study aimed to explore the mechanisms of α-amanitin in inducing hepatotoxicity in Sprague Dawley (SD) rats and the normal human liver cell line L02 cells. The SD rats and L02 cells exposed to α-amanitin were observed to determine whether α-amanitin could induce the autophagy of rat liver and L02 cells. The regulatory relationship between autophagy and the AMPK-mTOR-ULK pathway by exposing the autophagy agonist (rapamycin (RAPA)), autophagy inhibitor (3-methylademine (3-MA)), and AMPK inhibitor (compound C) was also explored. Autophagy-related proteins and AMPK-mTOR-ULK pathway-related proteins were detected using Western blot. The results of the study indicated that exposure to different concentrations of α-amanitin led to morphological changes in liver cells and significantly elevated levels of ALT and AST in the serum of SD rats. Additionally, the expression levels of LC3-II, Beclin-1, ATG5, ATG7, AMPK, p-AMPK, mTOR, p-mTOR, and ULK1 were significantly increased in the rat liver. And we found that L02 cells exposed to 0.5 μM α-amanitin for 6 h significantly induced autophagy and activated the AMPK-mTOR-ULK1 pathway. Pretreated with RAPA, 3-MA, and compound C for 1 h, the expression levels of autophagy-related proteins and AMPK-mTOR-ULK pathway-related proteins significantly changed. Our results indicates that autophagy and the AMPK-mTOR-ULK pathway are involved in the process of α-amanitin-induced liver injury. This study may foster the identification of actionable therapeutic targets for A. phalloides intoxication.

CT Volumetry Can Be Used for Monitoring Liver Function Recovery in Auxiliary Partial Orthotopic Liver Transplantation.

Scintigraphy with a 99m TC-trimethyl-Br-IDA tracer (TBIDA) is used to monitor liver function regeneration after auxiliary partial orthotopic liver transplantation (APOLT) for acute liver failure (ALF). As computed tomography (CT) is also regularly performed during patient follow-up, CT volumetry could be used as an alternative to monitor native liver recovery after APOLT for ALF. This was a retrospective cohort study of all patients who underwent APOLT (October 2006-July 2019). Collected data included liver graft and native liver CT volumetry measurements (expressed as fractions), TBIDA scintigraphy results, and biological and clinical data including immunosuppression therapy after APOLT. Four follow-up time points were defined (baseline, discontinuation of mycophenolate mofetil, beginning of tacrolimus reduction, and tacrolimus discontinuation) for analysis. Twenty-four patients (7 men; median age 28.5 y old) were included. The main etiologies of ALF were acetaminophen intoxication (n = 12), hepatitis B virus (n = 5), and amanita phalloides intoxication (n = 3). The median native liver function fractions on scintigraphy at baseline, at discontinuation of mycophenolate mofetil, at tacrolimus reduction, and at tacrolimus discontinuation were 22.0% (interquartile range 14.0-30.8), 30.5% (21.5-49.0), 32.0% (28.0-62.0), and 93.0% (77.0-100.0), respectively. The corresponding median native liver volume fractions on CT were 12.8% (10.4-17.3), 20.5% (14.2-27.3), 24.7% (21.3-48.4), and 77.9% (62.5-96.9), respectively. Volume and function were strongly correlated (r = 0.918; 95% confidence interval, 0.878-0.945; P < 0.01). Median time-to-immunosuppression discontinuation was 25.0 (17.0-35.0) mo. Estimated time-to-immunosuppression discontinuation was shorter in patients with acetaminophen-induced ALF (22 versus 35 mo; P = 0.035). In patients who receive APOLT for ALF, CT-based liver volumetry closely parallels native liver function recovery evaluated on TBIDA scintigraphy.

Gene expression profiles for apoptotic and necrotic pathways during Amanita phalloides intoxication in mice

Background and Aims: Amanita phalloides is the deadliest toxic mushroom in the world and causes death from acute liver failure. α-amanitin (α-AMA), the most potent toxin, inhibits RNA polymerase II in hepatocytes, stops protein synthesis, and causes hepatotoxicity. However, the information about the mechanisms underlying hepatotoxicity caused by α-AMA is quite inadequate. This study aims to reveal the complex necrotic and apoptotic mechanisms occurring in mouse hepatocytes depending on A. phalloides exposure time in vivo. Methods: BALB-c male mice were divided into 5 groups (n=7): control, α-AMA-2, α-AMA-12, α-AMA-72, and α-AMA-96 groups. A poisoning model was created by oral administration of A. phalloides mushroom extract containing 10 mg/kg of α-AMA to mice and they were sacrificed after 2, 12, 72, and 96 h. Then, TNF-α, Bax, caspase-3, and Bcl-2 gene expression levels in liver tissues were examined by the RT-qPCR method. Time-dependent damage to liver tissues was also evaluated histopathologically. Results: RT-qPCR results showed that proinflammatory cytokine TNF-α mRNA expression levels increased in mouse liver tissues at 2 and 12 h after A. phalloides administration compared among the groups. Bax mRNA expression levels increased in the 12 and 72 h after A. phalloides ingestion. It was observed that caspase-3 mRNA expression levels increased in the 72 and 96 h groups compared among the groups, while Bcl-2 mRNA expression levels decreased in the 72 and 96 h groups. Conclusion: Our findings showed that necrotic mechanisms develop in the early period after A. phalloides mushroom poisoning, and then apoptotic mechanisms are effective. In conclusion, understanding the mechanisms of A. phalloides-induced hepatotoxicity will provide important information for new treatment strategies to be developed.

Role of Silymarin in Cancer Treatment: Facts, Hypotheses, and Questions.

The flavonoid silymarin extracted from the seeds of Sylibum marianum is a mixture of 6 flavolignan isomers. The 3 more important isomers are silybin (or silibinin), silydianin, and silychristin. Silybin is functionally the most active of these compounds. This group of flavonoids has been extensively studied and they have been used as hepato-protective substances for the mushroom Amanita phalloides intoxication and mainly chronic liver diseases such as alcoholic cirrhosis and nonalcoholic fatty liver. Hepatitis C progression is not, or slightly, modified by silymarin. Recently, it has also been proposed for SARS COVID-19 infection therapy. The biochemical and molecular mechanisms of action of these substances in cancer are subjects of ongoing research. Paradoxically, many of its identified actions such as antioxidant, promoter of ribosomal synthesis, and mitochondrial membrane stabilization, may seem protumoral at first sight, however, silymarin compounds have clear anticancer effects. Some of them are: decreasing migration through multiple targeting, decreasing hypoxia inducible factor-1α expression, inducing apoptosis in some malignant cells, and inhibiting promitotic signaling among others. Interestingly, the antitumoral activity of silymarin compounds is limited to malignant cells while the nonmalignant cells seem not to be affected. Furthermore, there is a long history of silymarin use in human diseases without toxicity after prolonged administration. The ample distribution and easy accessibility to milk thistle—the source of silymarin compounds, its over the counter availability, the fact that it is a weed, some controversial issues regarding bioavailability, and being a nutraceutical rather than a drug, has somehow led medical professionals to view its anticancer effects with skepticism. This is a fundamental reason why it never achieved bedside status in cancer treatment. However, in spite of all the antitumoral effects, silymarin actually has dual effects and in some cases such as pancreatic cancer it can promote stemness. This review deals with recent investigations to elucidate the molecular actions of this flavonoid in cancer, and to consider the possibility of repurposing it. Particular attention is dedicated to silymarin's dual role in cancer and to some controversies of its real effectiveness.

Silymarin Dehydroflavonolignans Chelate Zinc and Partially Inhibit Alcohol Dehydrogenase

Silymarin is known for its hepatoprotective effects. Although there is solid evidence for its protective effects against Amanita phalloides intoxication, only inconclusive data are available for alcoholic liver damage. Since silymarin flavonolignans have metal-chelating activity, we hypothesized that silymarin may influence alcoholic liver damage by inhibiting zinc-containing alcohol dehydrogenase (ADH). Therefore, we tested the zinc-chelating activity of pure silymarin flavonolignans and their effect on yeast and equine ADH. The most active compounds were also tested on bovine glutamate dehydrogenase, an enzyme blocked by zinc ions. Of the six flavonolignans tested, only 2,3-dehydroderivatives (2,3-dehydrosilybin and 2,3-dehydrosilychristin) significantly chelated zinc ions. Their effect on yeast ADH was modest but stronger than that of the clinically used ADH inhibitor fomepizole. In contrast, fomepizole strongly blocked mammalian (equine) ADH. 2,3-Dehydrosilybin at low micromolar concentrations also partially inhibited this enzyme. These results were confirmed by in silico docking of active dehydroflavonolignans with equine ADH. Glutamate dehydrogenase activity was decreased by zinc ions in a concentration-dependent manner, and this inhibition was abolished by a standard zinc chelating agent. In contrast, 2,3-dehydroflavonolignans blocked the enzyme both in the absence and presence of zinc ions. Therefore, 2,3-dehydrosilybin might have a biologically relevant inhibitory effect on ADH and glutamate dehydrogenase.

Toxic Effects of Amanitins: Repurposing Toxicities toward New Therapeutics.

The consumption of mushrooms has become increasingly popular, partly due to their nutritional and medicinal properties. This has increased the risk of confusion during picking, and thus of intoxication. In France, about 1300 cases of intoxication are observed each year, with deaths being mostly attributed to Amanita phalloides poisoning. Among amatoxins, α- and β-amanitins are the most widely studied toxins. Hepatotoxicity is the hallmark of these compounds, leading to hepatocellular failure within three days of ingestion. The toxic mechanisms of action mainly include RNA polymerase II inhibition and oxidative stress generation, leading to hepatic cell apoptosis or necrosis depending on the doses ingested. Currently, there is no international consensus concerning Amanita phalloides poisoning management. However, antidotes with antioxidant properties remain the most effective therapeutics to date suggesting the predominant role of oxidative stress in the pathophysiology. The partially elucidated mechanisms of action may reveal a suitable target for the development of an antidote. The aim of this review is to present an overview of the knowledge on amanitins, including the latest advances that could allow the proposal of new innovative and effective therapeutics.

Amanita Phalloides intoxication - methods of treatment and epidemiology in Lublin voivodeship in last 5 years

Amanita Phalloides intoxication - methods of treatment and epidemiology in Lublin voivodeship in last 5 years

Acute Liver Failure due to Amanita phalloides Poisoning: Therapeutic Approach and Outcome

IntroductionAmanita phalloides poisoning is a potentially fatal cause of acute liver failure. The aim of this study was to analyze the impact of initial patients' characteristics and different treatment modalities on the outcome of patients with liver failure caused by Amanita poisoning. Material and methodsWe retrospectively evaluated 23 patients admitted to our center between July 2007 and August 2016. ResultsMean time interval between Amanita phalloides ingestion and the onset of gastrointestinal symptoms was 12.48 ± 9.88 hours and the interval between ingestion and hospital admission 26.26 ± 15.14 hours. The treatment was intiated by oral decontamination using activated charcoal followed by intravenous rehydration and high doses of intravenous N-acetylcysteine and silibinin. Fourteen patients (61%) underwent extracorporeal elimination method. Ten patients had plasmapheresis, 1 patient had hemoperfusion, and 5 patients had fractionated plasma separation and adsorption. Seven patients who met King's College Criteria were listed for urgent liver transplantation; one of them died before transplantation. Six patients underwent liver transplantation; the mean waiting time was 6.5 ± 12.0 days (range, 1–31 days). One patient died 2 months afterward. All 16 patients who did not meet King's College Criteria and received conservative treatment survived. ConclusionOur results documented a good prognostic value of standard King's College Criteria for indication of urgent liver transplantation in acute liver failure caused by Amanita phalloides poisoning. Fractionated plasma separation and adsorption may contribute to low mortality on the waiting list. Intensive care and extracorporeal elimination methods seem to be crucial points of the conservative treatment.

Mushroom poisoning: a retrospective study concerning 11-years of admissions in a Swiss Emergency Department.

Wild mushroom intoxication is an unusual cause of toxic ingestion in Europe. A great diversity of clinical symptoms may arise depending on the variety of wild mushrooms ingested. These initial symptoms are often non-specific, with frequent gastrointestinal symptoms, and have no direct correlation with the outcome. Therefore, management of mushroom poisoning and risk evaluation are a challenge for emergency clinicians. We retrospectively reviewed all cases of mushroom poisoning identified in the ED database spanning 11years. Demographic and clinical data, time from consumption to symptoms, type of mushrooms, the number of patients presenting at the same time, treatment(s) provided, length of stay, discharge diagnosis, in-hospital mortality, and serious complications were evaluated. We identify 87 cases of mushroom poisoning. The most common symptoms are nausea and vomiting (71 cases, 82%), followed by diarrhea (68%), syncope (10%), abdominal pain (8%), and hallucinations (7%). Sixty-four patients (74%) exhibited early symptoms (appearance <6h after ingestion) and 23 (26%) late symptoms (appearance >6h after ingestion). Eleven patients (13%) required hospitalization over 24h. Patients with late symptoms tended to have longer in-hospital lengths of stay. Only one patient had Amanita phalloides intoxication, with a favorable outcome. Thirty-eight patients (44%) were involved in cluster presentations. Mushroom poisoning is an unusual but potentially severe form of intoxication. Patients presenting with late-appearing symptoms (>6h) are associated with a higher risk of A. phalloides intoxication, and therefore require specific investigation and management.

Effectiveness of Fractionated Plasma Separation and Absorption as a Treatment for Amanita Phalloides Poisoning.

BACKGROUND Fractionated plasma separation and absorption (FPSA) is an extracorporeal liver support method that detoxifies accumulated toxins. There are limited data of its use in the treatment of Amanita phalloides intoxication. The objective of this study was to investigate whether FPSA before liver transplantation improves patients' short-term post liver transplantation survival in Amanita phalloides poisoning. MATERIAL AND METHODS The study population consisted of ten patients who had liver transplantation (LT) due to acute liver failure (ALF) caused by Amanita phalloides poisoning. Six patients were treated with FPSA before liver transplantation. All the patients who were started on FPSA were also placed on the liver transplantation list according to emergent liver transplantation criteria. RESULTS Patients treated with FPSA were in a more severe clinical condition presenting in higher mean MELD, total bilirubin, INR and ammonia along with more frequent hypoglycemia and hepatic encephalopathy grade 3/4. FPSA group had longer mean waiting time on the recipient list (3.5 vs. 1.25 days) but inferior thirty-day survival rate (16.5% vs. 100%). CONCLUSIONS When conservative medical modalities are ineffective, the only treatment for Amanita phalloides poisoning is a liver transplant. Although FPSA treated patients had inferior post-LT survival, FPSA was found to prolong the pre surgical waiting time for critically ill patients, consequently giving a chance of life-saving procedure.

Results of liver transplantation in patients with acute liver failure due to Amanita phalloides and paracetamol (acetaminophen) intoxication.

IntroductionAmanita phalloides and paracetamol intoxications are responsible for the majority of acute liver failures.AimTo assess survival outcomes and to analyse risk factors affecting survival in the studied group.Material and methodsOf 1369 liver transplantations performed in the Department of General, Transplant, and Liver Surgery, Medical University of Warsaw before December 2013, 20 (1.46%) patients with Amanita phalloides (n = 13, 0.95%) and paracetamol (n = 7, 0.51%) intoxication were selected for this retrospective study. Overall and graft survival at 5 years were set as primary outcome measures.ResultsFive-year overall survival after liver transplantation in the studied group was 53.57% and 53.85% in patients with paracetamol and Amanita phalloides poisoning, respectively (p = 0.816). Five-year graft survival was 26.79% for patients with paracetamol and 38.46% with Amanita phalloides intoxication (p = 0.737). Risk factors affecting patient survival were: pre-transplant bilirubin concentration (p = 0.023) and higher number of red blood cells (p = 0.013) and fresh frozen plasma (p = 0.004) transfused intraoperatively. Likewise, higher number of red blood cells (p = 0.012) and fresh frozen plasma (p = 0.007) transfused were risk factors affecting 5-year graft survival. Surprisingly, donor and recipient blood type incompatibility was neither the risk factor for 5-year overall survival (p = 0.939) nor the risk factor for 5-year graft survival (p = 0.189).ConclusionsIn selected intoxicated patients urgent liver transplantation is the only successful modality of treatment. Risk factors affecting survival are in correspondence with the patient's pre-transplant status (bilirubin level in serum) and intraoperative status (number of red blood cells and fresh frozen plasma transfused).

Acute liver failure caused by mushroom poisoning: a case report and review of the literature

It is estimated that there are over 5,000 species of mushrooms worldwide. Some of them are edible and some are poisonous due to containing significant toxins. In more than 95% of mushroom toxicity cases, poisoning occurs as a result of misidentification of the mushroom by an amateur mushroom hunter. The severity of mushroom poisoning may vary, depending on the geographic location where the mushroom is grown, growth conditions, the amount of toxin delivered, and the genetic characteristics of the mushroom. Amanita phalloides is the most common and fatal cause of mushroom poisoning. This mushroom contains amanitins, which are powerful hepatotoxins that inhibit RNA polymerase II in liver. Mushroom poisoning is a relatively rare cause of acute liver failure. A 63-year-old male patient was admitted to the emergency room with weakness, nausea, vomiting, and diarrhea. He reported ingesting several wild mushrooms about 36 hours earlier. In this article we report a case of lethal Amanita phalloides intoxication from stored mushrooms.

Successful outcome of severe Amanita phalloides poisoning in children

Amanita phalloides intoxication can lead to FHF with high mortality, especially in children. There is still ongoing discussion about the optimal treatment and decision criteria for emergency liver transplantation (LTx). Here, we summarize our experience with outcomes in five children. Five children with severe A.phalloides intoxication were treated at our tertiary center from 1995 to 2010 and studied retrospectively with respect to clinical and laboratory aspects that might help to decide between LTx or conservative therapy only. The findings are discussed with regard to recommended treatment and transplantation criteria for adults. All patients survived, of whom two of five received emergency LTx. Three patients survived with conservative treatment consisting of intravenous silibinin, NAC, detoxification measures, and intensive care. Indications for LTx in two children were progressive brain edema and cardiovascular failure. Children with FHF due to A.phalloides intoxication should be considered early for emergency LTx but should be monitored closely for the necessity of definite LTx. Early detoxification with active charcoal as well as silibinin and NAC seems to improve the outcome. Late recovery of liver function after day 4 post-ingestion is possible.

The Effects of N-acetylcysteine in Patients with Amanita phalloides Intoxication

Objectives: Mushroom intoxication with Amanita phalloides has a high incidence throughout the world. Treatment for this intoxication is similar in different centers, but N-acetylcysteine is rarely used. In this study, we aimed to investigate the effects of N-acetylcysteine treatment in patients with Amanita phalloides intoxication. Methods: A total of 40 patients with Amanita phalloides intoxication were included in this retrospective study. The study group consisted of 24 patients who were administered N-acetylcysteine in addition to the standard regimen; the control group consisted of 16 patients who were treated only with the standard treatment. Treatment results and biochemical measurements of groups were compared. Results: According to the biochemical measurements, it was found that patients in the control group were affected more seriously by Amanita phalloides than those in the study group. The mortality rate was lower in the study group (4.4% vs. 18.7% in the control group). Conclusions: Amanita phalloides intoxication can be successfully treated with N-acetylcysteine in addition to the standard regimen. Significantly, the simplicity of administration, good tolerance, and an affordable cost make N-acetylcysteine a viable option for the treatment of Amanita phalloides intoxication. The low mortality rate presented in the study group may be ascribed to N-acetylcysteine administration.

Acute Liver Failure Caused by Amanita phalloides Poisoning.

Mushroom poisoning is a relatively rare cause of acute liver failure (ALF). The present paper analyzes the pathogenesis, clinical features, prognostic indicators, and therapeutic strategies of ALF secondary to ingestion of Amanita phalloides, which represents the most common and deadly cause of mushroom poisoning. Liver damage from Amanita phalloides is related to the amanitins, powerful toxins that inhibit RNA polymerase II resulting in a deficient protein synthesis and cell necrosis. After an asymptomatic lag phase, the clinical picture is characterized by gastrointestinal symptoms, followed by the liver and kidney involvement. Amatoxin poisoning may progress into ALF and eventually death if liver transplantation is not performed. The mortality rate after Amanita phalloides poisoning ranges from 10 to 20%. The management of amatoxin poisoning consists of preliminary medical care, supportive measures, detoxification therapies, and orthotopic liver transplantation. The clinical efficacy of any modality of treatment is difficult to demonstrate since randomized, controlled clinical trials have not been reported. The use of extracorporeal liver assist devices as well as auxiliary liver transplantation may represent additional therapeutic options.

Results of Treatment of Acute Liver Failure Patients With Use of the Prometheus FPSA System

Objective Herein we have presented the results of treatment of acute liver failure (ALF) patients with the use of the Prometheus FPSA dialysis system. Materials and Methods To January 2009, we performed 278 FPSA procedures in 114 patients, including 52 experience and ALF. The patients who underwent the FPSA procedure consisted of 32 women and 20 men of overall mean age of 33 ± 12 years. The causes of ALF were: Wilson's disease (n = 15), unknown origin ALF (n = 11), amanita phalloides intoxication (n = 7), paracetamol intoxication (n = 8), acute hepatitis B virus (HBV)/hepatitis C virus (HCV) infection (n = 7), liver insufficiency after parenchymal resection (n = 2) drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome (n = 1), rabdomyolysis (n = 1), or primary nonfunction (PNF) after orthotopic liver transplantation (OLT) (n = 1). All procedures were performed using the Prometheus 4008H Fresenius Medical Care liver support system. The average number of treatments per patient was 2.41 and the average time for each FPSA treatment was 6.3 hours. The average heparin dose used during the procedure was 750 IU/h. Results After the whole treatment regimen, we observed significant improvements in the biochemical results. The average concentrations improved: serum ammonia (before 249.2 μg/dL versus after 109.7 μg/dL); serum bilirubin (before 21.53 mg/dL versus after 8.81 mg/dL), serum aspartate aminotransferase (AST; before 2456.4 U/L versus after 1068.8 U/L); serum alanine aminotransferase (ALT; before 2958.2 U/L versus after 1595.8 U/L); serum urea (before 58.5 mg/dL versus after 21.1 mg/dL); serum creatinine (before 2.9 mg/dL versus after 1.7 mg/dL); and pH value (before 7.11 versus after 7.32). After Prometheus treatment OLT was performed in 33 patients. Among the 28 who survived (53.8%), 22 underwent OLT and 6 did not have OLT. Among the 24 patients who died (46.2%), 13 were before OLT and 11 after OLT. Conclusion The Prometheus 4008H Fresenius Medical Care Liver support system was useful method of detoxification for patients with ALF, serving as an element of pretransplantation care.

Fetal Risk through MaternalAmanita phalloidesPoisoning at the End of Pregnancy

There is a paucity of knowledge about prenatal and perinatal risks through maternal amatoxin poisoning. No symptoms of amatoxin intoxication, except for a slight temporary increase in liver enzymes activity, occurred in a term newborn after delivery despite an Amanita phalloides intoxication of the mother 2 days before. Considering previous reports, severe fetal intoxication may not occur during the entire pregnancy.

Liver transplantation represents the optimal treatment for fulminant hepatic failure from amanita phalloides poisoning

Amanita phalloides (AP) mushrooms poisoning is a rare but serious occurrence. The main causes of this intoxication are the amatoxines, which inhibit DNA-dependent RNA polymerase II or B. The typical liver and kidney alterations of AP poisoning, consisting of massive hepatic central lobular cell necrosis and acute tubular necrosis of the kidney, are well known [1]. Recognizing the phalloides syndrome allows the institution of effective treatment to avoid possibly fatal complications. The overall prognosis for patients with fulminant hepatic failure (FHF) is poor without transplantation, with survival rates usually reported between 10% and 30% [2]. Medical treatment can prevent complications such as infections and cerebral oedema, which are the most common causes of death. Therapeutic options employed to treat mushroom intoxication include: haemodiaperfusion on activate charcoal, high dosages of penicillin G, oral charcoal, Molecular Adsorbent Recycling System (MARS) and N-acetyl cysteine infusion. When all of them fail, liver transplantation (LT) is the only option [3].When liver dysfunction occurs, transferring the patients to a liver transplant center is crucial to identify appropriate candidates for emergency LT. Indications for LT primarily include medically untreatable and markedly prolonged prothrombin time (PTT), and a constellation of findings such a metabolic acidosis, hypoglycaemia, hypofibrinogenemia and increased serum ammonia, following high serum aminotransferase levels [4]. Between May 1986 and October 2005, 515 LT procedures were performed at our Institution in Genoa. Of these, 32 adult patients underwent first LT to treat FHF. The indication for emergency LT was made according to Kings’ College Hospital criteria [5]. During the same period, 21 patients with acute AP poisoning were treated in our dedicated intensive care unit. Six of them developed irreversible signs of poisoning, FHF and were transplanted. Fifteen patients were successfully managed without LT by intensive care medical treatment with N-acetyl cysteine infusion and high dosages of penicillin G. Furthermore, among these, three of them required MARS and two haemodiaperfusion on activate charcoal. In all these patients, the amatoxines serum level was below the lethal concentration (LC) [6]. Six LT patients had an amatoxines serum level above the LC and therefore their outcome should have been fatal without LT. The findings and course of this series of patients, which is the largest reported, was analysed and prognostic criteria defined on the basis of this experience and available data. The prognosis of these six transplanted patients was assessed by monitoring liver function tests (PTT, INR, V factor, AT III, total and split bilirubin, transaminases, WBC and platelet count, serum ammonia, blood and urinary alpha-amanitin, ascites output) plus serum creatinine level as renal failure from amatoxines is often described. AP poisoning differs from other causes of acute liver failure in several respects. The following criteria suggests how to identify a lethal from a non-lethal course: PTT <20% over the course of several days, serum creatinine concentration >1.5 mg%– raising despite careful adjustment of water and electrolyte abnormalities, serum bilirubin >5 mg %, also progressive encephalopathy and or coma indicate a lethal course [5]. In our series of transplanted patients a PTT value <20% (range: 3–17%) was observed, conversely, PTT time value >20% (range: 23–41%) was found in patients successfully treated with a conservative medical approach. The whole group of transplanted patients survived. Medium follow-up is 52 months (range: 3–122 months). LT is the procedure of choice for the treatment of acute AP poisoning complicated by FHF. The identification of correct inclusion criteria for a lethal prognosis under conservative treatment is a key point. This should be taken into account when poisoned patients are to be transferred to a transplant centre for appropriate treatment. In conclusion, based on our series of patients, we believe that the key of success is represented by many factors, including immediate organ availability for LT and careful selection of patients eligible for emergency transplantation.

LIVER TRANSPLANTATION FOR FULMINANT HEPATIC FAILURE: EXPERIENCE WITH 40 ADULT PATIENTS OVER A 17 YEAR PERIOD

P577 Aims: The overall prognosis for patients with FHF is quite poor without transplantation, with survival rates usually reported between 10% and 30% in relation with the type of clinical presentation. Aim of this study is to evaluate the influence of pretransplant recipient and donor prognostic factors on graft-patient survival. Methods: From April 1986 to June 2003, 796 LT were performed in 696 patients. In the same period, 40 (5,7%) adult patients underwent to first liver transplantation for FHF. The mean age was 32 years (range 17-60); 45% of recipients were male and 55% were female. The coma’s grade was defined by Glasgow Coma Score (GCS) scale. Among the pretransplant recipients variables we analyzed: age, gender, type of FHF, aetiology, time list to LT, Glasgow Coma Score, prothrombin time, AST, ALT, total bilirubin, serum-creatinine, era of transplant, packed red blood cells (PRBC), ischemic period, total operation time, type of surgical procedure (with or without veno-venous by-pass). The following pretransplant donor variables were analyzed too: age, gender, cause of death, ICU stay, ABO match, type of perfusion solution. We used preoperative supportive therapies as bridge to LT by a Bio Artificial Liver (BAL) with porcine cells in one case and by Extra Corporeal Artificial Device with human hepatocytes in another one. The mean patient follow-up time was 41.6 months (range 0-178 months). Results: The indication for transplantation was hyperacute-FHF in 25 cases (62.5%), acute-FHF in 14 (35%), and subacute hepatic failure in one (2.5%). In 52,5%, the aetiology of FHF was virus B infection (21 patients). The other indications were: Amanita Phalloides intoxication in 5 cases, Wilson’s disease in 2, Budd-Chiari Syndrome in one and paracetamol intoxication in another one, in 10 cases (25%) the origin remained unknown. Pre-transplant GCS was <5 in 22 patients (55%) and ≥5 in 18 patients (45%). By far the majority of patients (24/40; 60%) the waiting list time was <48h, while in the remaining 16 patients (40%) it was ≥48h. An identical or compatible graft was used in 87,5% of recipients, while in 12,5% (5/40) a incompatible graft was transplanted. The overall graft survival was 48.3%, 41.1% and 41.1% at 1, 3 and 5 years, respectively, whereas patient survival was 61.3%, 54.6% and 50.4% at 1, 3 and 5 years, respectively. None of the donor parameters analyzed had a significant impact on graft and patient survival. The only recipient variable which had a statistically significant impact on graft survival resulted the waiting list to transplant <48 hours (p=0.05). The overall patient survival resulted slightly influenced by the mean AST level > 1043 U/l, as well as by the mean total operation time >533 minutes. In the incompatible group 4 out of 5 patients lost the graft for acute rejection (3 cases) and PNF (1 case). Conclusions: Liver transplantation remains the better treatment for fulminant hepatic failure. Based on our results the prognostic factors influencing the graft survival is represented by short waiting list time to LT less than 48 hours. Further studies are need to validate extracorporeal support system with either porcine liver cells or non utilized human hepatocytes as a bridge to transplantation.

Plasmapheresis in the treatment of Amanita phalloides poisoning: II. A review and recommendations.

Amanita phalloides poisoning is the most common cause of lethal mushroom poisoning (lethality >20% in adults, >50% in children). However, there is no standard treatment strategy and no antidote against the ensuing hepatic failure. This review of 14 investigations published over the last 20 years shows that the introduction of detoxification techniques, in particular the use of plasmapheresis, in combination with supportive therapy to prevent the absorption of aminitine toxins into blood, produced a substantial reduction in mortality. The main complications in using these techniques include infections and coagulation disorders. Because of the latency period in the development of symptoms, treatment should begin on the first suspicion that an intoxication is present. The best therapeutic results can be expected when the detoxification techniques are applied in combination with conservative therapies within the first 36--48 h. Using this approach, mortality rates in some recent studies have been below 10%.