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Kelgeri C, Kanthimathinathan HK, Couper M, Alnagar A, Biradar V, Sharif K, Hartley J, Mirza D, Gupte GL. Aetiology, Characteristics and Outcomes of Neonatal Liver Failure: lessons learned over the last 3 decades. J Pediatr 2024:114245. [PMID: 39151605 DOI: 10.1016/j.jpeds.2024.114245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 08/07/2024] [Accepted: 08/12/2024] [Indexed: 08/19/2024]
Abstract
OBJECTIVE To evaluate trends in etiology and outcomes of neonatal liver failure (NLF) over 30 years retrospectively at a single institution. STUDY DESIGN Inclusion criteria for this retrospective cohort study were babies presenting at a chronological age of ≤ 28 days between 1991 and 2020 with prothrombin time (PT) ≥ 20 seconds and biochemical liver injury. Demographics, etiology, laboratory investigations, need for extrahepatic organ support, acute kidney injury (AKI), and intervention with liver transplant (LT) were recorded. Survival outcomes were measured as discharge from the hospital alive with native liver or LT. The study period was stratified into three 10-year blocks. Trends were analyzed for hospital admissions, etiology, and survival outcomes. RESULTS 126 babies met the NLF criteria. Admissions to the hospital increased from 21 in 1991-2000 to 65 in 2011-2020. An increasing trend in infectious and metabolic causes, while a decreasing trend in indeterminate etiology, was noted. Survival with native liver improved from 23.8% in 1991-2000 to 55.4% in 2011-20 (p=0.021), and mortality reduced from 52.4 % to 35.4% during the same periods (p=0.213). Twenty-three (18.2 %) neonates received LT. Post-LT survival outcomes were 100% for gestational alloimmune liver disease (GALD), 66.6 % in the indeterminate group, and 25% for herpes simplex virus (HSV). Specific etiologies (GALD, OR=0.07 [0-0.77, p=0.048]), presence of acute kidney injury (OR= 6.22 [1.45, 29.38, p=0.015]) and need for inotropes (OR=6.22 [1.45, 29.38, p=0.028}) influenced mortality in multivariable logistic regression analysis. CONCLUSION In the last 30 years, advances in diagnosis, treatment, and increasing experience with LT have improved survival in NLF.
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Affiliation(s)
- Chayarani Kelgeri
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK.
| | | | - Michael Couper
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
| | - Amr Alnagar
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
| | | | - Khalid Sharif
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
| | - Jane Hartley
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
| | - Darius Mirza
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
| | - Girish L Gupte
- Liver Unit including small bowel transplant, Birmingham Women's and Children's Hospital, UK
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McDougall G, Murphy NG, Loubani O. N-Acetylcysteine treatment of neonatal acetaminophen toxicity caused by transplacental transfer - a case report. Clin Toxicol (Phila) 2021; 59:840-842. [PMID: 33527858 DOI: 10.1080/15563650.2021.1874405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
We describe a case of maternal acetaminophen toxicity leading to Caesarean section delivery of a pre-term neonate with acetaminophen-induced hepatic injury and encephalopathy at 33 weeks gestational age. Delayed treatment with N-acetylcysteine (NAC) was initiated in the baby 11 h after delivery, with eventual discharge of a healthy baby at 12 days of age. The baby was treated with a standard but extended duration NAC protocol. Post-operatively, liver biopsy of the mother demonstrated acetaminophen-induced hepatic injury overlying mild hepatic steatosis. This was also managed with NAC therapy leading to complete clinical resolution of acetaminophen induced hepatic injury and discharge on post-operative day 10. This case of delayed NAC therapy for the treatment of pre-term neonatal acetaminophen toxicity is one of very few reported in the literature and can be used as a guide in the management of subsequent cases.
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Affiliation(s)
| | - Nancy G Murphy
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada.,IWK Regional Poison Centre, Halifax, Canada
| | - Osama Loubani
- Department of Emergency Medicine, Dalhousie University, Halifax, Canada.,Department of Critical Care, Dalhousie University, Halifax, Canada
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Locci C, Cuzzolin L, Capobianco G, Antonucci R. Paracetamol overdose in the newborn and infant: a life-threatening event. Eur J Clin Pharmacol 2021; 77:809-815. [PMID: 33388821 DOI: 10.1007/s00228-020-03077-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 12/23/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Paracetamol is the only drug recommended to treat fever in neonates. At recommended doses, paracetamol has not been associated with liver injury in neonates, while hepatotoxicity may occur after intake of a single high dose or multiple excessive doses. The aim of this narrative review is to critically analyze and summarize the available literature on newborns and infants exposed to supratherapeutic doses of paracetamol, with special focus on their clinical features, outcome, and management. METHODS The PubMed, SCOPUS, and Google Scholar search engines were used to collect data, without time limitation. The following keywords were used: paracetamol/acetaminophen, overdose, hepatotoxicity, N-acetylcysteine, newborn, infant. RESULTS The literature search identified a total of 27 case reports, a number of review articles, and few other relevant publications. Neonatal poisoning from paracetamol resulted from transplacental drug transfer after maternal overdose in some published cases, while it was the consequence of medication errors in other cases. Newborns and infants who have received a single overdose and have paracetamol concentrations below the Rumack-Matthew nomogram limits are at low risk of serious hepatic damage, while those who have recently ingested more than one supratherapeutic dose of paracetamol should be managed with caution. The treatment of choice for paracetamol poisoning is N-acetylcysteine, a specific antidote which reduces paracetamol hepatotoxic effects. N-Acetylcysteine should be given according to specific regimens through weight-based dosing tables. CONCLUSIONS Caution should be used when paracetamol is administered to the newborn. In the event of an overdose, careful patient monitoring and personalization of post-overdose procedures are recommended.
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Affiliation(s)
- Cristian Locci
- Pediatric Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Laura Cuzzolin
- Department of Diagnostics & Public Health-Section of Pharmacology, University of Verona, Verona, Italy
| | - Giampiero Capobianco
- Gynecologic and Obstetric Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy
| | - Roberto Antonucci
- Pediatric Clinic, Department of Medical, Surgical and Experimental Sciences, University of Sassari, Sassari, Italy.
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Cuzzolin L, Bardanzellu F, Fanos V. The dark side of ibuprofen in the treatment of patent ductus arteriosus: could paracetamol be the solution? Expert Opin Drug Metab Toxicol 2018; 14:855-868. [PMID: 29938546 DOI: 10.1080/17425255.2018.1492550] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Patent ductus arteriosus (PDA) persistence is associated, in prematures, to several complications. The optimal PDA management is still under debate, especially regarding the best therapeutic approach and the time to treat. The available drugs are not exempt from contraindications and side effects; ibuprofen itself, although representing the first-choice therapy, can show nephrotoxicity and other complications. Paracetamol seems a valid alternative to classic nonsteroidal anti-inflammatory Drugs, with a lower toxicity. Areas covered: Through an analysis of the published literature on ibuprofen and paracetamol effects in preterm neonates, this review compares the available treatments for PDA, analyzing the mechanisms underlining ibuprofen-associated nephrotoxicity and the eventual paracetamol-induced hepatic damage, also providing an update of what has been yet demonstrated and a clear description of the still open issues. Expert Opinion: Paracetamol is an acceptable alternative in case of contraindication to ibuprofen; its toxicity, in this setting, is very low. Lower doses may be effective, with even fewer risks. In the future, paracetamol could represent an efficacious first-line therapy, although its safety, optimal dosage, and global impact have to be fully clarified through long-term trials, also in the perspective of an individualized and person-based therapy taking into account the extraordinary individual variability.
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Affiliation(s)
- Laura Cuzzolin
- a Department of Diagnostics & Public Health-Section of Pharmacology , University of Verona , Verona , Italy
| | - Flamina Bardanzellu
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
| | - Vassilios Fanos
- b Neonatal Intensive Care Unit, Neonatal Pathology and Neonatal Section , AOU and University of Cagliari , Cagliari , Italy
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Hemadsorption with Adult CytoSorb® in a Low Weight Pediatric Case. Case Rep Crit Care 2017; 2017:6987167. [PMID: 28127473 PMCID: PMC5239828 DOI: 10.1155/2017/6987167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2016] [Accepted: 11/28/2016] [Indexed: 12/30/2022] Open
Abstract
Cytokine adsorber (CytoSorb) has been used successfully as adjunctive treatment for adult patients with elevated cytokine levels in the setting with severe sepsis and septic shock and to reduce blood myoglobin, unconjugated bilirubin, and conjugated bilirubin. In this article we present the case of a nine-month-old male infant who was admitted to the NICU due to sepsis after cardiac surgery, Fallot tetralogy, and multisystem organ failure (MSOF) including liver failure and renal failure which was successfully treated by a combination of continuous hemodiafiltration (HDF) and hemadsorption with CytoSorb. HDF was safe and effective from the first day for urea removal, but the patient's bilirubin levels kept increasing gradually, culminating on the 9th day with a maximum value of 54 mg/dL of total bilirubin and 31.67 mg/dL of direct bilirubin when we performed hemadsorption with CytoSorb. Over the 49-hour period of hemadsorption, the total bilirubin value decreased from 54 to 14 mg/dL, and the patient's general status improved considerably accompanied by a rapid drop of aminotransferases. Hemodynamic status has been improved as well and inotropes dropped rapidly. The patient's ventilation settings improved during CytoSorb treatment permitting weaning the patient from mechanical ventilation after five days of hemadsorption. The patient was discharged home after 34 days of hospitalization, in a good general status.
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Bucaretchi F, Fernandes CB, Branco MM, De Capitani EM, Hyslop S, Caldas JPS, Moreno CA, Porta G. Acute liver failure in a term neonate after repeated paracetamol administration. ACTA ACUST UNITED AC 2015; 32:144-8. [PMID: 24676202 PMCID: PMC4183003 DOI: 10.1590/s0103-05822014000100021] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Accepted: 05/19/2013] [Indexed: 12/30/2022]
Abstract
Objective: Severe hepatotoxicity caused by paracetamol is rare in neonates. We report a case
of paracetamol-induced acute liver failure in a term neonate. Case description: A 26-day-old boy was admitted with intestinal bleeding, shock signs, slight liver
enlargement, coagulopathy, metabolic acidosis (pH=7.21; bicarbonate: 7.1mEq/L),
hypoglycemia (18mg/dL), increased serum aminotransferase activity (AST=4,039IU/L;
ALT=1,087IU/L) and hyperbilirubinemia (total: 9.57mg/dL; direct: 6.18mg/dL) after
receiving oral paracetamol (10mg/kg/dose every 4 hours) for three consecutive days
(total dose around 180mg/kg; serum concentration 36-48 hours after the last dose
of 77µg/ mL). Apart from supportive measures, the patient was successfully treated
with intravenous N-acetylcysteine infusion during 11 consecutive days, and was
discharged on day 34. The follow-up revealed full recovery of clinical and of
laboratory findings of hepatic function. Comments: The paracetamol pharmacokinetics and pharmacodynamics in neonates and infants
differ substantially from those in older children and adults. Despite the reduced
rates of metabolism by the P-450 CYP2E1 enzyme system and the increased ability to
synthesize glutathione - which provides greater resistance after overdoses -, it
is possible to produce hepatotoxic metabolites (N-acetyl-p-benzoquinone) that
cause hepatocellular damage, if glutathione sources are depleted. Paracetamol
clearance is reduced and the half-life of elimination is prolonged. Therefore, a
particular dosing regimen should be followed due to the toxicity risk of
cumulative doses. This report highlights the risk for severe hepatotoxicity in
neonates after paracetamol multiple doses for more than two to three days.
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Affiliation(s)
- Fábio Bucaretchi
- Departamento de Pediatria, Faculdade de Ciencias Medicas, Unicamp, Campinas, SP, Brasil
| | - Carla Borrasca Fernandes
- Centro de Controle de Intoxicacoes, Faculdade de Ciencias Medicas, Unicamp, Campinas, SP, Brasil
| | - Maíra Migliari Branco
- Centro de Controle de Intoxicacoes, Faculdade de Ciencias Medicas, Unicamp, Campinas, SP, Brasil
| | | | - Stephen Hyslop
- Departamento de Farmacologia, Faculdade de Ciencias Medicas, Unicamp, Campinas, SP, Brasil
| | - Jamil Pedro S Caldas
- Unidade de Terapia Intensiva Neonatal, Hospital da Mulher Professor Doutor Jose Aristodemo Pinotti, Unicamp, Campinas, SP, Brasil
| | | | - Gilda Porta
- Departamento de Pediatria, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brasil
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Shanmugam NP, Bansal S, Greenough A, Verma A, Dhawan A. Neonatal liver failure: aetiologies and management--state of the art. Eur J Pediatr 2011; 170:573-81. [PMID: 20886352 DOI: 10.1007/s00431-010-1309-1] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2010] [Accepted: 09/15/2010] [Indexed: 12/19/2022]
Abstract
Acute liver failure in neonates is rare, but carries a high mortality. Neonatal liver failure can be defined as "failure of the synthetic function of liver within 4 weeks of birth". Encephalopathy is not essential for the diagnosis. Acute liver failure in neonates differs from children with regard to aetiology and outcome. Common causes of neonatal liver failure are neonatal hemochromatosis, haematological malignancies, viral infections and liver-based metabolic defects. Early diagnosis and referral to a paediatric liver centre is recommended as liver transplantation is the only definitive treatment when supportive or a disease-specific treatment fails.
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Affiliation(s)
- Naresh P Shanmugam
- Paediatric Liver, GI & Nutrition Centre, King's College Hospital, London, UK
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Casaní-Martínez C, Morales-Suárez-Varela M. Accidents in neonatal period. J Perinat Med 2002; 29:450. [PMID: 11723848 DOI: 10.1515/jpm.2001.063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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