Is MARS system enough for A. phalloides-induced liver failure treatment?

Amanitin intoxication: effects of therapies on clinical outcomes - a review of 40 years of reported cases

BACKGROUND AND AIMS

Amanita phalloides poisoning causes severe liver damage which may be potentially fatal. Several treatments are available, but their effectiveness has not been systematically evaluated. We performed a systematic review to investigate the effect of the most commonly used therapies: N-acetylcysteine (NAC), benzylpenicillin (PEN), and silibinin (SIL) on patient outcomes. In addition, other factors contributing to patient outcomes are identified.

METHODS

We searched MEDLINE and Embase for case series and case reports that described patient outcomes after poisoning with amanitin-containing Amanita mushrooms. We extracted clinical characteristics, treatment details, and outcomes. We used the liver item from the Poisoning Severity Score (PSS) to categorize intoxication severity.

RESULTS

We included 131 publications describing a total of 877 unique cases. The overall survival rate of all patients was 84%. Patients receiving only supportive care had a survival rate of 59%. The use of SIL or PEN was associated with a 90% (OR 6.40 [3.14-13.04]) and 89% (OR 5.24 [2.87-9.56]) survival rate, respectively. NAC/SIL combination therapy was associated with 85% survival rate (OR 3.85 [2.04, 7.25]). NAC/PEN/SIL treatment group had a survival rate of 76% (OR 2.11 [1.25, 3.57]). Due to the limited number of cases, the use of NAC alone could not be evaluated. Additional analyses in 'proven cases' (amanitin detected), 'probable cases' (mushroom identified by mycologist), and 'possible cases' (neither amanitin detected nor mushroom identified) showed comparable results, but the results did not reach statistical significance. Transplantation-free survivors had significantly lower peak values of aspartate aminotransferase (AST), alanine aminotransferase (ALT), total serum bilirubin (TSB), and international normalized ratio (INR) compared to liver transplantation survivors and patients with fatal outcomes. Higher peak PSS was associated with increased mortality.

CONCLUSION

Based on data available, no statistical differences could be observed for the effects of NAC, PEN or SIL in proven poisonings with amanitin-containing mushrooms. However, monotherapy with SIL or PEN and combination therapy with NAC/SIL appear to be associated with higher survival rates compared to supportive care alone. AST, ALT, TSB, and INR values are possible predictors of potentially fatal outcomes.

[Acute intoxications in the intensive care unit: A 10-year analysis]

BACKGROUND

Acute intoxications play a special role in preclinical emergency medicine, in the emergency department, and in intensive care. This study characterizes cases of acute intoxications from an intensive care perspective.

OBJECTIVES

All cases of acute intoxications admitted to the intensive care units at the University Hospital Hamburg-Eppendorf between 01 January 2007 and 30 June 2017 were retrospectively analyzed.

RESULTS

During the study period, 587 patients with acute intoxications were admitted to the university hospital's intensive care units. Median age was 45 years (interquartile range [IQR] 31 years); 83.1% of patients were younger than 70 years. The most common cause of intoxication in the younger patients was a suicide attempt (55.1%), while in older patients it was an iatrogenic event (47.5%). Cases involving intoxications with psychotropic medication (48.7%), alcohol (32.9%), analgesics (23.3%), and drugs (17.0%) were most frequent. In 50.6% of cases, intoxication was due to more than one substance. Intoxication-specific therapy was performed in 40.0% of cases and intensive care therapy in 42.4% of cases. The median length of intensive care unit stay was 2 days (IQR 3). Hospital mortality was 5.5%. In older patients (≥ 70 years) compared with younger patients, the need for intensive care treatment (56.6% vs. 39.5% of cases, p = 0.002), the length of intensive care unit stay (3 days [IQR 5] vs. 2 days [IQR 3], p = 0.0004) and in-hospital mortality (17.2% vs. 3.1%, p < 0.001) were significantly higher.

CONCLUSIONS

Acute intoxications are part of the spectrum of disorders treated in the intensive care unit. In older patients, iatrogenic causes are frequently found, which is associated with an increased risk of death.

Medium Cut-Off Membrane Can Be a New Treatment Tool in Amanita phalloides Poisoning

Mushroom poisoning is a common health problem that can be seen seasonally and geographically. Most mushroom poisoning requiring treatment worldwide is due to Amanita phalloides. Although liver failure and kidney injury are frequent, poisoning can also lead to more serious clinical situations, such as shock, pancreatitis, encephalopathic coma, cardiac failure, disseminated intravascular coagulation, and multiple organ dysfunction syndrome, and may cause death. In addition, when standard treatment approaches fail, extracorporeal treatment methods are often used. We report 2 cases in which hemodialysis with medium cut-off membrane was performed. We observed an improvement in liver and kidney function in both of our cases. The first case recovered, but the second case proved fatal owing to Acinetobacter sepsis, despite an improvement in renal function. Medium cut-off membrane hemodialysis may be an alternative option in the treatment of Amanita phalloides poisoning.

Diagnosis of acute intoxications in critically ill patients: focus on biomarkers - part 2: markers for specific intoxications

In medical intensive care units, acute intoxications contribute to a large proportion of all patients. Epidemiology and a basic overview on this topic were presented in part one. The purpose of this second part regarding toxicological biomarkers in the ICU setting focuses on specific poisons and toxins. Following the introduction of anion and osmol gap in part one, it's relevance in toxic alcohols and other biomarkers for these poisonings are presented within this publication. Furthermore, the role of markers in the blood, urine and cerebrospinal fluid for several intoxications is evaluated. Specific details are presented, amongst others, for cardiovascular drug poisoning, paracetamol (acetaminophen), ethanol, pesticides, ricin and yew tree intoxications. Detailed biomarkers and therapeutic decision tools are shown for carbon monoxide (CO) and cyanide (CN^-) poisoning. Also, biomarkers in environmental toxicological situations such as mushroom poisoning and scorpion stings are presented.

Bulk Droplet Vitrification: An Approach to Improve Large-Scale Hepatocyte Cryopreservation Outcome

Loss of hepatocyte viability and metabolic function after cryopreservation is still a major issue. Although vitrification is a promising alternative, it has generally been proven to be unsuitable for vitrification of large cell volumes which is required for clinical applications. Here, we propose a novel bulk droplet (3-5 mm diameter) vitrification method which allows high throughput volumes (4 mL/min), while using a low preincubated CPA concentration (15% v/v) to minimize toxicity and loss of cell viability and function. We used rapid (1.25 s) osmotic dehydration to concentrate a low preincubated intracellular CPA concentration ahead of vitrification, without the need of fully equilibrating toxic CPA concentrations. We compared direct postpreservation viability, long-term viability, and metabolic function of bulk droplet vitrified, cryopreserved, and fresh hepatocytes. Simulations and cooling rate measurements confirmed an adequate concentration of the intracellular CPA concentration (up to 8.53 M) after dehydration in combination with high cooling rates (960-1320 °C/min) for successful vitrification. In comparison to cryopreserved hepatocytes, bulk droplet vitrified hepatocytes had a significantly higher viability, directly after preservation and after 1 day in culture. Moreover, bulk droplet vitrified hepatocytes had evidently better morphology and showed significantly higher metabolic activity than cryopreserved hepatocytes in long-term collagen sandwich cultures. In conclusion, we developed a novel bulk droplet vitrification method of which we validated the theoretical background and demonstrated the feasibility to use this method to vitrify large cell volumes. Moreover, we showed that this method results in improved hepatocyte viability and metabolic function as compared to cryopreservation.

Acute liver injury and acute liver failure from mushroom poisoning in North America

BACKGROUND & AIMS

Published estimates of survival associated with mushroom (amatoxin)-induced acute liver failure (ALF) and injury (ALI) with and without liver transplant (LT) are highly variable. We aimed to determine the 21-day survival associated with amatoxin-induced ALI (A-ALI) and ALF (A-ALF) and review use of targeted therapies.

METHODS

Cohort study of all A-ALI/A-ALF patients enrolled in the US ALFSG registry between 01/1998 and 12/2014.

RESULTS

Of the 2224 subjects in the registry, 18 (0.8%) had A-ALF (n = 13) or A-ALI (n = 5). At admission, ALF patients had higher lactate levels (5.2 vs. 2.2 mm, P = 0.06) compared to ALI patients, but INR (2.8 vs. 2.2), bilirubin (87 vs. 26 μm) and MELD scores (28 vs. 24) were similar (P > 0.2 for all). Of the 13 patients with ALF, six survived without LT (46%), five survived with LT (39%) and two died without LT (15%). Of the five patients with ALI, four (80%) recovered and one (20%) survived post-LT. Comparing those who died/received LT (non-spontaneous survivors [NSS]) with spontaneous survivors (SS), N-acetylcysteine was used in nearly all patients (NSS 88% vs. SS 80%); whereas, silibinin (25% vs. 50%), penicillin (50% vs. 25%) and nasobiliary drainage (0 vs. 10%) were used less frequently (P > 0.15 for all therapies).

CONCLUSION

Patients with mushroom poisoning with ALI have favourable survival, while around half of those presenting with ALF may eventually require LT. Further study is needed to define optimal management (including the use of targeted therapies) to improve survival, particularly in the absence of LT.

Severe mushroom poisoning in one Macedonian family

BACKGROUND

Collecting and consuming wild mushrooms is a historical tradition in many European countries, including The Republic of Macedonia. This activity is predominantly performed in the period between June and October, when the weather is warm and humidity in the air and soil is at higher levels.The Amanita genus consists of 500 different species of mushrooms; among these, Amanita phaloides, Amanita virosa and Amanita verna are most commonly found in oak forests in our country. These species are highly poisonous and because they can be similar to some edible mushrooms, they have often been misidentified. Their consumption causes severe intoxication.

PURPOSE

The aim of this case series report is to demonstrate a severe poisoning with Amanita mushrooms (A. verna) that occurred in 8 patients, all from 1 Macedonian family.

RESULTS

We show the differences in the clinical appearance and status of these patients, the wide spectrum of symptoms as well as the treatment and outcome of this rare poisoning. One patient, an 8-month-old baby, was excluded from the study because the infant was immediately transferred to the pediatric clinic after admission to our clinic.

CONCLUSIONS

Despite modern therapy, poisoning due to ingestion of Amanita mushrooms is a serious clinical and health problem that may even be potentially lethal. The most efficient way for the general public to protect itself against potential poisoning is to avoid ingesting mushrooms that may not be edible.

Mycetism: a review of the recent literature

Approximately 100 of the known species of mushrooms are poisonous to humans. New toxic mushroom species continue to be identified. Some species initially classified as edible are later reclassified as toxic. This results in a continually expanding list of toxic mushrooms. As new toxic species are identified, some classic teachings about mycetism no longer hold true. As more toxic mushrooms are identified and more toxic syndromes are reported, older classification systems fail to effectively accommodate mycetism. This review provides an update of myscetism and classifies mushroom poisonings by the primary organ system affected, permitting expansion, as new, toxic mushroom species are discovered.

Wild mushroom poisoning in north India: case series with review of literature

Mushroom is an important constituent of diet in many ethnic tribes in India. Ethnic Indian tribes are known to consume nearly 283 species of wild mushrooms out of 2000 species recorded world over. Although they are experts in distinguishing the poisonous from edible mushrooms, yet occasional cases of toxicity are reported due to accidental consumption of poisonous mushrooms. We report amanita like toxicity in a family after consumption of wild mushrooms resulting in fatal outcome.

Enhanced poison elimination in critical care

Nephrologists and critical care physicians are commonly involved in the treatment of severely poisoned patients. Various techniques exist presently to enhance the elimination of poisons. Corporeal treatments occur inside of the body and include multiple-dose activated charcoal, resin binding, forced diuresis, and urinary pH alteration. Extracorporeal treatments include hemodialysis, hemoperfusion, peritoneal dialysis, continuous renal replacement therapy, exchange transfusion, and plasmapheresis. This review illustrates the potential indications and limitations in the application of these modalities as well as the pharmacological characteristics of poisons amenable to enhanced elimination.

Use of the molecular adsorbent recirculating system (MARS™) for the management of acute poisoning with or without liver failure

INTRODUCTION

There is an increasing interest in recent developments in bioartificial and non-bioartificial devices, so called extracorporeal liver assist devices, which are now used widely not only to increase drug elimination, but also to enhance the removal of endogenous substances in acute liver failure. Most of the non-bioartificial techniques are based on the principle of albumin dialysis. The objective is to remove albumin-bound substances that could play a role in the pathophysiology of acute liver failure by dialysing blood against an albumin-containing solution across a high flux permeable membrane. The most widely used device is the Molecular Adsorbent Recirculating System (MARS™).

METHODS

The relevant English and French literature was identified through Medline using the terms, 'molecular adsorbent recirculating system', 'MARS', 'acute liver failure', 'acute poisoning', 'intoxication'. This search identified 139 papers of which 48 reported on a toxic cause for the use of MARS™. Of these 48 papers, 39 specified the substance (eighteen different substances were identified); two papers reported on the same group of patients. BIOARTIFICIAL AND NON-BIOARTIFICIAL SYSTEMS: Bioartificial systems based on porcine hepatocytes incorporated in the extracorporeal circuit are no longer in use due to the possibility of porcine retroviral transmission to humans. Historically, experience with such devices was limited to a few cases of paracetamol poisoning. In contrast, an abundant literature exists for the non-bioartificial systems based on albumin dialysis. The MARS™ has been used more widely than other techniques, such as the one using fractionated plasma separation and adsorption (Prometheus™). All the extracorporeal liver assist devices are able to some extent to remove biological substances (ammonia, urea, creatinine, bilirubin, bile acids, amino acids, cytokines, vasoactive agents) but the real impact on the patient's clinical course has still to be determined. Improvement in cardiovascular or neurological dysfunction has been shown both in acute liver failure and acute-on-chronic liver failure but no impact on mortality has been reported. ACUTE POISONING WITH LIVER FAILURE: Randomized controlled trials are very limited in number and patients poisoned by paracetamol or Amanita phalloides are usually included for outcome analysis in larger groups of acute liver failure patients. Initial results look promising but should be confirmed. Beyond its effect in liver failure, MARS™ could also enhance the elimination of the drug or toxin responsible for the failure, as is described with paracetamol. ACUTE POISONING WITHOUT LIVER FAILURE: Extracorporeal liver assist devices have also been used to promote elimination of drugs that are highly protein bound. Data in various case reports confirm a high elimination of phenytoin, theophylline and diltiazem. However, definite conclusions on the toxicokinetic or clinical efficacy cannot be drawn.

CONCLUSIONS

Despite the lack of large multicentre randomized trials on the use of MARS™ in patients with acute liver failure, the literature shows clinical and biological benefit from this technique. In drug or toxin-induced acute liver failure, such as paracetamol or mushroom poisoning, MARS™ has been used extensively, confirming in a non-randomized fashion, the positive effect observed in the larger population of acute liver failure patients. Furthermore, as MARS™ has been shown in experimental studies to remove protein-bound substances, it is potentially a promising treatment for patients with acute poisoning from drugs that have high protein-binding capacity and are metabolized by the liver, especially, if they develop liver failure concomitantly.

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.