Nationwide longitudinal analysis of acute liver failure in taiwan

Abstract

Acute liver failure (ALF) is uncommon but fatal. Current management is based mostly on clinical experience. We aimed to investigate the incidence, etiology, outcomes, and prognostic factors of ALF in Taiwan. Patients with the admission diagnosis of ALF between January 2005 and September 2007 were identified from the Longitudinal Health Insurance Database of Taiwan. ALF was further confirmed by disease severity based on laboratory orders, prescriptions, and duration of hospital stay, and acute onset without prior liver disease. Prognostic factors were identified using Cox regression analysis. During the study period, 218 eligible cases were identified from 28,078 potential eligible ALF patients. The incidence was 80.2 per million person-years in average and increased with age. The mean age was 57.9 ± 17.1 years and median survival was 171 days. The most common etiologies were viral (45.4%, mainly hepatitis B virus) and followed by alcohol/toxin (33.0%). Independent prognostic factors included alcohol consumption (hazard ratio, HR, 1.67 [1.01-2.77]), malignancy (HR 2.90 [1.92-4.37]), frequency of checkups per week for total bilirubin (HR 1.57 [1.40-1.76]), sepsis (HR 1.85 [1.20-2.85]), and the use of hemodialysis/hemofiltration (HR 2.12 [1.15-3.9]) and proton pump inhibitor (HR 0.94 [0.90-0.98]). Among the 130 patients who survived ≥90 days, 66 (50.8%) were complicated by liver cirrhosis. Eight (3.7%) were referred for liver transplantation evaluation, but only 1 received transplantation and survived. ALF in Taiwan is mainly due to viral infection. Patients with malignancy and alcohol exposure have worst prognosis. The use of proton pump inhibitor is associated with improved survival. Half of the ALF survivors have liver cirrhosis.

FIGURE 1

Schematic representation of the patient selection process. INR = international normalized ratio, NH3 = ammonia, TB = tuberculosis. *Liver-associated diagnosis included International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) 070.0–070.9, 571.1, 571.42, 573.3, 782.4, and V02.61. ^#Prior history of liver diseases included liver-associated diagnoses; chronic hepatitis (ICD-9: 571.4); hepatic stone (ICD-9: 574.5); hepatocellular carcinoma (ICD-9: 155.0); intrahepatic cholangiocarcinoma (ICD-9: 155.1); malignant neoplasm of gall bladder (ICD-9: 156.0); malignant neoplasm of extrahepatic bile ducts (ICD-9: 156.1); malignant neoplasm of ampulla of Vater (ICD-9: 156.2); malignant neoplasm of pancreas (ICD-9: 157.9); and liver metastasis (ICD-9: 197.7).

FIGURE 2

The calculated incidence (A) and etiology (B) of acute liver failure in Taiwan. (A) Note that the incidence increased with age in both genders. HBV = hepatitis B virus, HCV = hepatitis C virus, HDV = hepatitis D virus. *Fourteen were pathologically exposed to alcohol, 5 coinfected with hepatitis C virus, 2 exposed to TB, and 1 also exposed to recent anti-TB medications and 1 Wilson disease of age 25, and 4 pathologically exposed to alcohol. ¥ 18 were also exposed to nonacetaminophen hepatotoxic agents and 2 exposed to herbal agents. $ 4 were also exposed to herbal agents. £ 1 was exposed to Wilson disease of age 44.