Advertisement

Steroid use in acute liver failure

Authors

  • Jamuna Karkhanis,

    1. Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
    Search for more papers by this author
  • Elizabeth C. Verna,

    1. Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
    Search for more papers by this author
  • Matthew S. Chang,

    1. Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
    Search for more papers by this author
  • R. Todd Stravitz,

    1. Section of Hepatology, Virginia Commonwealth University, Richmond, VA
    Search for more papers by this author
  • Michael Schilsky,

    1. Division of Digestive Diseases and Section of Immunology and Transplantation, Department of Medicine and Surgery, Yale University School of Medicine, New Haven, CT
    Search for more papers by this author
  • William M. Lee,

    1. Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
    Search for more papers by this author
  • Robert S. Brown Jr.,

    Corresponding author
    1. Department of Medicine, Columbia University College of Physicians & Surgeons, New York, NY
    • Address reprint requests to: Robert S. Brown, Jr., M.D., M.P.H., Center for Liver Disease and Transplantation, New York Presbyterian Hospital-Columbia Presbyterian Medical Center, 622 West 168th St., PH 14 Center, New York, NY 10032-3784. E-mail: rb464@columbia.edu; fax: 212-305-4343.

    Search for more papers by this author
  • for the Acute Liver Failure Study Group


  • Potential conflict of interest: Dr. Lee consults for and received grants from Merck. He received grants from Anadys, Boehringer Ingelheim, Bristol-Myers Squibb, Vertex, Ocera, and Gilead.

Abstract

Drug-induced and indeterminate acute liver failure (ALF) might be due to an autoimmune-like hepatitis that is responsive to corticosteroid therapy. The aim of this study was to evaluate whether corticosteroids improve survival in fulminant autoimmune hepatitis, drug-induced, or indeterminate ALF, and whether this benefit varies according to the severity of illness. We conducted a retrospective analysis of autoimmune, indeterminate, and drug-induced ALF patients in the Acute Liver Failure Study Group from 1998-2007. The primary endpoints were overall and spontaneous survival (SS, survival without transplant). In all, 361 ALF patients were studied, 66 with autoimmune (25 steroids, 41 no steroids), 164 with indeterminate (21 steroids, 143 no steroids), and 131 with drug-induced (16 steroids, 115 no steroids) ALF. Steroid use was not associated with improved overall survival (61% versus 66%, P = 0.41), nor with improved survival in any diagnosis category. Steroid use was associated with diminished survival in certain subgroups of patients, including those with the highest quartile of the Model for Endstage Liver Disease (MELD) (>40, survival 30% versus 57%, P = 0.03). In multivariate analysis controlling for steroid use and diagnosis, age (odds ratio [OR] 1.37 per decade), coma grade (OR 2.02 grade 2, 2.65 grade 3, 5.29 grade 4), MELD (OR 1.07), and pH < 7.4 (OR 3.09) were significantly associated with mortality. Although steroid use was associated with a marginal benefit in SS overall (35% versus 23%, P = 0.047), this benefit did not persistent in multivariate analysis; mechanical ventilation (OR 0.24), MELD (OR 0.93), and alanine aminotransferase (1.02) were the only significant predictors of SS. Conclusion: Corticosteroids did not improve overall survival or SS in drug-induced, indeterminate, or autoimmune ALF and were associated with lower survival in patients with the highest MELD scores. (Hepatology 2014;59:612–621)

Ancillary