MR with Jossy and Dr. Shlager: Acute Liver Failure in a patient on Azathioprine

A middle aged female with history of renal transplant (in 2013 2/2 ANCA vasculitis) on immunosuppression presents with one month of jaundice, light stools, and vague abdominal pain. Her initial labs showed a bilirubin of 16 with transaminases in the 80s-90s, INR of 1.3, and AKI on CKD without evidence of structural obstruction on imaging. Her initial workup included a liver biopsy, after which she became more encephalopathic with a rising INR, meeting criteria for ALF. UCSF was then contacted for potential transplant. The etiology of her ALF is still not clear, but thought most likely a result of azathioprine hepatotoxicity
*One confusing thing in this presentation were the relatively low AST/ALT. We discussed that the patient could have had an insult several weeks ago and her liver enzymes are now just ‘burnt out’; because of this, she should still be worked up for all of the usual causes of ALF (i.e. hepatitis, autoimmune disease, etc) that are usually associated with higher transaminases.
*Definition of Acute Liver Failure: INR > 1.5 + Encephalopathy in a patient without pre-existing liver disease (often defined as developing in <26w)
-While only INR + encephalopathy define ALF, we discussed the following signs of poor prognosis as ALF progresses: hypoglycemia, signs of HRS (creatinine rising or oliguria), hypotension
*My patient with had negative hepatitis serologies in the last 5 years and is low risk. Do we need to resend these? What should we send?
In the case ALF (or concern for progression towards ALF), repeat hepatitis serologies AND viral loads should almost always be sent. We often forget about hepatitis A, but this is common and the biggest risk factor for this progressing to liver failure is age.
-Would send: hep A IgM, hep A IgG, hepB surface Ab, hepB core Ab, hepB surface Ag, hepB DNA, hepC ab, hepC RNA
*What causes ALF?
Acute Liver Failure actually has a nice differential because it’s actually quite limited with a few big categories: Toxins, Viral, Vascular, Metabolic, Other
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And, random antibiotic pearls:
*For every antibiotic you choose, ask yourself what you are covering and what you are missing. It is the only way to learn the nuances of these drugs over time!

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