Bavikatte Akshay P, Sudhindran S, Dhar Puneet, Sudheer O V, Unnikrishnan G, Balakrishnan Dinesh, Menon Ramachandran N
Department of Gastrointestinal and Multiviceral Transplant Surgery, Amrita Institute of Medical Sciences and Research Centre, Ponnekkara, Kochi, 572 101, India.
Indian J Gastroenterol. 2017 Jan;36(1):56-61. doi: 10.1007/s12664-016-0725-1. Epub 2017 Jan 9.
Antitubercular therapy (ATT)-induced hepatotoxicity is often over looked and active tuberculosis is considered a contraindication for liver transplantation, however it might be the only lifesaving option to certain patients of acute liver failure (ALF) due to ATT. We have assessed the outcome of live donor liver transplantation in ATT-induced ALF. A retrospective analysis of all the cases of ALF that underwent liver transplantation from 2006 to 2014 at the Amrita Institute of Medical Sciences was done. A total of seven (7.7%) patients with ATT-induced ALF who had underwent live donor liver transplantation were included in the study. Out of seven patients, three (42.8%) had established diagnosis of tuberculosis and the remaining (58.2%) patients were started on ATT empirically. The median duration of ATT intake was 2 months. All the patients underwent live donor liver transplant as they met King's College criteria, and their model for end-stage liver disease score was above 35 on admission, receiving graft from first degree relatives. Histopathology of explant liver showed pan acinar necrosis. Restarting of ATT after transplant was individualized. It was restarted only in two (28%) patients with prior sputum-positive pulmonary tuberculosis after a median time of 27 days after transplant. ATT was not restarted in rest of the (72%) patients. Postoperative mortality was seen in two (28%) patients due to conditions that masquerade the ATT-induced acute liver failure. The overall survival rate was 71.4% with a median follow up of 22 months. Live donor-related transplantation is feasible option in ATT-induced acute liver failure. Restarting of ATT post liver transplant is feasible and should be individualized along with frequent monitoring of immunosuppressant levels; however, if the primary diagnosis of tuberculosis was empirical, reintroduction of ATT can be omitted.
抗结核治疗（ATT）引起的肝毒性常常被忽视，活动性结核病被视为肝移植的禁忌证，然而对于某些因ATT导致急性肝衰竭（ALF）的患者而言，肝移植可能是唯一的救命选择。我们评估了活体肝移植治疗ATT所致ALF的疗效。对2006年至2014年在阿姆里塔医学科学研究所接受肝移植的所有ALF病例进行了回顾性分析。本研究纳入了7例（7.7%）因ATT导致ALF并接受活体肝移植的患者。7例患者中，3例（42.8%）已确诊为结核病，其余（58.2%）患者开始接受经验性ATT治疗。ATT摄入的中位持续时间为2个月。所有患者均符合国王学院标准，入院时终末期肝病模型评分高于35分，接受一级亲属的肝脏移植，因此均接受了活体肝移植。移植肝的组织病理学显示全腺泡坏死。移植后ATT的重新开始是个体化的。仅2例（28%）既往痰涂片阳性的肺结核患者在移植后中位时间27天重新开始使用ATT。其余（72%）患者未重新开始使用ATT。2例（28%）患者因伪装成ATT引起的急性肝衰竭的疾病而出现术后死亡。总体生存率为71.4%，中位随访时间为22个月。活体供肝相关移植是治疗ATT所致急性肝衰竭的可行选择。肝移植后重新开始使用ATT是可行的，应个体化进行，并频繁监测免疫抑制剂水平；然而，如果结核病的初步诊断是经验性的，则可以省略ATT的重新使用。
