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Semin Liver Dis 2011; 31(4): 420-426
DOI: 10.1055/s-0031-1297930
DIAGNOSTIC PROBLEMS IN HEPATOLOGY

© Thieme Medical Publishers

A Maxed-Out Liver: A Case of Acute-On-Chronic Liver Failure

Gene Y. Im1 , Sofia Kazi2 , Swan N. Thung2 , Ponni V. Perumalswami1
  • 1Division of Liver Diseases, The Mount Sinai Medical Center, New York, New York
  • 2The Lillian and Henry M. Stratton-Hans Popper Department of Pathology, The Mount Sinai Medical Center, New York, New York
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Publication History

Publication Date:
21 December 2011 (online)

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ABSTRACT

A 51-year-old man from Puerto Rico with Child-Turcotte-Pugh Class C decompensated cirrhosis due to genotype 1a chronic hepatitis C was referred for worsening jaundice and diuretic-resistant ascites. He began experiencing symptoms of hepatic decompensation 5 months prior to referral with new-onset ascites and spontaneous bacterial peritonitis, evolving into diuretic-resistant ascites, increasing jaundice, and a MELD increase from 12 to 29. During his hospitalization, his MELD score increased to >40 from a rapidly increasing international normalized ratio (INR) and evolving type 1 hepatorenal syndrome. Clinically, the patient appeared quite well despite such a high MELD score. After an extensive pretransplant evaluation and exclusion of infection, he underwent successful orthotopic liver transplantation. After histologic examination of the explanted liver, he subsequently admitted to 5 months of daily use of a detoxifying supplement known as MaxOne®, containing D-ribose-L-cysteine, consistent with a drug-induced acute-on-chronic liver failure. The use of complementary and alternative medicines and its potential for causing drug-induced liver injury and acute-on chronic liver failure requires a high index of suspicion and increased awareness among health care providers.

KEYWORDS

Drug-induced liver injury - acute-on-chronic liver failure - glutathione - hepatitis - liver transplantation

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Ponni V. PerumalswamiM.D. 

Division of Liver Diseases, The Mount Sinai Medical Center

Box 1104, One Gustave L. Levy Place, New York, NY 10029

Email: ponni.perumalswami@mountsinai.org