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Improving Transplant-free Survival With Low-volume Plasma Exchange to Treat Children With Rodenticide Induced
Leenath Thomas1, Jolly Chandran2, Ashish Goel1
1Department of Hepatology, Christian Medical College, Vellore, India.
Background:
In a prior report, no patient with rodenticidal hepatotoxicity who met Kochi criteria (MELD score ≥36 or baseline INR ≥6 with hepatic encephalopathy) (PMID: 26310868) for urgent liver transplantation survived with medical management alone. Plasma exchange (PLEX) may improve survival in these patients.
Objectives:
We describe our experience with low-volume PLEX (PLEX-LV) in treating rodenticide ingestion induced hepatotoxicity in children.
Methods:
From prospectively collected database of rodenticidal hepatotoxicity patients managed as in-patient with department of Hepatology from December 2017 to August 2021, we retrospectively studied outcomes in children (≤18 years). Hepatotoxicity was categorized as acute liver injury (ALI, coagulopathy alone) or acute liver failure (ALF, coagulopathy and encephalopathy). Kochi criteria was used to assess need for urgent liver transplantation. The primary study outcome was one-month survival.
Results:
Of the 110 rodenticidal hepatotoxicity patients, 32 children (females: 56%; age: 16 [4.7-18] years; median, range) constituted the study patients. The study patients presented 4 (1-8) days after poison consumption (impulsive suicidal intent:31, accidental:1). Twenty children (62%) had ALI [MELD: 18 (8-36)] and 12 (38%) had ALF [MELD: 37 (24-45)].All children received standard medical care, including N-acetyl cysteine; ALF patients also received anti-cerebral edema measures. None of the patient families opted for liver transplantation. Seventeen children (ALI: 6, ALF: 11) were treated with PLEX-LV (3 [1-5] sessions, volume of plasma exchanged per session: 26 [13-38] ml/kg body weight) and peri-procedure low dose prednisolone.At 1 month, 28 of the 32 children (87.5%) were alive (4 ALF patients died). Of 10 children who met Kochi listing criteria for urgent liver transplantation, two children were ineligible for PLEX-LV (due to hemodynamic instability) and of the remaining 8 children treated by PLEX-LV, 6 (75%) survived.
Conclusions:
PLEX-LV shows promise as an effective non-liver transplant treatment in children with rodenticidal hepatotoxicity.
Insights
Low-volume plasma exchange (PLEX-LV) offers a promising treatment for children with rodenticide-induced liver damage. This approach may improve survival rates in pediatric patients with severe hepatotoxicity, potentially avoiding the need for liver transplantation.
Area of Science:
- Pediatric Hepatology
- Toxicology
- Critical Care Medicine
Background:
- Rodenticidal hepatotoxicity can be fatal, with no survivors reported among patients meeting Kochi criteria (MELD ≥36 or INR ≥6 with hepatic encephalopathy) managed solely with medical therapy.
- Plasma exchange (PLEX) is a potential intervention to improve survival in severe cases of rodenticide-induced liver injury.
Purpose of the Study:
- To evaluate the efficacy and outcomes of low-volume plasma exchange (PLEX-LV) in pediatric patients with rodenticide ingestion-induced hepatotoxicity.
- To assess PLEX-LV as a non-transplant treatment option for severe liver injury in children.
Main Methods:
- Retrospective analysis of a prospectively collected database of pediatric patients (≤18 years) with rodenticidal hepatotoxicity from December 2017 to August 2021.
- Hepatotoxicity was classified as acute liver injury (ALI) or acute liver failure (ALF) using defined criteria, with the need for urgent liver transplantation assessed by Kochi criteria.
- Outcomes, including one-month survival, were analyzed for children treated with PLEX-LV (3 sessions, 26 ml/kg plasma exchange volume) and peri-procedure prednisolone.
Main Results:
- Of 32 pediatric patients, 20 had ALI and 12 had ALF. Standard medical care was provided, with no liver transplants performed.
- Seventeen children received PLEX-LV. At one month, 28 of 32 children (87.5%) survived.
- Among 10 children meeting Kochi criteria for urgent liver transplantation, 8 received PLEX-LV, and 6 (75%) survived, indicating potential benefit in critically ill patients.
Conclusions:
- Low-volume plasma exchange (PLEX-LV) demonstrates potential as an effective non-liver transplant therapeutic strategy for children suffering from rodenticide-induced hepatotoxicity.
- PLEX-LV may improve survival outcomes in pediatric patients with severe acute liver failure due to rodenticide poisoning, especially those meeting criteria for urgent transplantation.
