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Acetaminophen-induced ALF

Does bariatric surgery increase the risk of acute liver failure?

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Bariatric surgery was 25 times more common in patients with liver failure from acetaminophen than from other causes

Among patients with acetaminophen-induced acute liver failure (APAP-ALF), bariatric surgery was over 25 times more common than in the general population, according to a new study presented at the annual meeting of the American Association for the Study of Liver Diseases.

“To the best of our knowledge, this is the first study to report an association between bariatric surgery and acetaminophen-induced ALF,” said researcher Edward W Holt from the Department of Transplantation at California Pacific Medical Center, San Francisco.

The researchers studied a total of 101 patients with ALF; 54 with APAP-ALF and 47 with non APAP-ALF.

A total of nine patients (16.7%) with APAP-ALF had prior bariatric surgery (eight roux-en-Y gastric bypass and one duodenal switch, mean 5.9 (±2.8) years before presentation) compared with no patients with non APAP-ALF (p=0.003).

The prevalence of bariatric surgery in the APAP-ALF cohort was 25.3-fold higher than the estimated prevalence (0.66%) in the general US adult population. Among the 54 patients with APAP-ALF there were no differences in age, gender, ethnicity, need for liver transplantation or death between those with and those without prior bariatric surgery (p>0.05 for all). Importantly, the APAP-ALF patients with bariatric surgery did not have a higher rate of alcohol abuse, depression or intent to cause self-harm. 

Edward W Holt

"While it is possible that the striking difference in the percentage of patients with bariatric surgery between the APAP-ALF and non-APAP ALF groups  could become less pronounced in a study with a larger sample size, it is unlikely that an association this strong would completely disappear,” said Holt.

He went on to make reference to another group of patients known to be at higher risk of APAP-ALF.  “Patients with chronic alcohol abuse who take four grams of acetaminophen each day can inadvertently poison themselves and even develop acetaminophen-induced ALF. Based on our results, we suspect that bariatric surgery may also render patients more susceptible to acetaminophen-induced liver injury.”

"If these patients are predisposed to liver injury from acetaminophen, then clinical management and drug advertising should immediately be updated to reflect this risk," concluded Holt. "However, before an official warning is issued further research should be conducted to confirm this association.”

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