LAUSR

Drug-induced liver injury during treatment for tuberculosis (TB) causes substantial morbidity and may rarely lead to mortality if it progresses to acute liver failure (ALF). The literature regarding the benefits of liver transplantation (LT) for such cases is limited. Therefore, we aimed to investigate this issue in our current study. This study was conducted at a tertiary referral center in South Korea. Between January 2006 and December 2014, 25 patients were diagnosed with ALF while receiving anti-TB treatment. Among these, 19 patients were ultimately included after excluding patients with other possible etiologies. Of these 19 patients, only 3 were diagnosed with TB at our center, whereas the remaining 16 patients were referred for the management of ALF from other hospitals. A total of 10 of the 19 patients were men, and the mean age was 45.9 years. Among the 19 patients, 12 had pulmonary TB and 7 had extrapulmonary TB. Of the 12 patients with pulmonary TB, 8 were cultureconfirmed cases, whereas the remaining 4 patients were diagnosed on the basis of pathologic finding or clinical response to anti-TB medications. Extrapulmonary TB was diagnosed according to previously defined criteria. The mean period of TB treatment before ALF diagnosis was 61.0 days, and the majority of patients received a standard 4-drug anti-TB regimen at the time of ALF diagnosis. The mean Model for End-Stage Liver Disease (MELD) score was 30.1. Eight patients had grade 3-4 encephalopathy. Six patients were not listed for LT because of contraindications to the procedure (advanced age, n5 4; affordability, n5 2). Of the 13 patients listed, 6 received adult living donor liver transplantation (ALDLT). The remaining 7 patients did not receive LT because of the lack of a timely suitable donor. Six patients received emergency ALDLT after a mean of 4.3 days after ALF onset. All patients were alive and in good health at follow-up at a median of 8.2 years (interquartile range, 3.2-8.7 years). After ALDLT, 4 patients completed the course of anti-TB treatment after the regimen was changed to minimally hepatotoxic drugs for a mean of 16.3 months, with successful outcomes. Clinical characteristics of 6 patients are summarized in Table 1. Of the 13 patients who did not receive LT, 10 died of progressive ALF at a median of 15.6 days after ALF onset; 5 (5/6, 83.3%) patients had not been listed for LT and 5 (5/7, 71.4%) patients had been listed but could not undergo LT. Three patients survived following conservative treatment alone; all were in good health at a mean follow-up of 24.5 months. Two Abbreviations: ALDLT, adult living donor liver transplantation; ALF, acute liver failure; AR, acute rejection; CLT, cadaveric liver transplantation; CR, chronic rejection; CS, cycloserine; EMB, ethambutol; HE, isoniazid and ethambutol; HREZ, isoniazid, rifampicin, ethambutol and pyrazinamide; LT, liver transplantation; LVFX, levofloxacin; MELD, Model for End-Stage Liver Disease; PAS, para-aminosalicylate sodium; PTO, prothionamide; SM, streptomycin; TB, tuberculosis.