Fulminant hepatitis A virus infection in the United States: Incidence, prognosis, and outcomes

Abstract

Acute liver failure (ALF) due to hepatitis A virus (HAV) infection is an uncommon but potentially lethal illness. The aim of this study was to identify readily available laboratory and clinical features associated with a poor prognosis among ALF patients with HAV infection. The presenting features of 29 adults with anti-HAV IgM positive ALF enrolled in the ALFSG_between 1998 and 2005 were reviewed. The HAV patients listed for transplantation by UNOS were also reviewed. Acute HAV accounted for 3.1% of patients enrolled in the ALFSG. At 3 weeks follow-up, 16 had spontaneously recovered (55%), 9 underwent transplantation (31%), and 4 had died (14%). A prognostic model incorporating 4 presenting features (serum ALT <2,600 IU/L, creatinine >2.0 mg/dL, intubation, pressors) had an AUROC for transplant/death of 0.899 which was significantly better than the King's College criteria (0.623, P = .018) and MELD scores (0.707, P = .0503). Between 1988 and 2005, the frequency of patients requiring liver transplantation for HAV in the UNOS database significantly decreased from 0.7 % to 0.1% (P < .001). In addition, the proportion of HAV cases enrolled in the ALFSG significantly decreased from 5% to 0.8% (P = .007). In conclusion, the frequency of HAV patients enrolling in the ALFSG and being listed for liver transplantation in the United States has declined in parallel. A prognostic index consisting of 4 clinical and laboratory features predicted the likelihood of transplant/death significantly better than other published models suggesting that disease specific prognostic models may be of value in non-acetaminophen ALF.

Figures

Fig. 1

Outcomes of patients with hepatitis A virus enrolled in the Acute Liver Failure Study Group. All patients were enrolled between 1/98 and 9/15/05 and followed for 3 weeks after enrollment.

Fig. 2

Day 1 serum ALT and creatinine levels of patients with hepatitis A virus enrolled in the Acute Liver Failure Study Group. The mean serum ALT levels on study day 1 of survivors were significantly higher than the transplant/death group (3362 vs. 1675 IU/mL, P = .03) while the mean serum creatinine levels of survivors were significantly lower than the transplant/death group (1.2 vs. 3.1 mg/dL, P = .04). *Outliers were defined as patients with laboratory values that exceeded 1.5 times the interquartile range.

Fig. 3

Outcomes of patients with hepatitis A virus listed for liver transplantation in the UNOS database. All patients were listed between 1/98 and 9/15/05 and the diagnosis of fulminant HAV was made at the transplant center.

Fig. 4

Trends in the incidence of hepatitis A virus related acute liver failure in the United States. The incidence of patients undergoing liver transplantation for HAV related ALF in the UNOS database significantly declined between 1988 and 2005 (P < .001). Similarly, the frequency of HAV patients enrolled in the ALFSG significantly declined between 1998 and 2005 (P = .007).