New horizons in transplantationLiver transplantationUrgent Liver Transplantation for Dietary Supplements: An Under-Recognized Problem

- Limited regulation of herbal/dietary supplements sometimes results in severe hepatotoxicity.
- About 25% of the 2408 adults who underwent urgent liver transplantation had a drug-induced injury.
- Herbal/dietary supplement use was the fourth leading cause of drug-induced injury requiring transplant.
- This probably is an underestimate, because 25% of urgent transplant recipients had no recorded disease etiology and 20% of the drug-induced injuries did not list a drug.

BackgroundThe recent outbreak of acute liver failure caused by herbal/dietary supplements (HDS) in Hawaii prompted evaluation of those patients who underwent emergency liver transplantation (LT) for HDS in the United States.MethodsWe queried the Scientific Registry of Transplant Recipients (2003-2015) to identify patients who underwent urgent LT for acute hepatic necrosis (AHN) and identified those with HDS use. This group of patients was then characterized.ResultsOf 2408 adult cases, 625 were characterized as a drug-induced liver injury. The majority of cases (n = 300) were due to acetaminophen toxicity, but the fourth highest category was due to HDS (n = 21). Of these 21 cases caused by HDS, 13 did not list the specific agent responsible, mean age was 36 years, and all cases occurred after 2007. There probably are more cases because 25% of all LT cases in the study did not list a specific reason for liver failure and 20% of all drug-induced liver failure did not list a specific drug.ConclusionsHerbal/supplement use is the fourth most common cause of drug-induced AHN requiring LT, albeit an underestimation of the problem. Detailed questioning of patients and their support systems regarding herbal/supplement use and better reporting are imperative to further define this problem and identify products that have the potential to lead to liver failure.