Acute Liver Failure Secondary to Yellow Phosphorus Rodenticide Poisoning: Outcomes at a Center With Dedicated Liver Intensive Care and Transplant Unit

Background: Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly causes acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural, and industrial rodenticides and in production of ammunitions, firecrackers, and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary-care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. Methods: Patients with YPMP-related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG), and sequential organ failure assessment (SOFA) score and managed using uniform intensive care, treatment, and transplant protocols in LICU. Sociodemographic characteristics, clinical and biochemical parameters, and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients, and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. Results: Nineteen patients with YPMP-related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0-10) days after poisoning. YPMP-related cardiotoxicity was rapidly progressive and fatal, whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower-dose ingestion (<17.5 g), absence of cardiotoxicity, < grade 3 hepatic encephalopathy (HE), lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by 5.5. Patients with renal failure need for continuous veno-venous hemodiafiltration (CVVHDF) and King College criteria positivity on account of prothrombin time and international normalized ratio (PT-INR) 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer intensive care unit and hospital stay. At median follow-up of 3.4 (2.6-5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. Conclusions: Early transfer to a specialized center, preemptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis, and others may maximize their chances of spontaneous recovery, allowing accurate prognostication and a timely liver transplant.