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Jason D. Estes, MD; David Stolpman, MD; Ali Olyaei, PharmD; Christopher L. Corless, MD, PhD; John M. Ham, MD; Jonathan M. Schwartz, MD; Susan L. Orloff, MD

Arch Surg. 2003;138:852-858.

Hypothesis  The use of potentially hepatotoxic herbal and dietary supplements is highly prevalent in the fulminant hepatic failure (FHF) patient population at our institution, and this subgroup of patients has a worse prognosis.

Design  Retrospective case series.

Settings  An adult tertiary care university hospital and a Veterans Affairs hospital in Oregon.

Patients  All patients referred to the liver transplantation service for FHF from January 2001 through October 2002 (N = 20). We defined FHF as onset of encephalopathy within 8 weeks of onset of jaundice in the absence of preexisting liver disease. All patients underwent investigation for potential causes of liver injury. Potentially hepatotoxic supplements were defined as those with previously published reports of hepatic injury related to their use.

Results  Ten patients (50%) were recent or active users of potentially hepatotoxic supplements or herbs; 10 had no history of supplement use. In the supplement group, 7 patients (35%) had no other identified cause for hepatic failure. Six patients in the supplement group and 2 patients in the nonsupplement group underwent orthotopic liver transplantation. Five patients in each group died. There were no significant differences in transplantation rate (P = .07) or survival (P>.99) between groups. Supplement use alone accounted for the most cases of FHF during this period, exceeding acetaminophen toxicity and viral hepatitis.

Conclusions  Herbal and dietary supplements were potential hepatotoxins in a high proportion of patients with FHF at our institution. Enhanced public awareness of the potential hepatotoxicity of these commonly used agents and increased regulatory oversight of their use is strongly urged.

From the Division of Liver/Pancreas Transplantation, Oregon Health & Science University, and Portland Veterans Affairs Medical Center, Portland.

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