Gender differences in acetaminophen-induced acute liver failure
Miller J, Baltarowich L, Gardner-Gray J, Hurst G, Pflaum-Carlson J, Varma A, Brown K, and West JR. Gender differences in acetaminophen-induced acute liver failure. Acad Emerg Med 2019; 26:S171.
Acad Emerg Med
Background: The rate of acetaminophen-induced acute liver failure (Apap-ALF) has risen substantially. Our primary objective was to test differences in presentation and outcomes of Apap-ALF based on gender. We secondarily tested whether obesity may affect survival. Methods: We performed a retrospective observational study inclusive of Apap-ALF cases over a 12-year period from a regional transplant center. All case data was composed with standardized data collection tools by trained abstractors. We defined ALF by the presence of AST and ALT ≥ 1000 U/L and an INR ≥ 2.0. We excluded cases without Apap ingestion. Univariate analysis compared clinical characteristics and 28-day transplant-free survival based primarily on gender. We also performed multivariate logistic regression to include obesity (body mass index > 30), age, and sequential organ failure assessment (SOFA) score. Results: There were 327 patients included, of whom most were female (67%). Women had similar age (39 ±14 vs. 40 ±16 years) and comorbidities to men, but were less likely to have a history of alcohol use (34% vs. 63%, p<0.001), less likely to abuse street drugs (12% vs 23%, p=0.014), and more likely to have chronic pain (51% vs. 34%, p<0.001). Apap-opioid combinations were common causes of ALF in both genders (54% of men vs. 57% of women, p=0.38). Women had lower mean initial SOFA scores than men (19.5 vs. 22.0, difference 2.4, 95% CI -0.1 to 4.9). They also had lower MELD scores at 48-hours (24 vs. 28, difference 4, 95% CI 1 - 7). Transplant was performed in 6 patients, all of whom were women. Substance abuse was less commonly a reason for transplant denial in women (19% vs 29%, p=0.06). Females had higher rates of transplant free survival (76% vs. 67%, p=0.013) at 28-days compared to men. Nevertheless, in adjusted analysis, only age was significantly associated with transplant free survival (OR per 1-year increase in age 0.97, 95% CI 0.95 - 0.98). The OR (95% CI) for female gender was 1.5 (0.86-2.5), for obesity 1.5 (0.78 - 2.7), and for 1-point increase in SOFA 0.99 (0.97-1.0). Conclusion: In this study, women accounted for the majority of patients with Apap-ALF and had lower severity of illness compared to men. Women were less likely to be denied transplant for substance abuse.