Clin Drug Investig (2017) 37:473–482

DOI 10.1007/s40261-017-0505-4

ORIGINAL RESEARCH ARTICLE

Effect of N-Acetylcysteine on Mortality and Liver Transplantation

Rate in Non-Acetaminophen-Induced Acute Liver Failure:
A Multicenter Study
Samar K. Darweesh1 • Mona F. Ibrahim2 • Mahmoud A. El-Tahawy3

Published online: 15 February 2017

 Springer International Publishing Switzerland 2017

Abstract
Introduction and Aim Previous studies and systematic
reviews have not provided conclusive evidence on the
effect of N-acetylcysteine (NAC) in non-acetaminophen-
induced acute liver failure (NAI-ALF). We aimed to study
the value of intravenous NAC in reducing liver transplan-
tation and mortality in NAI-ALF.
Patients and Methods In a prospective, multicenter,
observational study, acute liver failure patients without
clinical or historical evidence of acetaminophen overdose
were enrolled. NAC infusion (in empirical dose) was given
as 150 mg/kg in 100 ml dextrose 5% over half an hour,
then 70 mg/kg in 500 ml dextrose 5% over 4 h, then
70 mg/kg in 500 ml dextrose 5% over 16 h. Thereafter
continuous infusion was administered over 24 h of
150 mg/kg in 500 ml dextrose 5% until up to two con-
secutive normal international normalized ratios (INRs)
were obtained. Our endpoints were recovery, transplanta-
tion, or death. The primary outcome of the study was to
assess reduction in mortality or liver transplantation. The
secondary outcome was the evaluation of other clinical
outcomes (length of ICU and hospital stays, organ system
failure, and hepatic encephalopathy).
& Samar K. Darweesh
samarkad@hotmail.com
1
Hepato-Gastroenterology and Tropical Medicine Department,
Faculty of Medicine, Cairo University, 63 Abo Dawood El-
Thahery St., Nasr City, Cairo, Egypt
2
Anesthesiology and ICU Department, Faculty of Medicine,
Cairo University, Cairo, Egypt
3
Internal Medicine and Hepatology Department, National
Liver Institute, Menoufya University, Al Minufya,
Shibin El Kom, Menoufya Governorate, Egypt
Results The study included a total of 155 adults; the NAC
group (n = 85) were given NAC between January 2011 to
December 2013 and the control group (n = 70) were not
given NAC and were included from files dating between
2010 and 2011. Both groups (before NAC) were compa-
rable with regard to etiology, age, sex, smoking, presence
of co-morbidities, encephalopathy, liver profile, and INR.
The success rate (transplant-free survival) in the NAC
group was 96.4%. While in the control group, 17 patients
(23.3%) recovered and 53 (76.6%) did not recover, of these
37 (53.3%) had liver transplantation and 16 (23.3%) died
(p \ 0.01). The NAC group had significantly shorter hos-
pital stays (p \ 0.001), less encephalopathy (p = 0.02),
and less bleeding (p \ 0.01) than the control group. The
control group reported a higher ICU admission (p = 0.01)
rate and abnormal creatinine and electrolytes (p = 0.002,
p \ 0.01, respectively). Liver profile and INR (after NAC
infusion) differed significantly between the two groups
with regard to bilirubin (increased in controls, p = 0.02),
AST and INR (decreased in NAC group, p \ 0.001 for
both), but the ALT decrease showed no statistical signifi-
cance between the two groups.
Conclusions When administered on admission, intra-
venous NAC caused a reduction in NAI-ALF mortality and
need for transplantation. NAC decreased encephalopathy,
hospital stay, ICU admission, and failure of other organs.
474
Key Points
Intravenous NAC caused significant reduction in
mortality and need for transplantation when applied
on admission in non-acetaminophen-induced acute
liver failure.
Intravenous NAC decreased encephalopathy,
hospital stay, ICU admission, failure of other organs
(i.e., kidney).
One of the strengths of the current study was the
diversity in patient race, gender, and etiology.
Results can be generalized to a broad range of
patients with non-acetaminophen-induced acute liver
failure.
1 Introduction
Acute liver failure (ALF) is a rare but severe life-threat-
ening, multisystemic medical emergency. It is defined as
the rapid development of acute liver injury with impaired
synthetic function and encephalopathy in a person who
previously had a normal liver [1–3].
The role of N-acetylcysteine (NAC) in the treatment of
acetaminophen-induced ALF is well established [4, 5].
NAC prevents toxicity by limiting the formation and
accumulation of N-acetyl-p-benzoquinoneimine, acts as a
glutathione substitute, and enhances nontoxic sulfate con-
jugation [6, 7]. Its anti-inflammatory, antioxidant, ino-
tropic, and vasodilation effects improve microcirculatory
blood flow to vital organs [8, 9] and in a trial conducted on
pigs with ALF improved cerebral perfusion pressure [10].
Interestingly, NAC can interfere with the production of
anti-tumor necrosis factor (considered to play an important
role in shock and multiple organs failure) [11].
Because of its multiple mechanisms of action, NAC has
also been used in small trials in non-acetaminophen-in-
duced ALF (NAI-ALF) with variable results [12, 13]. The
outcome of ALF in terms of survival is poor in patients
with NAI-ALF without liver transplant facilities [14].
In 2004, Sklar and Subramaniam [15] conducted a
systematic review and concluded that all of the studies
done before were small and do not provide conclusive
evidence that NAC benefits non-acetaminophen-induced
ALF.
In 2011, the American Association for Study of Liver
Disease (AASLD) [16] concluded that NAC may be ben-
eficial for ALF due to drug-induced liver injury based on
one study done by Lee and colleagues in 2009 [17] on 173
S. K. Darweesh et al.
patients with drug-induced liver injury (DILI), autoimmune
hepatitis (AIH), hepatitis B virus (HBV), or indeterminate
cause.
However, in 2013, Sales et al. [18] and Bass and Zook
[19] systematic reviews concluded that data regarding the
use of NAC for the treatment of NAI-ALF are inconclusive
and the routine use of NAC cannot be recommended. NAC
may be considered in non-transplant centers while awaiting
referral or when transplantation is not an option. They
advised that further studies are necessary to determine
optimal dosing, treatment duration, and criteria for patient
selection.
Also in 2015, Hu et al. [20] conducted a meta-analysis
that included four clinical trials. A total of 331 patients
receiving treatment with NAC (oral or intravenous) and
285 control patients were included. They concluded that
NAC can prolong patients’ survival with
native liver without transplantation (41 vs. 30%; p = 0.01)
and survival after transplantation (85.7 vs. 71.4%;
p = 0.03), but it cannot improve overall survival (71 vs.
67%; p = 0.42). This discrepancy could be due to statis-
tical results with different p value significance(s).
In 2016, in a systematic review carried out by Chughlay
and colleagues [21], a total of 691 records were identified
through a search until June 2015; they excluded 687
records, leaving only four studies, of which they excluded a
further three after full-text review, and identified only one
study for qualitative analysis. They concluded that the
current available evidence is limited and does not allow for
any firm conclusions to be made regarding the role of
NAC, and therefore highlighted the need for further
research in this area.
Based on so many trials without conclusive evidence,
we initiated our study. The primary outcome was to assess
the reduction in mortality or liver transplantation with the
use of NAC in patients with NAI-ALF. The secondary
outcomes were to evaluate the effect of NAC on other
clinical outcomes (length of ICU and hospital stays, organ
system failure, and hepatic encephalopathy incidence), and
the safety of NAC.
2 Patients and Methods
In this prospective study, we included NAI-ALF patients
admitted to the Hepatology and Gastroenterology Depart-
ment, Amiri Hospital, Infectious Diseases Hospital and
Sabah Hospital, Kuwait from 2011 to 2013. The control
(historic) group was collected from files of NAI-ALF
patients managed before implementing the NAC protocol
in 2011 (having the same inclusion and exclusion criteria).
The patients were admitted to these hospitals as ALF cases
evidenced by jaundice (bilirubin [25 lmol/L) and
Effect of NAC on Transplantation in Non-Acetaminophen-Induced Acute Liver Failure
coagulopathy (elevated INR [1.5) with or without
encephalopathy, without clinical or historical evidence of
acetaminophen overdose or prior liver disease.
The definition of ALF includes the presentation of acute
coagulopathy and encephalopathy. However, in our study
we also included ALF patients with less severe liver injury
with coagulopathy without encephalopathy [22], as these
patients, without specific treatment, usually progress to
frank ALF with encephalopathy.
We prospectively started implementation of an NAC
protocol with drug administration to patients and collection
of data. Then to add reliable strength to our results, we
added the control group gathered from files of NAI-ALF
patients managed before implementing the NAC protocol
as we decided it was unethical to assign a concomitant
treatment control group and thus possibly deprive patients
from lifesaving treatment.
2.1 Study Population
The patients were divided into two groups: (1) NAC group:
patients were given an NAC infusion at the standard dose
(see below). (2) Control group: collected from files of non-
acetaminophen ALF patients admitted before the start of
the study in the period between 2010 and 2011.
This study was approved by the Department’s Ethics
Committee based on the 1975 (as revised in 1983) Decla-
ration of Helsinki and according to the Institutional Review
Board (IRB) requirements. Informed consent was obtained
from all patients, or from the next of kin with
encephalopathy patients.
The patients in the control group received the normal
standard of care for ALF at that time with no new inter-
vention or drugs. Thus informed consent was not needed.
All patients were subjected to: (a) Thorough history taking
(including treatment with acetaminophen and other drugs) and
clinical examination, (b) biochemical profile: liver function
tests (LFT), INR, CBC, renal function tests (RFT), electrolytes,
both before and repeatedly after NAC infusion, (c) viral
markers for hepatitis A virus (HAV), hepatitis E virus (HEV),
hepatitis B virus (HBV), hepatitis C virus (HCV), cytomega-
lovirus (CMV), Epstein-Barr virus (EBV), and herpes simplex
virus (HSV), (d) autoimmune markers: ANA, ASMA, ADNA,
and ALKM, and (e) other hepatitis markers such as cerulo-
plasmin, serum ferritin, and transferrin saturation.
2.2 Study Course
Intravenous NAC was started for all admitted patients with
ALF after implementation of the NAC protocol (not the
control group), so there was no bias in the therapeutic
decision.
475
All patients received the same standard of care of ALF
whether in the NAC or the control group (AASLD guide-
lines) [16] and the difference in time period was minimal
with the same standard of care given to all critically ill
patients throughout the study period in the three hospitals.
All the patients received treatment for critically ill
patients, which is mostly treatment of symptoms and
complications. This involved:
• Continuous IV dextrose administration to prevent
hypoglycemia.
• Broad-spectrum prophylactic antimicrobials to prevent
bacterial infections and antifungals when indicated.
• Proton pump inhibitors (PPIs) for stress-related ulcers.
• ICU with assisted ventilation and propofol sedation (if
needed).
• Fluid and electrolyte balance checked and abnormali-
ties corrected.
• Fresh frozen plasma (FFP) was given to patients who
had spontaneous bleeding or required an invasive
procedure, such as a central venous catheter, but was
not given daily.
Fresh frozen plasma (FFP) was given according to the
same indications in patients and controls groups, so the
effect on INR was comparable. Moreover, the effect of
FFP lasts for hours or 1 day only.
• A nasogastric tube was inserted for feeding purposes in
patients with encephalopathy or for checking upper GI
bleeding.
Response to treatment was carefully recorded, including
vital signs, coma grade, serial biochemical profile, devel-
opment of other organs failure, need for intubation, use of
other supportive measures and assessment of adverse
events.
Our end-points for each patient were recovery and dis-
charge, death, or patient travelling abroad for liver trans-
plantation. We recorded these endpoints and compared
between both groups.
We used the MELD score (Model for End-stage Liver
Disease) that has three components: Bilirubin, INR, and
creatinine combined in a Log equation to form a score
(AASLD guidelines) [16]. We used a cutoff 15 as the
indication for liver transplantation, as a score of 15 or more
indicates expected survival of less than 3 months and the
urgent need for liver transplantation.
The time period for both groups was the patient reaching
any of the above-mentioned endpoints.
Renal impairment was defined as a serum creatinine
level of more than 2.0 mg/dl (normal range 0.6–1.2 mg/dl),
but we proposed a cutoff of 2 to exclude raised creatinine
(between 1.2 and 2) due to dehydration which is reversible
through administration of intravenous fluids. Hemodialysis
was performed whenever indicated. Infection was
476
diagnosed only when blood, urine, or tracheal aspirate
cultures were positive for pathogenic micro-organisms.
Intracranial hypertension was checked clinically by the
presence of abnormal pupillary reflexes or hypertonia.
2.3 N-Acetylcysteine Dose
NAC was started on the same day of admission after
obtaining the results of LFT and INR and continued
throughout the patient’s hospital stay.
NAC (Acetadote, Cumberland Pharmaceuticals,
Nashville, TN, USA) was given as an infusion of 150 mg/
kg in 100 ml dextrose 5% over 30 min, followed by
70 mg/kg in 500 ml dextrose 5% over 4 h, then 70 mg/kg
in 500 ml dextrose 5% over 16 h. Subsequently, a con-
tinuous infusion of 150 mg/kg in 500 ml dextrose 5% over
24 h was continued until two consecutive INR results of
less than 1.3 with improving LFT then the patient was
shifted to oral NAC in a dose of 600 mg/day and was
discharged 2–3 days after the change to oral NAC, so the
days of hospital admission could be considered the
recovery period and the duration of intravenous NAC
(minus 2 days).
This NAC dose was an empirical dose, as we thought
that we should continue intravenous NAC as long as the
INR was still high, indicating that the liver was still in
failure.
The patients in the NAC group were observed until
discharge, after which they were followed up in the out-
patient department of each hospital with visits every month
until normalization of bilirubin and liver enzymes, then
every 3–6 months afterwards for about 2–3 years.
2.4 Statistical Analysis
The study sample size was calculated taking into consid-
eration that the mortality in NAI-ALF without liver trans-
plantation ranges from 50 to 70% [12–15] and hence we
considered mortality with supportive care to be 66%. For
the NAC group, the mortality was put at 57% as reported in
previous NAI-ALF trials using NAC. With an alpha error
of 0.05, a beta error of 0.20, and a 5% level of significance
and 80% study power, the sample size was calculated as 44
patients in each arm.
We calculated the sample size needed (n = 44) and also
defined a period during which to include NAI-ALF patients
fulfilling the inclusion criteria.
Primary and secondary outcomes were compared
between the two treatment groups. Quantitative variables,
expressed as mean ± SD, were compared with the use of
Student’s t test. Qualitative variables, expressed as per-
centages, were compared with the use of a Chi square test
or Fisher’s exact test, when appropriate.
S. K. Darweesh et al.
Follow-up of changes in laboratory results before and
after among the studied groups were assessed by ANOVA
for repeated measures in which p within group and p be-
tween groups indicated significance with values less than
0.05. All reported p values are two-sided.
Survival in the study was considered till transplantation
or discharge.
3 Results
We treated 243 patients with ALF and 155 of them were
found to be eligible for this study. The sample size cal-
culated was 44 patients in each arm but the included
number exceeded the sample size as we wanted to give
more power to the results of the study.
The NAC group included 85 patients and the control
group included 70 patients. The NAC group included 34
(40%) females and 51 (60%) males with a mean age of
33.5 ± 11 years, and the control group included 28 (40%)
females and 42 (60%) males with a mean age of
34.8 ± 8.8 years.
Finally thus 155 were included, and 88 were excluded
for the following reasons: (1) age below 18 or [70 years,
(2) known or suspected acetaminophen intake 2–3 days
before admission, (3) liver failure due to cancer, (4) pre-
viously intake of oral NAC, and (5) ischemic hepatitis due
to severe heart failure or heart surgery.
The NAC and control groups were similar in their
general characteristics such as etiology, age, sex, smoking,
drug abuse, presence of co-morbidity (such as diabetes
mellitus or hypertension), encephalopathy at presentation,
liver and renal profile and INR before the start of NAC.
p values for these characteristics were non-significant
(Table 1).
The severity of ALF is determined by the presence of
encephalopathy, high INR, and liver profile (especially
bilirubin), and both groups were similar with respect to the
severity of ALF.
Moreover, a score-matching approach for different
variables to discern whether patients who received NAC
were as sick as the controls was not needed as all p values
concerning these variables were non significant.
The causes of ALF in both the NAC and control groups
are shown in Table 2. The difference between the two
groups was statistically not significant.
Recovery from ALF was reported in 82 (96.4%) patients
in the NAC group with no need for liver transplantation
(p \ 0.01). Three patients in the NAC group did not
recover from the ALF; two of them had liver transplanta-
tion and one died. These three patients did not receive the
optimal dose of NAC (two due to a severe allergic reaction
to the NAC infusion and therefore had a transplantation,
Effect of NAC on Transplantation in Non-Acetaminophen-Induced Acute Liver Failure 477

Table 1 General characteristics Characteristic NAC Control group p value

of the two groups before and
after N-acetylcysteine (NAC) Smoking 42 (50) 32 (46.7) 0.796
Drug abuse 5 (6.7) 6 (10.0) 1.0
Co-morbidity 40 (46.7) 37 (53.3) 0.606
Encephalopathy at admission 24 (28.2) 25 (35.7) 1.0
Encephalopathy grade
0 61 (71.7) 45 (64.2) 0.7
I–II 20 (23.5) 19 (27.1)
III–IV 4 (4.7) 6 (8.5)
During hospital course after NAC
Encephalopathy during course 28 (33.3) 44 (63.3) 0.02
Hospital stay (days) 10.1 ± 3.89 28.0 ± 5.32 \0.001
ICU admission 28 (33.3) 47 (66.7) 0.01
Bleeding 20 (23.3) 47 (66.7) \0.01
RFT during course (normal) 56 (66.7) 16 (26.7) 0.002
Electrolytes during course (normal) 65 (76.7) 16 (26.7) \0.01
Hb during course (normal) 56 (66.7) 32 (46.7) 0.118
WBCs during course (normal) 65 (76.7) 40(56.7) 0.1
Platelets during course (normal) 56 (66.7) 44 (63.3) 0.787
Values are expressed as N (%) or mean ± SD
RFT renal function tests, Hb hemoglobin, WBCs white blood cells

Table 2 Causes of acute liver Cause NAC (n = 85) Control group (n = 70) p value
failure in the N-acetylcysteine
(NAC) and control groups Viral infection 41 (46.7) 40 (56.7) 0.36
HAV 12 10
HBV 11 14
HEV 6 5
CMV 8 6
HAV ? HEV 3 3
EBV 1 (with INH) 2 (with liver iron overload)
Drugsa 31 (36.7) 28 (40)
Pregnancy
With viral infection 5 (6.7) –
Pregnancy related 5 (6.7)
SLE 3(3.3) 2 (3.3)
Values are expressed as N (%)
SLE systemic lupus erythematosus, HBV hepatitis B virus, HAV hepatitis A virus, HEV hepatitis E virus,
CMV cytomegalovirus, EBV Epstein-Barr virus
a
For example isoniazid (INH), weight loss herbal capsules, muscle building capsules

the other one due to improper premature cessation of the
NAC infusion). For that reason, any patient developing an
allergic reaction to NAC was given 100 mg hydrocortisone
IV and continued the dose as usual (Table 3).
So, the success rate (transplant-free survival) in the
NAC group was 96.4% when we included all 85 patients.
The success rate (transplant-free survival) in the control
group was 23.3% as only 17 patients survived without liver
transplantation. This difference was statistically significant
(p \ 0.01). The remaining 53 (76.6%) patients did not
recover from ALF, 37 (53.3%) of them had liver trans-
plantation and 16 (23.3%) died (Table 3). The causes of
death in control group were mostly liver failure with coma
(n = 5), renal failure (n = 7), or bleeding (INR C6)
(n = 3). The transplantation rate was lower in the NAC
group, two (6.7%) vs. 37 (53.3%) in the control group, and
this was significantly different between the groups
(p \ 0.01).
478
Table 3 Outcome of the study Outcome
in the two groups
Recovered
Died
Liver transplantation
Total
Values are expressed as N (%)
Univariate or multivariate survival analysis for the NAC
group variables were not possible in our study as 96% of
NAC patients recovered and survived.
Clinical features showed that the NAC group were less
likely to develop encephalopathy and bleeding than the
control group. In the NAC group 28 (33.3%) patients had
encephalopathy vs. 44 (63.3%) in the controls; also, a
bleeding tendency was found in 20 (23.3%) patients in the
NAC group vs. 47 (66.7%) in the controls. This was sta-
tistically significant (p = 0.02 and p \ 0.01, respectively)
(Table 1). All patients in both groups experienced fatigue.
Fever and abdominal pain were found in 23 patients in each
group with no statistical significance (p = 1.0).
The control group reported a higher number of ICU
admissions than the NAC group; 47 (66.7%) patients in the
control group were moved to the ICU compared to 28
(33.3%) in NAC group. This was statistically significant
(p = 0.01) (Table 1).
The duration of hospital stay was significantly shorter in
the NAC group, 10.1 ± 3.8 days compared to
28 ± 5.3 days in control group (p \ 0.01) (Table 1).
In the control group, the time to transplantation could
not be assessed as the patients were taken to specialized
hospitals in the USA or UK for liver transplantation as
there is no facility for this in Kuwait. The time from their
arrival till transplantation was not recorded.
Abnormal creatinine and electrolytes (sodium and
potassium) were more prevalent in the control group than
in the NAC group, with statistical significance (p = 0.02
and p \ 0.01, respectively). Abnormalities in hemoglobin,
white blood cell counts, and platelets were comparable
between the two groups.
Liver function tests (LFTs) and INR, before starting the
NAC infusion, were comparable in the two groups with no
statistical significance. However, after the NAC infusion,
LFTs and INR differed significantly between the two
groups with regard to bilirubin (increased significantly in
the control group), AST (decreased significantly in the
NAC group), and INR (decreased significantly in the NAC
group), but a decrease in ALT showed no statistical sig-
nificance between the two groups (Table 4).
Within each group, LFT showed a significant difference,
as ALT and AST decreased significantly after the NAC
infusion. Bilirubin decreased in the NAC group; however,
S. K. Darweesh et al.
N-acetyl cysteine group Control group p value
82 (96.4) 17 (23.3) \0.01
1 (3.3) 16 (23.3)
2 (6.7) 37 (53.3)
85 70
it did not show a significant difference. There was also no
significant difference in the INR level within each group
(p = 0.11), but there was a significant difference in the
pattern of change between the two groups (p \ 0.01) as the
INR decreased in the NAC group and increased in the
control group (Table 4).
Adverse events related to the NAC infusion included
prolonged cholestasis in 82 (96.4%) patients as bilirubin
showed a steady but slow decrease in a period of around
2–3 months. We considered this to be related to NAC as
our patients with acute hepatitis, who were not given NAC,
did not develop the prolonged slow decrease in bilirubin
(unlike our study patients). Fever and allergic reaction were
reported in three (10%) patients and dyspepsia in 11
(13.3%) patients. Although bronchospasm has been
reported with NAC, none of our patients experienced this
symptom.
None of our patients needed IV mannitol or intracranial
monitoring as none of them developed a rise in intracranial
pressure.
4 Discussion
Transplantation for ALF is a rescue therapy dependent
on organ availability, patient eligibility, and severity of
illness. This creates challenges when performing
research within the area of liver transplantation and ALF
[22, 23].
Treatment with NAC has beneficial effects even after
late administration in acetaminophen toxicity, which indi-
cates additional mechanisms of cellular protection. Data
imply that there are hepatoprotective effects independent of
glutathione replenishment which are based on changes in
intracellular energy metabolism. NAC acts as a radical
scavenger, stabilizes mitochondrial function, and influ-
ences cytokine synthesis (anti-TNF). Moreover, it has
inotropic and vasodilator effects, which improves micro-
circulation and oxygen delivery in multiorgan failure due
to ALF of all etiologies [24–26].
The success rate (transplant-free survival) in the NAC
group in our study was 96.4% compared to 23.3% in the
controls as only 17 patients had transplantation-free sur-
vival; this difference was statistically significant. Also, the
Effect of NAC on Transplantation in Non-Acetaminophen-Induced Acute Liver Failure 479

Table 4 Comparison of liver function tests (LFTs) within each group and between the two groups
LFT N-acetyl cysteine p within group Control p within group p between groups
Mean SD Mean SD

Se Bill, lmol/L (beforea) 91.27 41.31 0.397 101.43 36.02 0.03 0.314
Se Bill, lmol/L (afterb) 87.53 33.77 114.20 50.63 0.02
ALT, IU/L (before) 3144.00 1748.27 \0.01 2993.33 1294.80 \0.01 0.706
ALT, IU/L (after) 1930.67 1285.93 2113.33 1106.01 0.558
AST, IU/L (before) 3951.33 1630.23 \0.01 3956.33 1385.55 \0.01 0.990
AST, IU/L (after) 1154.73 539.04 2850.00 1320.85 \0.001
INR (before) 2.39 0.52 0.023 2.25 0.46 \0.01 0.283
INR (after) 1.97 1.04 3.05 1.13 \0.001
Se Bill serum bilirubin, ALT alanine transaminase, AST aspartate transaminase, INR international normalized ratio
a
Before NAC start
b
After NAC start

control group had significantly more mortality than the
NAC group.
Lee et al. [17] had the same conclusion but with a lower
success rate, as they demonstrated a statistically signifi-
cantly higher transplant-free survival in the NAC group
compared with the placebo group (40 vs. 27%). However,
they reported a non-significant overall survival rate at
3 weeks of 70% for NAC-treated and 66% for placebo-
treated patients. Similarly, in the study by Kortsalioudaki
et al. [27] on 111 ALF children who received NAC com-
pared to 55 controls, treated patients had better survival
with native liver compared to controls (43 vs. 22%,
p = 0.005) with an increase of survival post-liver
transplantation.
Furthermore, beneficial effects were reported by Mum-
taz et al. [1] with 47 ALF patients having NAC compared
to 44 historical controls. Twenty-two (47%) patients sur-
vived in the NAC group and 12 (27%) in the control group.
However, Gunduz et al. [28], who included 41 patients
(20 NAC and 21 controls) with acute viral hepatitis, found
that NAC administration did not affect the time necessary
for normalization of ALT and bilirubin with no statistical
significance. The lack of effect in their study, contrary to
ours, could be due to their use of a small oral dose
(600 mg/day) and inclusion of acute hepatitis not ALF.
The high recovery and survival rate in our study, which
reached 96% in contrast to other studies, could be due to
the start of intravenous NAC early in the course of ALF (on
the day of admission) using a higher dose than previous
studies.
In addition, during the implementation of this study
while giving patients intravenous NAC according to our
approved protocol, we gathered research published by
different colleagues, studied their methods, endpoints,
proposed outcomes, strengths, and weaknesses. In our
administration to patients, collection of data, and writing
the manuscript we tried to be systematic and conclusive, as
all the previous studies did not provide conclusive
evidence.
We used the same follow-up period as previous studies,
and patients were followed up until one of our endpoints:
recovery with discharge, death, or travel (to the USA or
UK) for liver transplantation.
Similar to our results, Lee et al. [17] found that the
apparent benefit for those with early encephalopathy sug-
gests that to affect outcome, NAC must be initiated early in
the course of the disease. Our high recovery rate could be
also be due to our inclusion of less severe ALF (coagu-
lopathy only, INR [1.5) patients.
However, unusual results were reported by Squires et al.
[29]. They conducted a placebo-controlled trial on 184
children with NAI-ALF with 92 children in each arm. The
1-year survival did not differ significantly (p = 0.19)
between the NAC (73%) and placebo (82%) groups. But
the 1-year liver transplantation-free survival was signifi-
cantly lower (p = 0.03) in those who received NAC (35%)
than placebo (53%), particularly, but not significantly so,
among those less than 2 years old with encephalopathy
grade 0–1 (NAC 25%; placebo 60%; p = 0.0493).
The cause of ALF in the NAC group, in our study, was
viral in 46.7%, drug related in 36.7% and pregnancy
related in 13.4%, while the causes in the control group
were viral in 56.7% and drug related in 40%. Similarly, in
the study by Lee et al. [17], the four main causes for ALF
in their trial were drug-induced liver injury, autoimmune
hepatitis (AIH), HBV, and indeterminate cause. Lee et al.
[17] found that ALF caused by drug-induced liver injury or
HBV seemed to have the highest benefit of NAC therapy,
and our results confirm this conclusion.
Viral causes in the NAC group in our study included
HAV, HBV, hepatitis E virus (HEV) in similar numbers,
cytomegalovirus (CMV), and HAV plus HEV. Viral causes
480
in the control group were from the same viruses again with
similar numbers. Similarly, Mumtaz et al. [1] included 47
patients and 44 controls. The majority of patients in both
groups were due to acute HEV, 24 were due to acute HBV
(with five co-infected and six super-infections with HDV).
Most of our patients in the NAC group developed
encephalopathy grade I–II, three patients developed
encephalopathy grade IV, one died (ALF due to isoniazid
as prophylaxis for TB with EBV) and two had liver
transplantation. We started intravenous NAC when the INR
was C1.5 before the development of encephalopathy in
most cases, but some patients presented with coagulopathy
and encephalopathy from the start. However, Squires et al.
[29] found in their study that there were no significant
differences between treatment arms for the highest recor-
ded grade of encephalopathy.
An important finding that confirms our results was
reported by Lee et al. [17] as they found that the benefits of
transplant-free survival were apparent in patients with
coma grade I–II who received NAC (52 vs. 30% for pla-
cebo), while transplant-free survival with coma grade III–
IV was 9% in NAC vs. 22% in the placebo group.
In our control group, more patients required ICU
admission than in the NAC group. Strangely, however, in
the Mumtaz et al. [1] study that included 91 ALF patients, a
total of 56 were moved to the ICU; of these, most (36
patients) belonged to the NAC group (p = 0.001).
The duration of hospital stay (recovery period) was
significantly shorter in the NAC group in our study. A
longer hospital stay in the control group was due to many
factors such as slow or non-recovery of LFT or INR,
development of complications (i.e., organ failure), more
ICU admissions, and waiting to be transferred for liver
transplantation. Kortsalioudaki et al. [27] also, similar to
our study, reported a significantly shorter hospital stay in
NAC patients compared to controls. Moreover, a trend was
observed in the Lee et al. [17] study for NAC patients to
have shorter hospital stays (median 9 vs. 13 days).
On the other hand, Gunduz et al. [28] found that the
duration of hospitalization was not affected, probably due
to their use of a small oral dose of NAC (600 mg/day) and
inclusion of acute hepatitis not ALF.
Abnormal kidney function and electrolytes (sodium,
potassium, and calcium) developed more in the control
group than in the NAC group; this could mean that NAC
protected the liver and kidneys and also prevented elec-
trolyte complications. Similar to our results, Nguyen-Khac
et al. [30] found that death due to the hepatorenal syndrome
was less frequent in the prednisone ? NAC group than in
the prednisone-only group at 6 months (9 vs. 22%).
However, Lee et al. [17] failed to demonstrate significant
differences in organ system failure(s) between the two
groups. This appears to relate to the small number of
S. K. Darweesh et al.
defined organ failure events occurring during the immedi-
ate study period. Also, Squires et al. [29] found no sig-
nificant differences between their two groups regarding
other organ failures.
After NAC infusion, LFT differed significantly, in our
study, between the two groups with regard to bilirubin and
AST, but a decrease in ALT showed no statistical signifi-
cance. Within each group, ALT and AST decreased sig-
nificantly after NAC infusion. Likewise, in a double-blind
trial carried out by Singh et al. [31], 173 NAI-ALF patients
received either intravenous NAC or dextrose (placebo) for
72 h. They reported that the decreased risk of transplan-
tation or death with NAC was reflected in improvement in
parameters related to hepatocyte necrosis and bile excre-
tion (ALT and bilirubin, but not in creatinine or AST) in
the first 4 days of hospitalization, and bilirubin or ALT
were predictors of transplantation or death.
Also, Nguyen-Khac et al. [30] provided validation that a
decrease in the bilirubin level after 7 days of NAC is
associated with a favorable prognosis and also that a
decrease on day 14 is associated with increased survival.
In our study, there was a significant difference in the
pattern of INR change between the two groups, as INR
decreased in the NAC group and increased in controls. A
similar conclusion was found by Singh et al. [31], who
reported that by holding constant all other values, a higher
INR was a predictor of more transplantation in ALF
patients.
In our study, the route and the dose of NAC were
probably related to our high recovery rate. Many doses and
routes were used in different studies with different success
rates. Mumtaz et al. [1] administered oral NAC at a dose of
140 mg/kg, followed by 70 mg/kg, for a total of 17 doses,
and reported liver transplantation-free survival in 47%.
Gunduz et al. [28] administered a very small dose, orally
600 mg/day with no significant effect, in their study. Lee
et al. [17] administered intravenous NAC at 150 mg/kg/h at
1 and 2 h (as a loading dose), then decreased to 12.5 mg/
kg/h at 3 and 4 h, then decreased to 6.25 mg/kg/h in the
next 67 h. Liver transplantation-free survival was 40 vs.
27% in controls. Kortsalioudaki et al. [27] gave NAC as a
continuous infusion of 100 mg/kg/day until normalization
of INR, death, or transplantation, liver transplantation-free
survival was 43 vs. 22% in controls.
In the Nguyen-Khac et al. [30] study, the prednisone-
NAC group received intravenous NAC on day one
(150 mg/kg in 250 ml of 5% glucose over 30 min, 50 mg/
kg in 500 ml over 4 h, then 100 mg/kg in 1000 ml over
16 h) and on days two through five (100 mg/kg/day in
1000 ml of 5% glucose). Mortality was significantly lower
at 1 month but not at 3 or 6 months.
From these different studies, it appears that the loading
dose at the start of the course is important in determining a
Effect of NAC on Transplantation in Non-Acetaminophen-Induced Acute Liver Failure
better effect of NAC and higher liver-transplantation-free
survival.
However, some researchers reported surprisingly con-
trary results to ours. For example Squires et al. [29] gave a
continuous infusion of NAC (150 mg/kg/day in 5% dex-
trose) for up to 7 days or until liver transplantation or
death. Surprisingly, their 1-year liver transplantation-free
survival was significantly lower with NAC (35 vs. 53%
with placebo). This result will need to be properly
analyzed.
Oral and intravenous NAC were well tolerated in large
clinical trials. At the dose used for acetaminophen toxicity,
NAC does not have hepatotoxic effects. Adverse effects
included rash, transient bronchospasm, arrhythmias, head-
ache, dizziness, and peripheral edema. Anaphylactic reac-
tions have been reported and typically are infusion related
[18].
Adverse events of NAC infusion, in our study, included
prolonged cholestasis in 82 (96.4%) patients as bilirubin
showed a steady but slow decrease over a period of
2–3 months. However, patients were discharged from
hospital when ALT and AST were around 100 IU with
repeatedly normal INR, while elevated bilirubin was fol-
lowed up in the outpatient department until normalization.
Fever and allergic reaction were reported in three (10%)
patients, and dyspepsia in 11 (13.3%).
The side effects of NAC identified by Hu et al. [20]
included nausea, vomiting, and diarrhea or constipation. In
the study by Lee et al. [17], vomiting occurred more often
in the NAC group (14 vs. 4% in controls).
One of the main strengths of the current study was the
diversity in the patients’ race, gender, and underlying eti-
ology, therefore, the results could be generalizable or
applicable to a broad range of patients with NAI-ALF.
A limitation of the study is that the study was conducted
in three non-transplant hospitals. This made it difficult to
have a concomitant control group at the same time.
Before the implementation of the NAC protocol, we saw
most of the patients with ALF (of non-acetaminophen
etiologies) die in the ICU (as reported in the control group)
and few managed to complete their documentation for
travel to specialized hospitals in the USA or UK for liver
transplantation, and some even died after arrival.
Therefore, after we discovered the significant effect of
NAC, we could not separate patients into a concomitant
control group (placebo group), as it was unethical to
deprive a dying patient from a chance at having a safe
lifesaving treatment for a grave diagnosis with a poor
outcome in a non-transplant country. The historical control
(placebo) group therefore offered no randomization and
blinding, but the study can provide conclusive evidence on
the value of NAC when started very early (day of admis-
sion) with a high intravenous dose.
481
5 Conclusions
NAC is safe and leads to a greater degree of spontaneous
recovery in NAI-ALF patients (especially with coagu-
lopathy only), making it effective in saving this cohort
from death, reducing the need for transplantation, and
reducing other complications, especially when started as
early as possible at a high intravenous dose. This is con-
firmed by greater improvements in all parameters of liver
injury.
However, the use of NAC should not prevent early
contact with a transplant center for any patient demon-
strating evidence of coagulopathy with any degree of
encephalopathy, since referral ensures that these critically
ill patients can undergo urgent transplantation, should it be
needed.
Acknowledgements The authors thank Prof. Dr. Wafaa Al-Akel who
provided the statistics for this study.
Compliance with Ethical Standards
Funding This research did not receive any specific grant from any
funding agency in the public, commercial, or not-for-profit sector.
Conflicts of interest The authors declare no conflicts of interest.
Ethical approval All procedures in this study were in accordance
with the 1964 Declaration of Helsinki (and its amendments), and the
requirements of the ethics committee or institutional review board
that approved the study.
Informed consent Written informed consent obtained from patients,
parents, or care givers.
Data sharing statement No additional data are available.
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