Amanita phalloides poisoning: Reassessment of prognostic factors and indications for emergency liver transplantation

Background/Aims Amanita phalloides poisoning is an uncommon cause of acute liver failure with an especially rapid course. The aim of this study was to re-assess transplantation criteria in patients with mushroom poisoning. Methods Twenty-seven patients admitted for Amanita phalloides poisoning were studied. Previously reported transplantation criteria, including the recent Ganzert’s criteria, were tested retrospectively. Results The rate of fatal intoxication (death and/or transplantation) was 8/27 (30%). An interval between ingestion and diarrhea <8 h was a very early predictor of a fatal outcome (accuracy of 78%). Later on, non-paracetamol and paracetamol King’s College criteria were superior to Clichy’s and Ganzert’s criteria (accuracy of 100% compared to 85% and 85%, respectively). Encephalopathy and renal insufficiency were not constant in the fatal intoxication group. Prothrombin index below 10% 4 days or more after ingestion had a 100% accuracy for predicting a fatal outcome. Conclusions Liver transplantation should be strongly considered in patients with an interval between ingestion and diarrhea <8 h. Encephalopathy should not be an absolute prerequisite for deciding transplantation. From day 4 after ingestion, prothrombin index lower than 10% (≈INR of 6) alone is a reliable tool for deciding emergency transplantation.