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Poisoning is one of most cause of death in developing agrarian countries which is more often suicidal and sometimes accidental. Ratol poison also known as rat killer poison is widely available rodenticide in India which contains yellow phosphorus which is a protoplasmic poison that causes acute liver failure and can be fatal.Liver transplantation is the best mode of treatment option for acute liver failure when caused by the protoplasmic toxin yellow phosphorus . Here, we provide our clinical findings on the use of plasma exchange in ALF caused by YP poisoning when liver transplantation is not readily available in resource limited settings .
Retrospective study group consisted of patients who underwent TPE for ALF due to yellow phosphorous poisoning (YPP) between 2021 and 2022. Demographic data and biochemical parameters were recorded before and after TPE
Aim of the study was
1. To assess the therapeutic plasma exchange with patient outcome
2.To assess liver function tests pre and post PLEX
3.To assess time of admission after consuming YP with mortality
Inclusion criteria was:
. All Yellow phosphorus poisoning patients with ALF requiring PLEX .
Exclusion criteria was :
· Age <18 YRS
. Pre-existing liver disease
. All causes of ALF other than YP
Procedure done-
All Yellow phosphorus poisoning patients with ALF requiring PLEX were included
PLEX was indicated in
Acute Liver failure which was defined as hepatic injury upto duration of 4weeks in patient with no pre-existing liver disease with one of the following
1.INR> 1.5 or worsening of INR
2.Neurological dysfunction with any degree of hepatic encephalopathy
The dialysis machine used was 4008 S Fresenius and the filter used was Plasma Flux P2 filter. PE with standard volume of each session using formula 0.065 × weight (kg) × [1 − Hct] with a duration of 2 hours done through noncuffed two-lumen temporary dialysis catheter . Equal volumes of replacement fluid and fresh frozen plasma were utilized. All of the patients received the same standard of care, which included intravenous prophylactic antibiotics, parenteral vitamin K, intravenous NAC, correction of dyselectrolytemia, and mechanical ventilation if necessary. Number of sessions planned was minimum of three.
Patient outcomes was recorded as
1. Recovered or expired
2.liver parameter outcomes as recovered or not
3. With time to admission after consuming YP in days.
Recovery was defined as
1.Resoultion of symptoms of hepatic encephalopathy
2.Resoultion of coagulation abnormality
There were 30 patients available for analysis. Out of which 22 (73%) were male and 8 (27)% were female . Age ranged from 19–35 years (mean age of 26 years). Due to different issues, including marital and financial difficulties, 100 percent of patients' YP consumption was in the form of a paste with suicidal aim.
Baseline laboratory characteristics are summarized in Table 1. All patients had icterus (n = 30) high total bilirubin (mean -21.8), low platelets (mean -0.31), high INR(mean -8.6), higher liver enzymes( mean SGOT-700; mean SGPT-1066) at presentation resulted in poor recovery from ALF and increased mortality. Time to admission after consuming YP(days) was higher in patients who expired ( mean-5.30)when compared to patients who recovered (Mean-1.85).Total number of PE sessions given were 88( expired [mean-1.40],Recovered [mean-3.70]). Early referral and higher odds of survival are stressed by the fact that a patient who arrived late to the hospital after consuming died even before receiving three sessions of plasma exchange as shown in table-1. The mean time to starting PE after admission ( days ) among recovered was(mean -1.50) when compared to those expired(mean-1.0), with significant P value(P<0.05) in all above mentioned characteristics.
A total of 30 patients in which (66.66%) recovered from ALF in which males were 14 (70%) and females 6(30%) were whereas 10 (33.33%)did not recover and succumbed in which males were 8 (80%) and females were 2(20%) as depicted in graph -1. For recovery from ALF, mean time to get admitted to the hospital was 1.85 days (p= 0.001) and mean time to start PE was 1.55 days (p= 0.004) when compared to those who did not recover from ALF and expired.
Table 2 summarizes the laboratory parameters before and after PE with Significant improvements in liver functions and coagulation profile. Total bilirubin declined from 5.45 before PE to 1.18 after PE (p = 0.001); SGOT declined from 336 to 25.15 (p = 0.001); SGPT from 557–34 (p = 0.001); INR to 1.09 from 4.55 (p = 0.001).
This modality of treatment requires more awareness among doctors as many still are unaware and patient are referred in late stage of liver failure which lead to mortality among the patients Early initiation of PE and early admission to hospital was found to have significant benefits in patient survival. Due to YP poisoning and the associated costs associated with liver transplantation, plasmapheresis could potentially be regarded as the first line of therapy in ALF.