Eight fold increase in the dietary supplement related liver failure leading to transplant waitlisting over the last quarter century in the US.

Introduction We investigated the trends in listing and outcomes of drug induced acute liver failure (DIALF) over the last quarter century in the United States using the United Network for Organ Sharing (UNOS) database. Methods We examined waitlisted patients in the UNOS database between 1995 and 2020 with a diagnosis of DIALF, and assessed trends in etiologies, demographic and clinical characteristics, and outcomes over 3 periods, 1995-2003, 2004-2012 and 2013-2020. Patients with DIALF and cirrhosis were classified as drug induced acute on chronic liver failure (DI-ACLF). Implicated agents including acetaminophen (APAP) and herbal or dietary supplements (HDS) were ascertained. Results There were 2146 individuals with DIALF during the study period. The observed demographic trends between the earliest and latest period included fewer pediatric patients (19% to 13%), but with increasing male gender in non-APAP DIALF (32% to 41%), and increased racial diversity in APAP DIALF. Antimicrobials remained the most common non-APAP agents across all periods, but antiepileptics, propylthiouracil and mushroom poisoning decreased, while HDS markedly increased from 2.9% to 24.1% of all non-APAP DIALF. The overall 5-year post liver transplant (LT) patient survival improved significantly over the 3 periods (69.9% to 77.4% to 83.3%) and was evident for both APAP and non-APAP DIALF. Discussion Over the last quarter century, there has been an eight-fold increase in HDS related liver failure necessitating waitlisting for liver transplantation in the US. There are other important temporal trends during the study period, including improved survival following LT among both APAP and non-APAP DIALF.