Liver Transplantation Society of India Guidelines for the Management of Acute Liver Injury Secondary to Yellow Phosphorus-Containing Rodenticide Poisoning Using the Modified Delphi Technique of Consensus Development

Abstract

Background: Acute liver failure caused by the ingestion of yellow phosphorus-containing rodenticide has been increasing in incidence over the last decade and is a common indication for emergency liver transplantation in Southern and Western India and other countries. Clear guidelines for its management are necessary, given its unpredictable course, potential for rapid deterioration and variation in clinical practice.

Methods: A modified Delphi approach was used for developing consensus guidelines under the aegis of the Liver Transplantation Society of India. A detailed review of the published literature was performed. Recommendations for three areas of clinical practice, assessment and initial management, intensive care unit (ICU) management and liver transplantation, were developed.

Results: The expert panel consisted of 16 clinicians, 3 nonclinical specialists and 5 senior advisory members from 11 centres. Thirty-one recommendations with regard to criteria for hospital admission and discharge, role of medical therapies, ICU management, evidence for extracorporeal therapies such as renal replacement therapy and therapeutic plasma exchange, early predictors of need for liver transplantation and perioperative care were developed based on published evidence and combined clinical experience.

Conclusion: Development of these guidelines should help standardise care for patients with yellow phosphorus poisoning and identify areas for collaborative research.

Keywords: ALF, acute liver failure; ALI, acute liver injury; DDLT, deceased donor liver transplantation; ICU, intensive care unit; INR, international normalised ratio; KCC, Kings College Criteria; LDLT, living donor liver transplantation; LT, liver transplantation; LTSI, Liver Transplantation Society of India; MELD, model for end-stage liver disease; RRT, renal replacement therapy; TPE, therapeutic plasma exchange; YP, yellow phosphorus; acute liver failure; consensus guidelines; liver transplantation; rat killer poison; yellow phosphorus.