N-acetylcysteine therapy for ischaemic hepatic failure: a successful antidote


  • Pearl Wong Liverpool Hospital, Sydney, Australia
  • Rafael Gaszynki Upper Gastrointestinal Department, Bankstown-Lidcombe Hospital, Sydney, Australia
  • Yasser Farooque Upper Gastrointestinal Department, Liverpool Hospital, Sydney, Australia




NAC, Ischaemic hepatopathy, Acute liver failure


Acute liver failure (ALF) is characterised by severe liver injury with the onset of coagulopathy (INR ≥1.5) and encephalopathy in the absence of pre-existing liver disease. It is associated with a high mortality rate of 10-57%, which is largely driven by multi-organ failure, sepsis and cardiac arrhythmia. Current management focuses on identifying and treating the aetiology, providing supportive care and monitoring liver function. The use of N-acetylcysteine (NAC) therapy is well-studied in the treatment of paracetamol toxicity but is controversial in other causes of ALF. We reported the first case of ischaemic hepatic failure secondary to prolonged portal vein occlusion treated with 72 hours of NAC therapy. Although ischaemic hepatopathy is a relatively uncommon cause of ALF, it is associated with a high mortality rate. The case highlights how early use of NAC therapy may improve hepatic serology biomarkers and should warrant consideration in ALF secondary to ischaemic hepatopathy.


Hey P, Hanrahan T, Sinclair M, Testro A, Angus P, Peterson A, et al. Epidemiology and outcomes of acute liver failure in Australia. World J Hepatol. 2019;11(7):586-95.

Guo G, Wu XZ, Su LJ, Yang CQ. Clinical features of ischemic hepatitis caused by shock with four different types: a retrospective study of 328 cases. Int J Clin Exp Med. 2015;8(9):16670-5.

Siu J, Nguyen T, Turgeon R. N-acetylcysteine for non-paracetamol (acetaminophen)-related acute liver failure. Cochrane Database of Syst Rev. 2020;12:12123.

Kothari S, Kalinowski M, Kobeszko M, Brindise E. NAC attack update: an emerging therapy for ischemic hepatopathy. Hepatol. 2020;158(6):1306.

Tapper E, Sengupta N, Bonder A. The incidence and outcomes of ischemic hepatitis: a systematic review with meta-analysis. Am J Med. 2015;128(12):1314-21.

Ciobanu AO, Gherasim L. Ischemic hepatitis - intercorrelated pathology. Maedica. 2018;13(1):5-11.

Seeto RK, Fenn B, Rockey DC. Ischemic hepatitis: Clinical presentation and pathogenesis. Am J Med. 2000;109(2):109-13.

Harrison P, Wendon J, Gimson A, Alexander G, Williams R. Improvement by acetylcysteine of hemodynamics and oxygen transport in fulminant hepatic failure. N Engl J Med. 1991;324(26):1852-7.

Mokhtari V, Afsharian P, Shahhoseini M, Kalantar S, Moini A. A review on various uses of n-acetyl cysteine. Cell Journal. 2017;19(1):11-7.

Harrison P, Wendon J, Williams R. Evidence of increased guanylate cyclase activation by acetylcysteine in fulminant hepatic failure. Hepatol. 1996;23(5):1067-72.

Rank N, Michel C, Haertel C, Lenhart A, Welte M, Meier-Hellmann A, et al. N-acetylcysteine increases liver blood flow and improves liver function in septic shock patients: results of a prospective, randomized, double-blind study. Crit Care Med. 2000;28(12):3799-807.

Lee W, Hynan L, Rossaro L, Fontana R, Stravitz R, Larson A, et al. Intravenous N-Acetylcysteine improves transplant-free survival in early stage non-acetaminophen acute liver failure. Gastroenterol. 2009;137(3):856-64.

Amjad W, Thuluvath P, Mansoor M, Ali F. N-acetylcysteine in non-acetaminophen induced acute liver failure: a systematic review. Gastroenterol. 2020;158(6):1306.

Sansone RA, Sansone LA. Getting a knack for NAC: N-acetyl-cysteine. Innov Clin Neurosci. 2011;8(1):10-4.






Case Reports