A 38-year-old man presents with acute liver failure (encephalopathy, INR 3.2) 10 days after starting isoniazid for LTBI. What is the MOST important immediate management step?
- A Start N-acetylcysteine (NAC)
- B Urgent listing for liver transplant evaluation
- C Stop isoniazid; transfer to a liver transplant center for evaluation and listing ✓
- D Start prednisolone to suppress drug-induced hepatitis
Explanation
In drug-induced acute liver failure (ALF), stopping the offending agent (isoniazid) is the mandatory first step. Given the presence of hepatic encephalopathy and INR >1.5 meeting ALF criteria, urgent transfer to a liver transplant center for evaluation and possible listing is lifesaving — the 21-day transplant-free survival with INH-induced ALF without transplant is poor. NAC may be considered (evidence from the NAC in ALF trial showing survival benefit in non-acetaminophen ALF — NEJM 2011), but transfer for transplant evaluation is the most important step. Steroids have no proven benefit.
Reference: Harrison's Principles of Internal Medicine, 21st ed.
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Written and medically reviewed by the StethoPrep medical team.