65 years old male with past medical history of ischemic cardiomyopathy with Automatic Implantable Cardioverter Difibrillator (AICD) presented with complaints of multiple AICD shocks. Lab works at presentation were within normal limits. AICD interrogation showed 16 episodes of Ventricular Tachycardias with 10 episodes of appropriate AICD firing. Patient was admitted to intensive care unit for intravenous(IV) loading of amiodarone over 24 hours after which his lab work revealed acute liver failure and also acute renal failure requiring emergent dialysis. Amiodarone was discontinued and a detailed work up ruled out any other possible etiology behind liver and renal failure. Patient was monitored in the hospital for 5 days for downward trend of Liver Function Test and creatinine and was discharged home with arrangements for further follow-up. After one month, oral amiodarone was started which patient tolerated well with follow up lab work done at 6 months showing normal values.
Amiodarone is an antiarrhythmic drug highly effective against a wide spectrum of ventricular tachyarrhythmias. Amiodarone is notoriously known to cause various adverse effects. While most of the known toxic effects of amiodarone is seen on prolonged oral use, for reasons unknown, few of the rare side effects that include acute liver failure, cardiac arrest, Acute Respiratory Distress Syndrome (ARDS), acute renal failure and hypotension are exclusively seen with the IV administration of amiodarone and not with oral loading or maintenance dosing of amiodarone. The most widely accepted mechanisms are ischemic liver injury secondary to relative hypotension in the setting of congestive hepatopathy, E-ferol syndrome or cardio-renal syndrome causing renal failure.
Limited knowledge about the mechanism behind acute liver and renal failure secondary to intravenous amiodarone always puts a physician in a dilemma whether to start a potentially live saving medication once the acute effect has resolved or to withhold it altogether owing to the adverse effects exclusively seen with the IV form. We report an unusual case of acute liver and renal failure within 24 hours of initiation of IV amiodarone which reversed after discontinuation of the medication .
Various mechanisms have been suggested that lead to acute liver and renal failure. Irrespective of the pathogenesis, acute toxicity of IV amiodarone is a distinctly different entity from the chronic toxicities of oral amiodarone, and this case supports the recommendation of not withholding the potentially lifesaving oral amiodarone after the acute toxicity due to IV amiodarone has resolved, although further monitoring of the liver enzymes and renal function is recommended.
To cite this abstract:Paudel R, Suman S, Dogra P, Matta J, Acharya S. Acute Liver and Renal Failure : A Rare Adverse Effect Exclusive to Intravenous Form of Amiodarone. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 645. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/acute-liver-and-renal-failure-a-rare-adverse-effect-exclusive-to-intravenous-form-of-amiodarone/. Accessed April 4, 2020.