S5969 Kava Chaos: A Case of Acute Liver Failure Due to Kava Supplements

Introduction: Herbal supplementation use in the US has been increasing over the past decades. These supplements are not subject to FDA regulation and frequently lack evidence to support their use. Many patients are unaware of harmful side effects. In this case report, we describe a patient who presented with acute liver failure secondary (ALF) to kava supplementation. Case Description/Methods: A 36-year-old man with a prior history of a traumatic brain injury presented to the Emergency Department for dizziness and diarrhea after taking duloxetine and drinking 3 bottles of beer the night prior. On presentation, the patient’s blood pressure was 136/92 mmHg, pulse 88, and afebrile. The patient was alert and oriented to date, time and place. Physical exam was remarkable for jaundice. Labs demonstrated aspartate aminotransferase 2,730, alanine aminotransferase 1,582, international normalized ratio 2.0, total bilirubin 3.5, and Cr 0.78. Viral hepatitis testing was negative. Acetaminophen and salicylate levels were not elevated. Abdominal ultrasound demonstrated moderate hepatic steatosis, without any evidence of portal or hepatic vein thrombosis. The patient was started on N-acetylcysteine (NAC) drip for management of acute liver injury. Soon after admission, he became encephalopathic and developed ALF. Further laboratory workup was unrevealing, including hemochromatosis panel, antimitochondrial antibodies, anti-smooth muscle antibody, HIV, IgG, and antinuclear antibody. Upon further investigation, it was revealed that the patient was taking daily Kava supplements for his anxiety for the past 3 months, in addition to daily acetaminophen. An emergent transplant evaluation was initiated, but he was not a candidate due to social circumstances. Fortunately, the patient’s transaminase levels stabilized with continued medical therapy on a NAC drip and vitamin K. The patient was educated on implication of kava on acute liver injury and ALF when combined with acetaminophen and alcohol, and was referred to our hepatology clinic to establish care. Discussion: Our case provides an important discussion around herbal supplements. Because herbal supplements are not regulated by the FDA, safety data is frequently lacking and patients are unaware of potential harms. As in this case, the harms can be quite severe and lead to ALF. In cases of acute liver injury, it is becoming increasingly important to not only investigate which prescribed medications patients take, but to also inquire about herbal supplementation use. It is imperative to provide education to our patients regarding the risks of herbal supplements and highlight the frequent lack of empirical data to support their use.