Predictors of mortality and liver transplant requirement in patients with hepatitis A virus: A case series from Mexico

Abstract

BACKGROUND

Hepatitis A virus (HAV) infection remains a significant cause of acute viral hepatitis globally, and the endemicity pattern is intermediate in Mexico. Although most cases follow a benign and self-limited course, less than 5% of patients with HAV infection progress to acute liver failure, which carries mortality rates of 13%-33% depending on access to liver transplantation (LT). The identification of clinical and biochemical predictors of adverse outcomes is crucial to improve early risk stratification, optimize patient management, and guide timely referral to transplant centers.

AIM

To assess the utility of clinical and biochemical variables and prognostic scores in predicting mortality and the need for LT in patients with acute HAV infection.

METHODS

We conducted a retrospective case series of all patients hospitalized at Medica Sur Clinic between 2018 and 2024 who were positive for immunoglobulin M antibodies for HAV. Clinical and laboratory data were collected from patients’ electronic medical records. Continuous variables were summarized as the means ± SD or median and interquartile range and compared using Student’s t-test or the Mann-Whitney U test, as appropriate. Categorical variables were expressed as frequencies and percentages and compared using the χ² test or Fisher’s exact test.

RESULTS

A total of 69 patients with HAV infection (mean age, 38 ± 11 years; 65% male) were included. 14% of patients had a history of hepatic steatosis, 10% had type 2 diabetes, and 45% were smokers. Acute liver injury was observed in 47 patients (68%), acute liver failure was detected in five patients (7.2%), and mortality or LT occurred in three patients (4.3%; two deaths and one transplant). Patients who died or required orthotopic LT were older, and they had higher heart and respiratory rates at admission. These patients additionally exhibited greater liver dysfunction, including higher bilirubin and transaminase levels, prolonged coagulation times, lower sodium and albumin levels, and worse albumin-bilirubin scores. Severity scores [model for end-stage liver disease (MELD), MELD with sodium, MELD version 3.0] were significantly higher in patients with complications than in those without complications.

CONCLUSION

Advanced age, elevated severity, and higher albumin-bilirubin scores emerged as predictors of adverse outcomes in patients with HAV infection, and consideration of these factors could guide the need for more intensive monitoring strategies. These findings highlight the importance of incorporating prognostic scoring systems into routine clinical evaluation to improve outcomes in high-risk patients.

Keywords: Hepatitis A virus; Acute liver failure; Liver transplantation; Mortality risk factors; Predictors; Risk stratification; Mexico; Prognostic scoring systems; Liver function tests

Core Tip: Hepatitis A virus infection is among the most common causes of acute viral hepatitis globally. Predicting the clinical course of hepatitis A virus infection remains challenging. Risk factors such as encephalopathy, leukocytosis, acute kidney injury, hypoalbuminemia, and hyperbilirubinemia can be used to identify patients at risk for developing acute liver failure. Previously, we reported a fulminant hepatitis incidence of 0.3%, which increased to 1.8% in individuals older than 49 years, with serum creatinine level > 2 mg/dL being the strongest predictor of fulminant hepatitis or mortality. Given the epidemiological transition of this disease in Mexico, updated data are crucial.