In survivors, hepatic regeneration is normally rapid and complete, with normalisation of liver function tests within 1 to 3 weeks.[67]Lesna M, Watson AJ, Douglas AP, et al. Evaluation of paracetamol-induced damage in liver biopsies: acute changes and follow-up findings. Virchows Arch A Pathol Anat Histol. 1976 Jul 21;370(4):333-44.
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[68]Portmann B, Talbot IC, Day DW, et al. Histopathological changes in the liver following a paracetamol overdose: correlation with clinical and biochemical parameters. J Pathol. 1975 Nov;117(3):169-81.
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[69]Baeg NJ, Bodenheimer HC Jr, Burchard K. Long-term sequellae of acetaminophen-associated fulminant hepatic failure: relevance of early histology. Am J Gastroenterol. 1988 May;83(5):569-71.
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Renal injury is rare, and when it occurs serum creatinine typically begins to rise soon after serum aminotransferase activity has peaked. Occasionally, renal injury occurs without liver injury.[70]Hamlyn AN, Douglas AP, James O. The spectrum of paracetamol (acetaminophen) overdose: clinical and epidemiological studies. Postgrad Med J. 1978 Jun;54(632):400-4.
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[71]Prescott LF, Proudfoot AT, Cregeen RJ. Paracetamol-induced acute renal failure in the absence of fulminant liver damage. Br Med J (Clin Res Ed). 1982 Feb 6;284(6313):421-2.
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In unselected patients referred to hospital without specific therapy, <10% developed hepatotoxicity; 1% developed acute renal failure; and 1% to 2% died in hepatic failure.[72]Prescott LF, Critchley JA. The treatment of acetaminophen poisoning. Annu Rev Pharmacol Toxicol. 1983;23:87-101.
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Several studies have identified an increased risk of severe hepatotoxicity and higher mortality in patients with staggered overdoses or delayed presentation.[19]Bond GR, Hite LK. Population-based incidence and outcome of acetaminophen poisoning by type of ingestion. Acad Emerg Med. 1999 Nov;6(11):1115-20.
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[20]Makin AJ, Wendon J, Williams R. A 7-year experience of severe acetaminophen-induced hepatotoxicity (1987-1993). Gastroenterology. 1995 Dec;109(6):1907-16.
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[21]Schiødt FV, Rochling FA, Casey DL, et al. Acetaminophen toxicity in an urban county hospital. N Engl J Med. 1997 Oct 16;337(16):1112-7.
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[73]Craig DG, Bates CM, Davidson JS, et al. Staggered overdose pattern and delay to hospital presentation are associated with adverse outcomes following paracetamol-induced hepatotoxicity. Br J Clin Pharmacol. 2012 Feb;73(2):285-94.
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