What are the diagnostic criteria for Liver Failure?

From the Guidelines

Liver failure is diagnosed based on clinical, laboratory, and imaging findings that indicate severe impairment of liver function, with the most recent guidelines from the European Association for the Study of the Liver (1) emphasizing the importance of recognizing acute-on-chronic liver failure (ACLF) and its management. The diagnosis of liver failure typically requires evidence of hepatic synthetic dysfunction, such as decreased albumin and elevated INR >1.5 that doesn't respond to vitamin K, along with signs of hepatic encephalopathy.

• Laboratory abnormalities include elevated liver enzymes (AST, ALT), elevated bilirubin (>2 mg/dL), and abnormal coagulation parameters.
• Acute liver failure specifically requires the absence of pre-existing liver disease, development of hepatic encephalopathy within 26 weeks of the first symptoms, and coagulopathy.
• The West Haven criteria grades encephalopathy from 1-4, ranging from mild confusion to coma, and should be used for HE grading when at least temporal disorientation is present (1). Additional diagnostic criteria include elevated ammonia levels, low glucose, electrolyte abnormalities, and acidosis.
• Imaging studies like ultrasound, CT, or MRI help assess liver structure and rule out other causes.
• The Model for End-Stage Liver Disease (MELD) score, which incorporates bilirubin, creatinine, and INR values, helps predict mortality and prioritize patients for transplantation (1). Early diagnosis is crucial as liver failure can progress rapidly, leading to multi-organ dysfunction including hepatorenal syndrome, respiratory failure, and cerebral edema, which significantly worsen prognosis.
• The management of liver failure in the general intensive care unit should involve contact with a liver transplantation centre for each patient with severe ALF, allowing discussion about diagnostic and consideration for transfer to a dedicated centre (1).

From the Research

Liver Failure Diagnosis Criteria

The diagnosis of liver failure, specifically acute liver failure (ALF), is based on several key criteria, including:

• Coagulopathy and hepatic encephalopathy within 26 weeks in the absence of preexisting liver disease 2
• Fulminant liver failure occurs when hepatic encephalopathy occurs within 8 weeks of jaundice 2
• The presence of severe hepatic dysfunction characterized by coagulopathy and hepatic encephalopathy in a patient with no known liver disease 3

Diagnostic Considerations

In diagnosing ALF, it is essential to:

• Determine the etiology of ALF, as many causes have specific treatments 2, 4
• Consider histopathologic findings on a liver biopsy or liver explant to identify the underlying etiology 4
• Use molecular testing to diagnose and manage non-necrotic acute liver failure 4
• Assess for cerebral edema and intracranial hypertension, which are significant contributors to morbidity and mortality 5

Prognostic Criteria

Several prognostic scoring systems are available to predict outcomes in ALF, including:

• The King's College Criteria 5
• The Model for End-stage Liver Disease score 5 These scoring systems can help identify patients who may require liver transplantation or other intensive interventions.