What is the treatment approach for hepatic (liver) failure?

From the Guidelines

The treatment approach for hepatic failure should prioritize a comprehensive strategy addressing the underlying cause while providing supportive care, with a focus on early recognition and prompt management of liver failure and its complications to improve outcomes, as recommended by the most recent guidelines 1.

Key Components of Treatment

• Identifying and treating the precipitating factor, whether it's viral hepatitis, drug toxicity, alcohol, or other causes
• Supportive measures including maintaining fluid and electrolyte balance, correcting coagulopathy, managing ascites, and controlling hepatic encephalopathy
• Nutritional support with 1.2-1.5 g/kg/day of protein and adequate caloric intake
• Close monitoring for complications like spontaneous bacterial peritonitis, variceal bleeding, and hepatorenal syndrome

Role of Liver Transplantation

• Liver transplantation evaluation should be initiated promptly in cases of fulminant hepatic failure or end-stage liver disease, as it represents the ultimate treatment for hepatic encephalopathy and can result in rapid resolution of symptoms and improved survival 1
• Patients with recurrent or persistent hepatic encephalopathy should be considered for liver transplantation, and a first episode of overt hepatic encephalopathy should prompt referral to a transplant centre for evaluation 1

Management of Specific Complications

• Hepatic encephalopathy should be controlled with lactulose (25-30 mL every 6-8 hours) and rifaximin (550 mg twice daily) 1
• Ascites should be managed with diuretics like spironolactone (100-400 mg daily) and furosemide (40-160 mg daily) 1
• Coagulopathy should be corrected with vitamin K or fresh frozen plasma 1

Importance of Early Recognition and Prompt Management

• Early recognition and prompt management of liver failure and its complications can improve outcomes, as emphasized by the most recent guidelines 1
• Close monitoring and individualized management are crucial, taking into account the patient's age, comorbidities, and specific circumstances 1

From the FDA Drug Label

For patients whose acetaminophen concentrations are at or above the "possible" toxicity line (dotted line in nomogram): Administer a loading dose of acetylcysteine The total recommended dosage of acetylcysteine is 300 mg/kg given intravenously as 3 separate, sequential doses (i.e., 3-bag method to administer the loading, second, and third doses). Monitor hepatic and renal function and electrolytes throughout treatment. If there is any uncertainty as to patient's risk of developing hepatotoxicity, it is recommended to administer a complete treatment course The treatment approach for hepatic (liver) failure due to acetaminophen overdose involves administering a loading dose of N-acetylcysteine (IV) if the acetaminophen concentration is at or above the "possible" toxicity line. The recommended dosage is 300 mg/kg given intravenously as 3 separate doses over 21 hours. It is essential to monitor hepatic and renal function and electrolytes throughout treatment. If there is any uncertainty about the patient's risk, it is recommended to administer a complete treatment course 2.

• Key considerations:
  • Administer a loading dose of N-acetylcysteine (IV) if the acetaminophen concentration is at or above the "possible" toxicity line.
  • Monitor hepatic and renal function and electrolytes throughout treatment.
  • Complete treatment course is recommended if there is any uncertainty about the patient's risk.

From the Research

Hepatic Failure Workup and Treatment

• Hepatic failure, also known as acute liver failure (ALF), is defined as severe hepatic dysfunction, marked by transaminases elevation, detoxification disorder, and the presence of hepatic encephalopathy, with exclusion of underlying chronic liver disease and secondary causes like sepsis or cardiogenic shock 3.
• The treatment approach for hepatic failure involves identifying the underlying cause, which can include paracetamol and warfarin toxicity, autoimmune and viral hepatitis, and herbal and dietary supplements 3.
• In some cases, the cause of hepatic failure may remain unknown, highlighting the need for meticulous and careful review of the patient 3.

Treatment Options

• For patients with hepatic encephalopathy (HE), a complication of acute and chronic liver disease, treatment options include non-absorbable disaccharides (lactulose and lactitol), rifaximin, and branched chain amino acids (BCAA) 4.
• The combination of rifaximin and lactulose has been shown to be more effective than lactulose alone in increasing the effective rate and reducing mortality in patients with HE 5.
• Long-term management of HE with lactulose and/or rifaximin has been found to be effective and safe, with the addition of rifaximin to lactulose significantly reducing the risk of overt HE recurrence and HE-related hospitalization 6.

Intensive Care and Liver Transplantation

• In severe cases of hepatic failure, intensive care and liver transplantation (LTx) may be necessary, with LTx being the only curative option for some causes of ALF 3, 7.
• The decision to perform LTx should be made on a case-by-case basis, taking into account the underlying cause of ALF, the patient's prognosis, and the availability of a liver graft 7.

Prognosis and Clinical Management

• The prognosis of patients with hepatic failure depends on various factors, including the underlying cause, the severity of liver dysfunction, and the presence of complications like HE 7.
• Clinical management of ALF patients should involve etiology-specific treatment, intensive care, and consideration of LTx, with individual prognosis evaluated using scoring systems like the Model for End-Stage Liver Disease, the King's College Criteria, and the Clichy criteria 7.