What is the treatment for severe jaundice in liver failure?

From the Guidelines

Treatment for severe jaundice in liver failure should prioritize liver transplantation as the definitive treatment, especially when considering morbidity, mortality, and quality of life outcomes. This approach is supported by the most recent and highest quality evidence, which emphasizes the importance of early liver transplantation in improving outcomes for patients with end-stage liver failure 1.

Initial Management

Initial management of severe jaundice in liver failure includes supportive care with:

• Intravenous fluids to maintain hydration
• Correction of coagulopathy with vitamin K (10 mg IV daily) or fresh frozen plasma
• Nutritional support to prevent malnutrition

Symptomatic Treatment

Symptomatic treatment may include:

• Lactulose (20-30 g orally 2-4 times daily) to reduce ammonia levels and prevent hepatic encephalopathy
• Rifaximin (550 mg twice daily) as an adjunct therapy for hepatic encephalopathy
• Cholestyramine (4 g orally 1-4 times daily) or ursodeoxycholic acid (13-15 mg/kg/day) for pruritus

Definitive Treatment

However, liver transplantation is the most effective treatment for severe jaundice in end-stage liver failure, as it corrects the underlying hepatic metabolic defects and can significantly improve quality of life and survival rates 1. The decision to proceed with liver transplantation should be made early, as outcomes are better when transplantation is performed before multi-organ failure develops.

Special Considerations

In cases of acute liver failure with severe jaundice, N-acetylcysteine (150 mg/kg IV loading dose, followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours) may be beneficial, and albumin dialysis systems like MARS (Molecular Adsorbent Recirculating System) can temporarily remove bilirubin and other toxins. However, these treatments are temporary measures and should not delay the consideration of liver transplantation as the definitive treatment.

The effectiveness of these treatments varies based on the underlying cause of liver failure, with some conditions responding better to specific interventions than others. Therefore, it is crucial to identify the underlying cause of liver failure to tailor the treatment approach accordingly.

From the FDA Drug Label

Although in man, cholestyramine resin produces an increase in hepatic synthesis of cholesterol, plasma cholesterol levels fall In patients with partial biliary obstruction, the reduction of serum bile acid levels by cholestyramine resin reduces excess bile acids deposited in the dermal tissue with resultant decrease in pruritus

The treatment for severe jaundice in liver failure is not directly addressed in the provided drug label. However, cholestyramine may be used to reduce serum bile acid levels in patients with partial biliary obstruction, which can lead to a decrease in pruritus.

• It is essential to note that the label does not explicitly mention the treatment of severe jaundice in liver failure.
• The use of cholestyramine in this context would be based on its mechanism of action, which involves the reduction of serum bile acid levels 2.

From the Research

Treatment for Severe Jaundice in Liver Failure

The treatment for severe jaundice in liver failure, also known as acute liver failure (ALF), involves a multi-faceted approach. Some key considerations include:

• Close monitoring of the patient's condition, including vital signs and laboratory tests, to quickly identify any complications that may arise 3, 4
• Management of coagulopathy, which is a common complication of ALF, using medications such as vitamin K and fresh frozen plasma 4
• Treatment of hepatic encephalopathy, which can be done using medications such as lactulose and rifaximin 4, 5
• Supportive care, including nutritional support and management of any underlying infections 3, 4

Role of Liver Transplantation

Liver transplantation is a critical component of the treatment for severe jaundice in liver failure. It is considered in patients who have advanced liver disease and are at risk of death without transplantation 3, 4, 5, 6, 7. The decision to proceed with liver transplantation is based on a variety of factors, including the patient's overall health, the severity of their liver disease, and the presence of any contraindications to transplantation.

Medical Management

Medical management of severe jaundice in liver failure includes the use of medications to support liver function and manage complications. For example, corticosteroids such as prednisone may be used to treat autoimmune hepatitis, which is a common cause of ALF 5, 6. Other medications, such as mannitol, may be used to manage increased intracranial pressure, which is a common complication of ALF 4.

Experimental Therapies

There are several experimental therapies that have been investigated for the treatment of severe jaundice in liver failure, including:

• Plasmapheresis, which involves the removal of plasma from the blood and replacement with fresh frozen plasma 7
• Heterotopic liver grafting, which involves the transplantation of a liver graft into a location outside of the normal liver location 4
• Administration of hepatocyte growth factor, which is a protein that promotes liver cell growth and regeneration 4
• Use of an extracorporeal liver-assist device, which is a machine that performs some of the functions of the liver outside of the body 4
• Liver cell transplantation, which involves the transplantation of liver cells into the patient's liver 4