What is the treatment for hepatitis failure?

Treatment of Hepatitis Failure

For patients with hepatitis failure, treatment must include immediate supportive care in an intensive care unit, identification of the underlying cause, and prompt initiation of specific therapies based on etiology, with early referral to a liver transplant center for severe cases. 1

Diagnosis and Initial Management

Immediate Assessment

• Determine severity using laboratory tests:
  • PT/INR, factor V
  • Complete blood count
  • Comprehensive metabolic panel
  • Arterial blood gases with lactate
  • Arterial ammonia levels 1

Etiological Workup

• Essential diagnostic tests:
  • Serum acetaminophen levels
  • Viral hepatitis serologies (IgM HAV, HBsAg, anti-HBc IgM)
  • Toxicology screen (amphetamine, cocaine)
  • Hepatic Doppler ultrasound
  • Echocardiography 1

Treatment Based on Etiology

Viral Hepatitis

1. Hepatitis B

   • Nucleos(t)ide analogues (entecavir or tenofovir) should be started immediately
   • These medications can improve hepatic function and potentially avoid liver transplantation 1
   • For severe HBV reactivation, prompt treatment with nucleos(t)ide analogues is essential 2

2. Hepatitis C

   • Direct-acting antivirals (DAAs) may be used in patients with compensated disease
   • In decompensated disease, treatment decisions should be made in consultation with a transplant center 1
   • Viral clearance may improve liver function in some patients with decompensated cirrhosis 1

3. Herpes Virus Hepatitis

   • Acyclovir should be administered immediately when herpes simplex virus is suspected 1
   • These patients should be placed on the liver transplant list 1

Drug-Induced Liver Failure

1. Acetaminophen toxicity

   • N-acetylcysteine should be administered regardless of the time since ingestion 1
   • Continue treatment until clinical improvement or liver transplantation

2. Immune Checkpoint Inhibitor Hepatitis

   • For grade 2 hepatitis (AST/ALT >3-5× ULN): Hold immunotherapy and consider prednisone 0.5-1.0 mg/kg/day
   • For grade 3 hepatitis (AST/ALT >5-20× ULN): Discontinue immunotherapy and start methylprednisolone 1-2 mg/kg/day
   • For grade 4 hepatitis (AST/ALT >20× ULN): Hospitalize patient, permanently discontinue immunotherapy, and start methylprednisolone 2 mg/kg/day 1
   • If no response within 3-5 days, consider second-line immunosuppressants (azathioprine, mycophenolate mofetil, tacrolimus) 1

Autoimmune Hepatitis

• Liver biopsy should be considered to establish diagnosis
• Corticosteroids (prednisone 40-60 mg/day) should be initiated
• Patients should be placed on the transplant list even while receiving corticosteroids 1

Wilson Disease

• Acute liver failure due to Wilson disease is typically fatal without transplantation
• Copper-lowering measures (albumin dialysis, hemofiltration, plasmapheresis) should be initiated
• Avoid penicillamine due to risk of hypersensitivity 1

Supportive Care

Central Nervous System Management

• Monitor encephalopathy frequently
• Maintain serum sodium between 140-145 mmol/L
• Monitor blood glucose at least every 2 hours
• Perform tracheal intubation for progressive hepatic encephalopathy (Glasgow <8)
• Minimize sedation depth 1

Cardiovascular Support

• Assess volume status and cardiac function
• Use crystalloid fluids for initial volume expansion
• Administer norepinephrine for refractory hypotension 1

Coagulation Management

• Avoid routine correction of coagulation abnormalities
• Restrict clotting factor administration to cases with active bleeding 1

Infection Prevention

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 1

Liver Transplantation

• Early contact with a transplant center is essential for all patients with acute liver failure 1
• Patients with grade 4 hepatitis should be hospitalized at a center with expertise in liver failure 1
• Specific indications for urgent transplantation include:
  • Herpes virus hepatitis 1
  • Wilson disease 1
  • Fulminant autoimmune hepatitis unresponsive to steroids 1

Important Considerations

What to Avoid

• Benzodiazepines and psychotropic drugs (including metoclopramide)
• Treatments aimed at lowering ammonia levels (lactulose, rifaximin)
• Nephrotoxic drugs, including NSAIDs
• Routine correction of coagulation abnormalities 1

Prognosis

• Mortality remains high (30-100%) despite advances in care 3
• Outcomes have improved with early recognition and aggressive management
• Two-year survival rate is approximately 90% after transplantation for severe acute liver failure 1

By following this algorithmic approach to hepatitis failure management, focusing on immediate supportive care, etiology-specific treatment, and early transplant referral when indicated, patient outcomes can be optimized.