Treatment Approach for Acute Liver Failure vs. Toxicity
The treatment of acute liver failure requires immediate admission to 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
Initial Assessment and Management
Diagnostic Workup
Essential laboratory tests:
- Prothrombin time/INR, complete blood count
- Comprehensive metabolic panel (AST, ALT, alkaline phosphatase, bilirubin)
- Arterial blood gases with lactate
- Arterial ammonia levels 2
Critical etiologic investigations:
Immediate Supportive Care
- 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 2
Etiology-Specific Treatment Approaches
1. Acetaminophen Toxicity
Acetaminophen is the leading cause of ALF in the United States and Europe 2.
- Treatment protocol:
- Administer N-acetylcysteine (NAC) immediately regardless of time since ingestion 2, 3
- Oral NAC regimen: 140 mg/kg loading dose, followed by 70 mg/kg every 4 hours for 17 doses
- IV NAC regimen: 150 mg/kg loading dose over 15 minutes, then 50 mg/kg over 4 hours, followed by 100 mg/kg over 16 hours 2
- For patients presenting within 4 hours of ingestion, administer activated charcoal (1g/kg) prior to NAC 2
- Continue NAC treatment based on acetaminophen concentration and Rumack-Matthew nomogram 3
2. Drug-Induced Liver Injury (Non-acetaminophen)
- Immediately discontinue all but essential medications 2
- Obtain detailed medication history including prescription drugs, OTC medications, herbs, and supplements
- Most idiosyncratic drug reactions occur within first 6 months of drug initiation 2
- No specific antidotes for most drug-induced liver injuries; treatment is primarily supportive
3. Viral Hepatitis
- Hepatitis B: Initiate nucleos(t)ide analogues (entecavir or tenofovir) immediately 1
- Herpes virus hepatitis: Administer acyclovir immediately and place patient on liver transplant list 1
- For other viral hepatitis (A, E), treatment is primarily supportive 2
4. Mushroom Poisoning
- Administer penicillin G (300,000 to 1 million units/kg/day IV) and silymarin (30-40 mg/kg/day) 2
- Consider early listing for transplantation as this is often the only lifesaving option 2
Critical Management Considerations
Monitoring and Supportive Care
- Assess volume status and cardiac function
- Use crystalloid fluids for initial volume expansion
- Administer norepinephrine for refractory hypotension
- Initiate renal replacement therapy according to specific indications
- Administer empirical broad-spectrum antibiotics for worsening encephalopathy or SIRS 2, 1
Coagulation Management
- Avoid routine correction of coagulation abnormalities
- Restrict clotting factor administration to cases with active bleeding 2, 1
Transplantation Considerations
- Early contact with a transplant center is essential for all ALF patients
- Two-year survival rate is approximately 90% after transplantation for severe ALF 2, 1
Important Cautions and Contraindications
- Avoid:
Prognosis
- Acetaminophen-related ALF: 65% overall survival rate; 27% mortality without transplantation 4
- Non-acetaminophen drug-induced ALF: mortality exceeds 75% without transplantation 5
- Early identification of etiology and appropriate management significantly impacts survival 6
The treatment approach must be tailored to the specific cause of liver failure, with early transfer to a transplantation center being crucial for optimal outcomes in severe cases.