What is the immediate management for acute liver failure?

Immediate Management of Acute Liver Failure

The immediate management of acute liver failure requires prompt fluid resuscitation, maintenance of adequate intravascular volume, and transfer to a liver transplant center as soon as possible. 1

Initial Assessment and Stabilization

• Diagnosis confirmation: Measure prothrombin time/INR and assess mental status (ALF defined as INR ≥1.5 with any mental alteration in a patient without preexisting cirrhosis with illness duration ≤26 weeks) 2

• Laboratory evaluation: Obtain comprehensive labs including:

  • Prothrombin time/INR, CBC, comprehensive metabolic panel
  • AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin
  • Arterial blood gases with lactate and arterial ammonia levels 2
  • Serum acetaminophen levels (regardless of history) 1

• Imaging: Perform hepatic Doppler ultrasound to evaluate vascular patency 2

Hemodynamic Management

• Fluid resuscitation: Administer colloid (albumin preferred) rather than crystalloid; all solutions should contain dextrose to maintain euglycemia 1
• Vasopressor support: If MAP remains <50-60 mmHg despite adequate fluid resuscitation, initiate epinephrine, norepinephrine, or dopamine (avoid vasopressin) 1
• Hemodynamic monitoring: Consider pulmonary artery catheterization in hemodynamically unstable patients to guide volume replacement 1

Specific Etiologic Management

Acetaminophen Overdose

• Administer N-acetylcysteine immediately:
  • Loading dose: 150 mg/kg IV
  • Followed by maintenance doses for a total of three separate doses over 21 hours 2, 3
  • For patients presenting within 4 hours of ingestion, administer activated charcoal (1g/kg) prior to NAC 2

Viral Hepatitis

• For acute hepatitis B with ALF, consider nucleos(t)ide analogues (entecavir or tenofovir) 2
• For herpes virus hepatitis, immediately administer acyclovir and consider for liver transplantation 2

Autoimmune Hepatitis

• Administer corticosteroids (prednisone 40-60 mg/day) 1
• Place patient on transplant list even while administering corticosteroids 1

Acute Fatty Liver of Pregnancy/HELLP Syndrome

• Consult obstetrical services and perform expeditious delivery 1

Wilson Disease

• Consider albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 1
• Place patient on transplant list (recovery is infrequent without transplantation) 1

Supportive Care

Neurological Management

• Encephalopathy monitoring: Perform tracheal intubation for progressive hepatic encephalopathy (Glasgow <8) 2
• Avoid: Benzodiazepines, psychotropic drugs, and treatments aimed at lowering ammonia levels (lactulose, rifaximin) 2

Infection Prevention

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 2
• Monitor for infections, particularly fungal pathogens 1

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions 1
• Monitor and replace phosphate, magnesium, and potassium as needed 1
• Initiate enteral nutrition early (60 grams of protein per day is reasonable) 1

Renal Support

• For acute renal failure requiring dialysis, use continuous modes (CVVH) rather than intermittent hemodialysis 1
• Avoid nephrotoxic drugs including NSAIDs 2

Transplantation Considerations

• Contact transplant center early for all ALF patients 2
• Urgent transplantation is indicated when prognostic indicators suggest high likelihood of death 1
• Specific indications for urgent transplantation include:
  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Budd-Chiari syndrome (after excluding underlying malignancy) 1, 2

Prognostic Indicators for Poor Outcome

• Etiology: Idiosyncratic drug injury, acute hepatitis B, autoimmune hepatitis, mushroom poisoning, Wilson disease, Budd-Chiari syndrome, indeterminate cause 1
• King's College Criteria for acetaminophen-induced ALF:
  • Arterial pH <7.3 (after adequate volume resuscitation) regardless of coma grade, OR
  • PT >100 seconds (INR >6.5) and serum creatinine >3.4 mg/dL in patients with grade III/IV coma 1

Common Pitfalls to Avoid

• Delaying transfer to a transplant center
• Excessive fluid administration leading to cerebral edema
• Routine correction of coagulation abnormalities without bleeding
• Overlooking acetaminophen toxicity (check levels regardless of history)
• Failing to consider and treat herpes virus in pregnant women with ALF
• Administering sedatives that may worsen encephalopathy

The management of ALF has improved significantly with advances in critical care, with survival rates increasing from 15% in the pre-transplant era to approximately 60% currently 1, 4. Early recognition, prompt supportive care, and timely referral to a transplant center remain the cornerstones of management.