What is the management approach for acute liver failure?

Management of Acute Liver Failure

Patients with acute liver failure must be immediately transferred to an intensive care unit at a liver transplant center for comprehensive management, as this approach significantly improves survival from 15% in the pre-transplant era to approximately 60% currently. 1

Diagnosis and Initial Evaluation

• Diagnosis of ALF requires:

  • INR ≥1.5
  • Any degree of mental status alteration
  • No preexisting cirrhosis
  • Illness duration ≤26 weeks 1

• Essential initial laboratory testing: 2, 1

  • Prothrombin time/INR
  • Complete blood count
  • Comprehensive metabolic panel
  • Liver function tests (AST, ALT, alkaline phosphatase, GGT)
  • Total bilirubin and albumin
  • Arterial blood gases with lactate
  • Arterial ammonia
  • Serum acetaminophen level (regardless of history)
  • Toxicology screen
  • Viral hepatitis serologies
  • Autoimmune markers
  • Ceruloplasmin (if Wilson disease suspected)
  • Pregnancy test in females

• Imaging:

  • Hepatic Doppler ultrasound to evaluate vascular patency 1

Etiologic Management

1. Acetaminophen overdose: 1, 3

   • Administer N-acetylcysteine (NAC) immediately
   • Loading dose: 140 mg/kg orally or 150 mg/kg IV
   • Follow with maintenance doses
   • For ingestion <4 hours: give activated charcoal (1g/kg) before NAC

2. Viral hepatitis:

   • Acute hepatitis B: Most cases recover spontaneously; consider nucleos(t)ide analogues (entecavir/tenofovir) only in severe cases 1
   • Herpes virus hepatitis: Immediate acyclovir administration 1

3. Autoimmune hepatitis:

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

4. Drug-induced liver injury:

   • Discontinue all non-essential medications 1

5. Mushroom poisoning:

   • Consider penicillin G and silymarin 1

6. Wilson disease and Budd-Chiari syndrome:

   • Early transplant evaluation 2, 1

Critical Care Management

Hemodynamic Support

• Fluid resuscitation with colloid (albumin preferred) containing dextrose 1
• Initiate vasopressors (epinephrine, norepinephrine, or dopamine) if MAP <50-60 mmHg despite adequate fluids 1
• Consider pulmonary artery catheterization in unstable patients 1

Cerebral Edema and Intracranial Hypertension Management

• Grade I-II encephalopathy: Monitor on medical ward with frequent neurological checks 2
• Grade III-IV encephalopathy: Requires intensive monitoring and intervention for cerebral edema 2
• Stepwise approach based on encephalopathy grade to prevent herniation 2

Infection Prevention and Management

• Monitor for infections, particularly fungal pathogens 1
• Administer empirical broad-spectrum antibiotics for:
  • Worsening hepatic encephalopathy
  • Signs of systemic inflammatory response syndrome 1

Metabolic Support

• Continuous glucose infusions to manage hypoglycemia 1
• Monitor and replace phosphate, magnesium, and potassium 1
• Initiate early enteral nutrition (approximately 60g protein/day) 1

Renal Support

• For acute renal failure requiring dialysis, use continuous modes (CVVH) rather than intermittent hemodialysis 1
• Consider albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 1

Liver Transplantation

• Contact transplant center early for all ALF patients 1
• Urgent transplantation indicated when prognostic indicators suggest high likelihood of death 1
• Specific indications for urgent transplantation:
  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Budd-Chiari syndrome 1
• Two-year survival rate approximately 90% after transplantation for severe cases 1

Prognostic Assessment

• King's College Criteria for acetaminophen-induced ALF: 1
  • Arterial pH <7.3 after adequate volume resuscitation, OR
  • PT >100 seconds AND serum creatinine >3.4 mg/dL in patients with grade III/IV coma

Common Pitfalls to Avoid

• Delaying transfer to a transplant center
• Failing to check acetaminophen levels in all ALF cases
• Using intermittent hemodialysis instead of continuous modes
• Administering crystalloid instead of colloid for fluid resuscitation
• Overlooking metabolic derangements (especially hypoglycemia)
• Delaying empiric antibiotics in deteriorating patients
• Missing rare but treatable causes (Wilson disease, autoimmune hepatitis)

By following this comprehensive approach to ALF management with early transplant center involvement, patient outcomes can be significantly improved.