What are the guidelines for managing acute liver failure?

Management of Acute Liver Failure

The management of acute liver failure requires immediate transfer to a liver transplant center, administration of N-acetylcysteine for acetaminophen-induced cases, and comprehensive supportive care with close monitoring for complications including cerebral edema, coagulopathy, and infections. 1

Diagnosis and Initial Assessment

• Perform complete blood analysis including:

  • Prothrombin time (PT)/INR, factor V
  • Complete metabolic panel and liver function tests
  • Arterial blood gases with lactate
  • Ammonia levels 1

• Critical etiologic investigations:

  • Serum acetaminophen levels (regardless of clinical history)
  • Viral hepatitis serologies (IgM VHA, HBsAg, anti-HBc IgM)
  • Toxicology screen
  • Hepatic Doppler ultrasound
  • Autoantibody testing for autoimmune hepatitis 2, 1

Etiology-Specific Management

Acetaminophen-Induced ALF

• Administer N-acetylcysteine immediately with a loading dose of 150 mg/kg IV, followed by maintenance doses of 300 mg/kg divided into 3 sequential doses over 21 hours 2, 3
• For patients presenting within 4 hours of ingestion, administer activated charcoal (1g/kg) prior to NAC 1
• Continue NAC if acetaminophen levels remain detectable or liver enzymes continue to rise 3

Viral Hepatitis

• For herpes virus hepatitis: Immediate administration of acyclovir 1
• For acute hepatitis B: Consider nucleos(t)ide analogues (entecavir or tenofovir) only in cases of persistent serious hepatitis 1

Autoimmune Hepatitis

• Administer corticosteroids (prednisone 40-60 mg/day) 2
• Place patient on transplant list even while administering corticosteroids 2

Drug-Induced or Toxin-Induced ALF

• Discontinue all but essential medications 1
• For mushroom poisoning: Consider penicillamine G and silymarin 1

Supportive Care

Neurological Management

• Monitor for encephalopathy progression
• Maintain serum sodium levels between 140-145 mmol/L 1
• Consider intubation and sedation for progressive encephalopathy (Glasgow <8) 1
• The AGA suggests against empiric treatments to reduce intracranial pressure due to lack of proven mortality benefit 2

Hemodynamic Support

• Evaluate volume status, cardiac output, and cardiac function
• Use crystalloids for initial volume expansion
• Administer colloid (albumin preferred) rather than crystalloid for fluid resuscitation 2, 1
• Initiate vasopressors (norepinephrine preferred) for refractory hypotension 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients 1

Renal Support

• Provide renal replacement therapy as needed
• Use continuous modes (CVVH) rather than intermittent hemodialysis 1
• Avoid nephrotoxic drugs including NSAIDs 1

Coagulation Management

• Do not routinely correct coagulopathy
• Administer coagulation factors only for active bleeding or planned invasive procedures 1

Infection Prevention and Management

• Consider broad-spectrum empirical antibiotics for worsening hepatic encephalopathy or signs of SIRS 1
• Monitor for infections, particularly fungal pathogens 1

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions
• Monitor glucose levels every 2 hours 1
• Monitor and replace phosphate, magnesium, and potassium as needed 1
• Initiate early enteral nutrition (approximately 60 grams of protein per day) 1

Advanced Therapies

Liver Transplantation

• Early contact with a liver transplant unit is crucial for all ALF patients 1
• 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 1

Extracorporeal Support

• The AGA recommends that extracorporeal artificial liver support systems only be used within clinical trials 2
• Consider albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange for specific indications such as Wilson disease 2, 1

Special Considerations

Pregnancy-Related ALF

• For acute fatty liver of pregnancy or HELLP syndrome, consultation with obstetrical services and expeditious delivery are recommended 2

Wilson Disease

• Treatment to acutely lower serum copper should include albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 2
• Recovery is infrequent without transplantation 2

Prognosis

• Survival rates have improved from 15% in the pre-transplant era to approximately 60% currently 1
• Two-year survival rate is approximately 90% after transplantation for severe cases 1
• 90% survival after severe ALF due to acetaminophen without transplantation with appropriate management 1

The management of ALF has evolved significantly with improved critical care strategies and the availability of liver transplantation, making early recognition, appropriate supportive care, and timely referral to a transplant center essential components of successful treatment 4, 5.