From the Guidelines
Management of acute liver failure requires immediate hospitalization in an intensive care unit with potential transfer to a liver transplant center, focusing on identifying and treating the underlying cause, and providing supportive care to manage complications and prevent further deterioration, as recommended by the most recent guidelines 1. The initial management of acute liver failure involves identifying and treating the underlying cause, such as discontinuing hepatotoxic medications, administering N-acetylcysteine for acetaminophen toxicity, or providing antiviral therapy for viral hepatitis.
- Key aspects of supportive care include:
- Maintaining glucose levels with dextrose infusions as needed
- Correcting coagulopathy with vitamin K and possibly fresh frozen plasma for active bleeding
- Managing complications like hepatic encephalopathy with lactulose and rifaximin
- Monitoring cerebral edema in severe cases with head elevation, minimal stimulation, and possible intracranial pressure monitoring
- Preserving renal function with careful fluid management, avoiding nephrotoxic agents, and initiating continuous renal replacement therapy if needed
- Infection surveillance with cultures and prophylactic antibiotics, as suggested by recent guidelines 1 According to the guidelines, early consultation with a liver transplant center is essential, as transplantation remains the definitive treatment for many cases of acute liver failure that don't show signs of spontaneous recovery 1.
- The guidelines also emphasize the importance of individualized care, taking into account the unique pathophysiology of liver disease and its manifestations in various organ systems, as highlighted in the study by Nanchal et al 1. In contrast to older studies, such as the 2005 AASLD position paper 1, which noted the lack of effective therapies for acute liver failure, the recent guidelines provide a more comprehensive approach to management, emphasizing the importance of supportive care and early consultation with a liver transplant center 1.
From the FDA Drug Label
Acetylcysteine solution, USP administered orally, is indicated as an antidote to prevent or lessen hepatic injury which may occur following the ingestion of a potentially hepatotoxic quantity of acetaminophen. The acute ingestion of acetaminophen in quantities of 150 mg/kg or greater may result in hepatic toxicity.
The management of acute liver failure (ALF) due to acetaminophen overdose involves the administration of N-acetylcysteine (IV) as an antidote to prevent or lessen hepatic injury. It is essential to initiate treatment as soon as possible after the overdose and, in any case, within 24 hours of ingestion 2.
- Key considerations in management include:
- Initiating treatment as soon as possible after overdose
- Determining plasma or serum acetaminophen concentrations to assess potential risk of hepatotoxicity 2
- Using a nomogram to determine if plasma concentration is in the potentially toxic range 2
- Continuing with maintenance doses of acetylcysteine if the predetoxification plasma level is above the broken line on the nomogram 2
From the Research
Management of Acute Liver Failure (ALF)
The management of ALF involves several key components, including:
- Identifying the cause of ALF to guide specific therapies 3
- Early commencement of continuous renal replacement therapy (CRRT) to control hyperammonaemia 3
- Plasma exchange may have a role in the sickest of ALF patients, although other blood purification modalities still lack supporting evidence 3
- Close monitoring, regular investigations, careful attention to neuroprotective measures, and optimizing general physiological supports 3, 4
- Transfer to a liver transplant centre to achieve the best chance of transplant-free survival or to undergo emergency liver transplantation if required 3, 5
Critical Care Management
Critical care management of ALF includes:
- Management of hepatic encephalopathy, cerebral edema, fluid and electrolytes, and prevention of infections 4
- Organ support, such as plasma exchange, timely mechanical ventilation, or continuous renal replacement therapy 4
- Monitoring of cerebral edema, fluid status assessment, and interventions for sepsis prevention, nutritional support, and management of electrolytes 4
Supportive Care
Supportive care remains the mainstay of ALF management, including:
- Supportive care in the critical care setting 6
- Management of multiple organ failure, including renal impairment, coagulopathy, hypoglycaemia, haemodynamic instability, and cerebral oedema 5
- Quadruple H therapy, a combination of therapies aimed to reduce cerebral oedema in ALF 5
Prognosis and Transplantation
Prognosis and transplantation considerations include: