What are the priorities in the medical management of acute liver failure?

Priorities in the Medical Management of Acute Liver Failure

The primary priorities in the medical management of acute liver failure (ALF) are early identification of etiology, aggressive organ support, consideration for liver transplantation, and appropriate palliative care consultation for all patients admitted to the ICU with ALF, regardless of transplant listing status. 1

Initial Diagnostic Evaluation

• Perform critical etiologic investigations immediately:

  • Serum acetaminophen levels (regardless of clinical history)
  • Viral hepatitis serologies
  • Toxicology screen
  • Hepatic Doppler ultrasound
  • Autoantibody testing for autoimmune hepatitis 1

• Complete laboratory workup:

  • Prothrombin time (PT)/INR and factor V
  • Complete blood count
  • Comprehensive metabolic panel
  • Liver function tests
  • Total bilirubin and albumin
  • Arterial blood gases with lactate
  • Ammonia levels 1

• When etiology remains unclear after initial evaluation, consider transjugular liver biopsy to identify specific causes that might influence treatment strategy 2

Etiology-Specific Management

1. Acetaminophen-induced ALF:

   • Administer N-acetylcysteine (NAC) immediately without waiting for acetaminophen levels
   • Loading dose: 150 mg/kg IV
   • Maintenance: 300 mg/kg divided into 3 sequential doses over 21 hours 1, 3
   • Consider liver transplant evaluation early, but stabilize with FFP, vitamin K, and NAC first 1

2. Ischemic injury:

   • Cardiovascular support is the treatment of choice 2
   • Maintain euvolemia with crystalloid fluids; consider albumin for fluid resuscitation 1

3. Budd-Chiari syndrome:

   • Confirm diagnosis with hepatic imaging studies
   • Consider liver transplantation if significant liver failure is present
   • Rule out underlying malignancy prior to transplantation 2

4. Malignant infiltration:

   • Diagnose via imaging and biopsy
   • Treat underlying malignancy appropriately
   • Note that transplantation is not an option for these patients 2

Supportive Care Management

Neurological Management

• Monitor for and aggressively treat hepatic encephalopathy and cerebral edema 1, 4
• Consider mechanical ventilation for severe respiratory failure, but recognize this requires goals of care discussion if continuing >48 hours 1

Cardiovascular Support

• Maintain euvolemia with crystalloid fluids
• Consider colloids (albumin preferred) for fluid resuscitation 1

Renal Support

• Use continuous renal replacement therapy (CVVH) rather than intermittent hemodialysis for acute renal failure requiring dialysis 1
• For patients with hepatorenal syndrome-acute kidney injury (HRS-AKI) who are not transplant candidates and unresponsive to pharmacotherapy, offer palliative care 1

Coagulopathy Management

• Administer fresh frozen plasma (FFP) and vitamin K for patients with severe coagulopathy 1
• Monitor coagulation parameters closely but avoid prophylactic correction unless invasive procedures are planned 4

Infection Prevention and Management

• Consider broad-spectrum empirical antibiotics in patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 1
• 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

Nutritional Support

• Initiate early enteral nutrition (approximately 60 grams of protein per day) 1
• Early nutritional evaluation and supplementation are recommended 1

Liver Transplantation Considerations

• Consider expedited liver transplantation for selected patients with ALF 1
• Specific indications for urgent transplantation include:
  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Budd-Chiari syndrome 1
• Liver transplantation has shown approximately 90% 2-year survival rate 1

Palliative Care Integration

• All patients with ALF admitted to the ICU should receive a palliative care consult to:
  • Define prognosis
  • Determine goals of care
  • Document medical power of attorney and code status 1
• Identify surrogate decision-maker within 48 hours of hospital admission 1
• For patients requiring mechanical ventilation >48 hours or ICU stay >48 hours, goals of care should be discussed and documented 1
• Offer palliative care or hospice to patients expected to survive <6 months 1

Prognostic Considerations

• Patients with ACLF and CLIF-C ACLF score ≥70 at 48 hours after intensive care have shown 100% 28-day mortality 1
• Patients with four or more organ failures at Days 3-7 after diagnosis of ACLF-3 have shown 90% and 100% mortality at 28 and 90 days, respectively 1

Common Pitfalls to Avoid

1. Delaying NAC administration in suspected acetaminophen toxicity while waiting for lab results
2. Failing to consider liver transplantation early in the disease course
3. Overlooking underlying malignancy in patients with Budd-Chiari syndrome
4. Neglecting to identify and treat the precipitating cause of ALF
5. Inadequate monitoring of metabolic parameters and coagulation status
6. Delaying palliative care consultation in appropriate cases