What is the treatment for acute liver failure?

Treatment of Acute Liver Failure

The treatment of acute liver failure requires immediate intensive care support, identification of the underlying cause, and early referral to a liver transplantation center, as liver transplantation is the only definitive treatment for many cases of acute liver failure that do not respond to medical therapy. 1

Initial Assessment and Monitoring

• Determine severity by monitoring:

  • Coagulation factors (PT/INR, factor V)
  • Presence and grade of hepatic encephalopathy
  • Electrolytes, glucose, and renal function
  • Signs of infection 1

• Critical etiologic investigations:

  • Serum acetaminophen levels
  • Viral hepatitis serologies
  • Toxicology screen
  • Hepatic Doppler ultrasound
  • Autoantibody testing 1

• Complete laboratory workup:

  • Liver function tests (AST, ALT)
  • Bilirubin and albumin
  • Complete blood count
  • Arterial blood gases with lactate
  • Ammonia levels 1

Etiology-Specific Treatment

Acetaminophen Overdose

• N-acetylcysteine (NAC) is the specific antidote
• Administer loading dose immediately if:
  • Acetaminophen level is above the "possible toxicity" line on the Rumack-Matthew nomogram
  • Time of ingestion is unknown
  • Clinical evidence of acetaminophen toxicity exists 2
• Continue with maintenance doses for a total of three doses over 21 hours 2

Wilson Disease

• For acute liver failure due to Wilson disease, liver transplantation is life-saving
• While awaiting transplantation, consider:
  • Plasmapheresis
  • Hemofiltration
  • Exchange transfusion
  • Albumin dialysis 3

Budd-Chiari Syndrome

• Liver transplantation is indicated for hepatic vein thrombosis with liver failure
• Important to rule out underlying malignancy prior to transplantation 3

Acute Ischemic Injury ("Shock Liver")

• Cardiovascular support is the primary treatment
• Address underlying cause of hypotension/hypoperfusion 3

Pregnancy-Related Liver Failure

• For acute fatty liver of pregnancy or HELLP syndrome:
  • Obstetrical consultation
  • Expeditious delivery 3

Supportive Care Measures

Coagulation Management

• Administer vitamin K
• Give fresh frozen plasma only for active bleeding or invasive procedures
• Administer platelets for counts <10,000/mm³ or before invasive procedures 1

Metabolic Management

• Monitor glucose every 2 hours
• Treat hypoglycemia with continuous glucose infusions
• Target sodium levels between 140-145 mmol/L
• Monitor and replace phosphate, magnesium, and potassium as needed 1

Infection Prevention

• Administer empirical broad-spectrum antibiotics if signs of sepsis or worsening encephalopathy
• Monitor for bacterial infections (60-80% of ALF patients) and fungal infections (one-third of ALF patients) 1

Gastrointestinal Care

• Provide stress ulcer prophylaxis with H2 blockers or PPIs 1

Hepatic Encephalopathy Management

• Avoid sedation in patients without intracranial hypertension
• Minimize patient stimulation
• Avoid procedures that cause straining
• Note: Osmotic laxatives (lactulose) or non-absorbable antibiotics (rifaximin) are not recommended 1

Renal Complications

• Use continuous modes of hemodialysis rather than intermittent hemodialysis
• Avoid nephrotoxic agents
• Monitor regional citrate anticoagulation during renal replacement therapy 1

Nutritional Support

• Initiate early enteral nutrition
• 60 grams of protein per day is reasonable 1

Liver Transplantation

• Early referral to liver transplant centers is crucial, particularly for:

  • Patients >40 years old
  • Those jaundiced for >7 days before onset of encephalopathy 1

• Expedited transplantation is indicated for:

  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Budd-Chiari syndrome 1

• For indeterminate etiology cases, liver biopsy using a transjugular approach may help diagnose:

  • Malignant infiltration
  • Autoimmune hepatitis
  • Certain viral infections
  • Wilson disease 3

Important Caveats and Pitfalls

1. Delayed Referral: Never delay referral to a liver transplantation center, as this significantly worsens outcomes 1

2. Prophylactic Coagulation Factors: Avoid prophylactic administration of coagulation factors as this precludes assessment of disease progression 1

3. Volume Management: Excessive volume expansion in patients with renal complications should be avoided 1

4. Sodium Levels: Serum sodium levels above 150 mmol/L can be deleterious and should be avoided 1

5. Metabolic Disturbances: Hypoglycemia can mimic hepatic encephalopathy and should not be overlooked 1

6. Liver Support Systems: Extracorporeal liver support systems (MARS, Prometheus) have not demonstrated significant survival benefits and should not delay transfer to a liver transplantation center 1

7. Palliative Care: Consider palliative care for patients with poor prognosis, such as those with multiple organ failures who are not transplant candidates 1