Management of Chronic Liver Failure
The management of chronic liver failure requires a systematic approach focused on identifying and treating the underlying cause, preventing complications, and providing supportive care to improve mortality and quality of life outcomes.
Initial Assessment and Classification
- Determine if the patient has acute liver failure (ALF), chronic liver failure, or acute-on-chronic liver failure (ACLF)
- ACLF is defined as a clinical syndrome of sudden hepatic decompensation observed in patients with chronic liver disease and associated with the failure of one or more extrahepatic organs 1
- Assess severity using validated scoring systems:
- Child-Pugh score for chronic liver disease
- MELD (Model for End-Stage Liver Disease) score for transplant prioritization
- CLIF-SOFA (Chronic Liver Failure-Sequential Organ Failure Assessment) for ACLF
Diagnostic Workup
Essential Laboratory Tests:
- Complete blood count
- Comprehensive metabolic panel
- Prothrombin time/INR
- Arterial blood gases and lactate
- Arterial ammonia levels
- Viral hepatitis serologies (HAV IgM, HBsAg, anti-HBc IgM, HCV)
- Toxicology screen
- Autoimmune markers if indicated 1
Imaging:
- Abdominal Doppler ultrasound to:
- Exclude chronic liver disease features
- Verify vessel permeability (hepatic veins, portal vein)
- Rule out malignancy 1
- Echocardiography if ischemic injury suspected
Management of Specific Complications
1. Hepatic Encephalopathy
- Do not use sedatives such as benzodiazepines and psychotropic drugs 1
- Do not routinely use lactulose or rifaximin to lower ammonia levels in acute liver failure 1
- For chronic liver failure with encephalopathy:
2. Renal Dysfunction
- Avoid nephrotoxic drugs, including NSAIDs 1
- Renal replacement therapy according to specific recommendations 1
- For hepatorenal syndrome:
3. Coagulopathy
- Do not routinely correct coagulation abnormalities unless active bleeding is present 1
- Restrict clotting factor administration to cases of active hemorrhage
4. Infection Management
- Administer empirical broad-spectrum antibiotics to patients with:
- Worsening hepatic encephalopathy
- Signs of systemic inflammatory response syndrome (SIRS) 1
- Consider antifungal prophylaxis in high-risk liver transplant recipients 1
5. Nutritional Support
- Provide adequate protein intake
- Ensure sufficient caloric intake to prevent catabolism
- Target positive nitrogen balance to prevent sarcopenia 1
Specific Therapeutic Interventions
N-acetylcysteine Therapy
- For acetaminophen-induced liver failure: initiate N-acetylcysteine therapy without waiting for serum acetaminophen levels 1
- Consider N-acetylcysteine therapy for non-acetaminophen-related acute liver failure to improve morbidity and mortality 1
Liver Transplantation
- Early contact with transplant unit for patients with severe liver failure 1
- Consider liver transplantation for:
- Use balanced crystalloid solutions over normal saline for peri-transplant fluid replacement 1
- Consider albumin over crystalloid for intraoperative volume replacement during liver transplantation 1
Monitoring and Follow-up
- Daily assessment of mental status
- Monitor serum creatinine, electrolytes, and ammonia levels
- Continuous pulse oximetry for patients receiving terlipressin 3
- Blood glucose monitoring at least every 2 hours 1
- Target serum sodium levels between 140-145 mmol/L 1
Cautions and Pitfalls
- Avoid sedatives and psychotropic drugs in patients with hepatic encephalopathy
- Avoid nephrotoxic medications
- Do not routinely correct coagulation abnormalities unless active bleeding
- Monitor for respiratory failure in patients with volume overload or ACLF Grade 3
- Recognize that terlipressin-related adverse reactions may make a patient ineligible for liver transplantation 3
Early recognition of liver failure, prompt management of complications, and timely referral for liver transplantation when appropriate are essential for improving outcomes in patients with chronic liver failure.