What is the management of acute liver injury?

Management of Acute Liver Injury

The management of acute liver injury requires prompt identification of the underlying cause, immediate initiation of appropriate therapy, and early consideration for liver transplantation in severe cases. 1, 2

Initial Assessment and Management

• Admit patients to ICU or intermediate care setting with continuous monitoring 3
• Obtain laboratory tests to assess liver function:
  • Complete blood analysis: PT/INR, factor V, CBC, metabolic panel, liver enzymes, bilirubin, albumin
  • Arterial blood gases with lactate and ammonia levels 3
• Determine etiology through:
  • Detailed medication history (prescription, over-the-counter, supplements)
  • Viral hepatitis serologies
  • Autoimmune markers
  • Consider liver biopsy via transjugular approach for indeterminate cases 1

Etiology-Specific Management

1. Acetaminophen-Induced Liver Injury

• Administer N-acetylcysteine (NAC) immediately in all suspected or confirmed cases 1, 4
• Dosing regimen: 300 mg/kg total dose given as:
  • Loading dose: 150 mg/kg IV over 15 minutes
  • First maintenance dose: 50 mg/kg over 4 hours
  • Second maintenance dose: 100 mg/kg over 16 hours 4
• Continue NAC beyond 21 hours if INR remains elevated or liver enzymes continue to rise 4
• Consider activated charcoal if presentation is within 4 hours of ingestion 1

2. Autoimmune Hepatitis

• Treat with corticosteroids (prednisone 40-60 mg/day) 1
• Place on transplant list even while administering corticosteroids 1
• Consider liver biopsy to confirm diagnosis 1

3. Acute Fatty Liver of Pregnancy/HELLP Syndrome

• Expedite delivery in consultation with obstetrical services 1
• Provide supportive care post-delivery 1
• Consider postpartum transplantation if necessary 1

4. Ischemic Liver Injury ("Shock Liver")

• Provide cardiovascular support as primary treatment 1
• Use crystalloids for volume expansion and norepinephrine for refractory hypotension 3
• Transplantation is rarely indicated 1

5. Budd-Chiari Syndrome

• Confirm diagnosis with hepatic imaging (CT, Doppler ultrasound, venography, MR venography) 1
• Consider liver transplantation if significant liver failure is present 1
• Rule out underlying malignancy before transplantation 1

Supportive Care Measures

• Manage hepatic encephalopathy:

  • Use lactulose for overt hepatic encephalopathy
  • Consider L-ornithine L-aspartate (LOLA) as adjunctive therapy 3

• Pain management:

  • Acetaminophen up to 3 g/day can be used as first-line treatment (if not the cause of liver injury)
  • Avoid NSAIDs due to risk of GI bleeding, worsening ascites, and nephrotoxicity
  • Opioids may be used with caution and with proactive bowel regimen 3

• Avoid medications that worsen mental status:

  • Benzodiazepines increase risk of falls, injuries, and worsened mental status 3

Transplantation Considerations

• Contact transplant center early in the evaluation process 1

• Expedited liver transplantation should be considered for:

  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids
  • Budd-Chiari syndrome 3

• Use prognostic scoring systems to guide transplant decisions:

  • CLIF-C ACLF score > 70 at admission or Day 3 (90% 90-day mortality)
  • Four or more organ failures at Days 3-7 (90% 28-day mortality) 3

Palliative Care

• Initiate palliative care consultation for all patients with end-stage liver disease 3
• Consider withdrawal of intensive care support in non-transplant candidates with ≥4 organ failures after one week of adequate treatment 3
• Document goals of care, including medical power of attorney, code status, and preferences regarding life-sustaining treatments 3

Pitfalls to Avoid

• Delaying NAC administration in suspected acetaminophen toxicity (can be beneficial even 48+ hours after ingestion) 1
• Failing to recognize acetaminophen toxicity when history is unclear (very high aminotransferases >3,500 IU/L are highly suggestive) 1
• Delaying contact with transplant centers for potential candidates 1
• Underutilizing palliative care services for patients with poor prognosis 3
• Overlooking pregnancy-related causes of liver failure in pregnant women 1

The management of acute liver failure requires a multidisciplinary approach with early consideration for liver transplantation, as mortality can exceed 80% without transplantation in certain cases 5.