What is the treatment for acute liver failure?

Treatment of Acute Liver Failure

The treatment of acute liver failure requires immediate hospitalization in an ICU setting, early referral to a transplant center, and a comprehensive approach including N-acetylcysteine administration, supportive care, and liver transplantation for appropriate candidates. 1

Initial Management and Diagnosis

• ICU Admission: All patients should be admitted to an ICU or intermediate care setting with continuous monitoring 1
• Diagnostic Workup:
  • Determine etiology through detailed medication history, viral hepatitis serologies, autoimmune markers
  • Consider transjugular liver biopsy for indeterminate cases
  • Obtain comprehensive laboratory tests: liver function tests, coagulation studies (PT/INR, factor V), complete blood count, metabolic panel, arterial blood gases with lactate, and ammonia levels 1

Specific Treatments Based on Etiology

Acetaminophen-Induced Liver Failure

• N-acetylcysteine (NAC): Administer immediately in all suspected or confirmed cases
  • Dosing regimen: 300 mg/kg total dose given as loading dose followed by maintenance doses 1, 2
  • Critical ingestion-treatment interval for maximal protection is 0-8 hours 2
  • Use Rumack-Matthew nomogram to guide treatment decisions for acetaminophen overdose 2
  • Consider activated charcoal if presentation is within 4 hours of ingestion 1

Other Etiologies

• Viral Hepatitis: Initiate nucleoside analogues for HBV reactivation 1
• Autoimmune Hepatitis: Treat with corticosteroids (prednisone 40-60 mg/day) 1
• Alcoholic Hepatitis: Consider steroid therapy 1

Supportive Care

Management of Complications

1. Hepatic Encephalopathy:

   • Use lactulose for overt hepatic encephalopathy
   • Consider L-ornithine L-aspartate (LOLA) as adjunctive therapy 1

2. Hemodynamic Support:

   • Volume expansion with crystalloids as first option
   • Norepinephrine for refractory hypotension
   • Avoid terlipressin in patients with hypoxia or ACLF Grade 3 due to risk of respiratory failure 1

3. Infection Control:

   • Start broad-spectrum antibiotics within 1 hour of shock onset
   • Regular surveillance for infections 1

4. Cerebral Edema Management:

   • Monitor for signs of increased intracranial pressure
   • Maintain head elevation and avoid stimulation
   • Consider intracranial pressure monitoring in severe cases 1

Liver Transplantation

• Early Referral: Contact transplant center early in the evaluation process 1
• Indications: Consider for significant liver failure, especially in:
  • Herpes virus hepatitis
  • Wilson disease
  • Fulminant autoimmune hepatitis unresponsive to steroids 1
• Outcomes: Even patients with multiple organ failures may achieve >80% 1-year survival with transplantation 1
• Contraindications: Rule out underlying malignancy before transplantation 1

Prognostic Assessment and Palliative Care

• Poor Prognosis Indicators:

  • CLIF-C ACLF score > 70 at admission or Day 3 (associated with ~90% 90-day mortality)
  • Four or more organ failures at Days 3-7 after diagnosis of ACLF-3 (90% 28-day mortality and 100% 90-day mortality) 1

• Palliative Care:

  • Consider for patients with expected survival <6 months
  • Associated with lower procedure burden, shorter hospital stays, and increased likelihood of hospice discharge 1

Common Pitfalls to Avoid

• Delayed NAC Administration: Delaying NAC in suspected acetaminophen toxicity can be detrimental 1
• Overlooking Pregnancy-Related Causes: Important consideration in pregnant women 1
• Inappropriate Pain Management: Use acetaminophen up to 3 g/day as first-line for pain; avoid NSAIDs due to risk of bleeding and worsening portal hypertension 1
• Delayed Transplant Referral: Early referral is critical for optimal outcomes 1
• Underutilizing Palliative Care: Can deprive patients and families of specialized support and care 1