When are corticosteroids (steroids) indicated in acute liver failure?

Steroids in Acute Liver Failure: When to Use and When to Avoid

Corticosteroids are indicated in acute liver failure only for autoimmune hepatitis and should not be used in other causes of acute liver failure. 1, 2

Indications for Corticosteroid Use in Acute Liver Failure

Autoimmune Hepatitis

• Definite indication: Acute liver failure due to autoimmune hepatitis 1
• Recommended dosing: Prednisone 40-60 mg/day 1, 2
• Timing: Should be initiated as early as possible when autoimmune hepatitis is suspected 2
• Diagnostic considerations:
  • Liver biopsy should be considered to establish diagnosis when autoimmune hepatitis is suspected 1
  • Histological findings supporting autoimmune etiology include interface hepatitis, plasma cell infiltration, and hepatocyte rosettes 1
  • Centrilobular necrosis with otherwise typical features of autoimmune hepatitis should be treated with conventional corticosteroid therapy 1

Alcoholic Hepatitis

• Indication: Severe alcoholic hepatitis with Maddrey Discriminant Function ≥32 or MELD >20 1
• Dosing: Prednisolone 40 mg daily for 28 days 1
• Response assessment: Lille score at day 7 1
  • If Lille score <0.45: Continue prednisolone for 28 days total
  • If Lille score ≥0.45 (especially ≥0.56): Stop treatment and consider liver transplantation in selected patients

Contraindications to Corticosteroid Use in Acute Liver Failure

Absolute Contraindications

• Uncontrolled infections 1
• Acute kidney injury with serum creatinine >2.5 mg/dL 1
• Uncontrolled upper gastrointestinal bleeding 1
• Intracranial hypertension management in acute liver failure 2

Relative Contraindications

• Drug-induced liver injury (DILI) 3, 4
• Indeterminate acute liver failure 3
• Alcoholic hepatitis with MELD >51 (no benefit shown) 5

Monitoring During Corticosteroid Therapy

• Early response assessment: Evaluate response after 7 days of therapy using Lille score for alcoholic hepatitis 1
• Infection surveillance: Systematic screening for infection before and during treatment 1, 2
• Transplant consideration: Patients should be placed on transplant list even while receiving corticosteroids 1
• Laboratory monitoring:
  • Weekly liver tests and blood counts for first 4 weeks
  • Monthly monitoring once stable 2

Important Considerations

Risk of Treatment Failure

• Higher MELD scores (>40) are associated with poorer response to steroids 3
• Patients with severe coagulopathy and encephalopathy may have poor outcomes with steroids alone 6

Liver Transplantation

• Do not delay transplantation evaluation with protracted courses of corticosteroids 6
• Consider transplantation if no improvement in serum bilirubin, MELD-Na, or clinical parameters within 7 days 2

Special Situations

• In centrilobular necrosis with acute liver failure, a short (≤2 weeks) treatment trial with prednisolone may determine responsiveness or need for immediate liver transplantation 1
• Prophylactic antibiotics should be considered due to increased infection risk in patients receiving steroids 2

Conclusion

Corticosteroids have a limited but important role in the management of acute liver failure. They are primarily indicated for autoimmune hepatitis and severe alcoholic hepatitis but should be avoided in other causes of acute liver failure. Early identification of non-responders and timely consideration of liver transplantation are critical for improving outcomes.