What is the treatment for acute liver failure?

Treatment of Acute Liver Failure

The treatment of acute liver failure (ALF) requires immediate supportive care in an intensive care unit setting, with liver transplantation as the definitive life-saving intervention for patients with poor prognostic indicators. 1

Etiology-Specific Treatments

Acetaminophen Toxicity

• Administer N-acetylcysteine (NAC) immediately to prevent or lessen hepatic injury, regardless of the time since ingestion 2
• For acute ingestion, use the Rumack-Matthew nomogram to guide treatment decisions when timing and acetaminophen levels are known 2
• Continue NAC treatment with maintenance doses for a total of three separate doses over an infusion period of 21 hours 2

Viral Hepatitis

• Viral hepatitis A and B-related ALF must be treated with supportive care as no virus-specific treatment has been proven effective 1
• For patients with hepatitis B who require chemotherapy or immunosuppression, nucleoside analogs should be given prior to and continued for 6 months after completion of treatment to prevent reactivation 1
• Patients with known or suspected herpes virus or varicella zoster as the cause of ALF must be immediately placed on the liver transplant list and treated with acyclovir 1

Wilson Disease

• Wilson disease-related ALF is considered uniformly fatal without transplantation 1
• Treatment to acutely lower serum copper and limit hemolysis should include albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 1
• Penicillamine is not recommended in ALF due to risk of hypersensitivity 1

Autoimmune Hepatitis

• Liver biopsy should be considered to establish this diagnosis 1
• Treat with corticosteroids (prednisone, 40-60 mg/day) 1
• Patients should be placed on the transplant list even while corticosteroids are being administered 1

Acute Fatty Liver of Pregnancy/HELLP Syndrome

• Consultation with obstetrical services and expeditious delivery are recommended 1
• Recovery is typically rapid after delivery, with supportive care as the only other treatment required 1

Drug-Induced Hepatotoxicity

• Discontinue all but essential medications 1
• Obtain detailed medication history including prescription drugs, non-prescription medications, herbs, and dietary supplements 1

Mushroom Poisoning

• Consider administration of penicillin G and silymarin 1
• Patients should be listed for transplantation, as this procedure is often the only lifesaving option 1

Supportive Care Management

Hemodynamic Support

• Careful attention must be paid to fluid resuscitation and maintenance of adequate intravascular volume 1
• Pulmonary artery catheterization should be considered in hemodynamically unstable patients 1
• If fluid replacement fails to maintain mean arterial pressure of 50-60 mm Hg, use systemic vasopressor support with agents such as epinephrine, norepinephrine, or dopamine (but not vasopressin) 1

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions 1
• Monitor and supplement phosphate, magnesium, and potassium levels as needed 1
• Initiate enteral feedings early with moderate protein intake (approximately 60 grams per day) 1
• If enteral feedings are contraindicated, parenteral nutrition is an option despite risks of fungal infection 1

Renal Support

• If dialysis support is needed for acute renal failure, use continuous modes rather than intermittent modes 1

Liver Transplantation

• Urgent hepatic transplantation is indicated in ALF where prognostic indicators suggest a high likelihood of death 1
• Post-transplant survival rates for ALF have been reported to be as high as 80% to 90% 1
• Poor prognostic indicators include idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning, Wilson disease, Budd-Chiari syndrome, and indeterminate cause 1

Liver Support Systems

• Various liver support systems have been tested with no certain evidence of efficacy 1
• Sorbent systems may show transient improvement of hepatic encephalopathy but no improvement in hepatic function or long-term benefit 1
• Recent studies have shown improved short-term survival for some patients with ALF treated with porcine hepatocyte-based bioartificial liver, but further research is needed 1

Recent Trends in Management

• Between 1998 and 2013, overall 21-day survival rates for ALF patients increased from 67.1% to 75.3%, with transplant-free survival improving from 45.1% to 56.2% 3
• Reductions in blood product transfusions, mechanical ventilation, and vasopressor use have been observed 3
• Increased use of N-acetylcysteine has been noted even in non-acetaminophen ALF cases 3