What is the management and treatment of acute liver failure?

Management and Treatment of Acute Liver Failure

The management of acute liver failure (ALF) requires urgent supportive care, etiology-specific treatments, and early consideration of liver transplantation for cases with poor prognostic indicators. 1, 2

Initial Assessment and General Management

• Perform comprehensive blood analysis including serum acetaminophen levels, hepatitis serology, and toxicology screening to identify the underlying cause and guide specific treatments 2
• Conduct hepatic Doppler ultrasound to exclude chronic liver disease and verify vessel permeability 2
• Monitor coagulation parameters, blood glucose, arterial blood gases, lactate levels, and arterial ammonia to assess disease severity 2
• Provide careful fluid resuscitation and maintain adequate intravascular volume using colloid (such as albumin) rather than crystalloid solutions 3, 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients to guide fluid management 3, 4
• Use systemic vasopressor support (epinephrine, norepinephrine, or dopamine but not vasopressin) if fluid replacement fails to maintain mean arterial pressure of 50-60 mm Hg 3, 4

Etiology-Specific Treatments

• Acetaminophen toxicity: Administer N-acetylcysteine regardless of time since ingestion, as it may benefit ALF of various etiologies 2, 5
• Viral hepatitis:
  • For hepatitis A and B, provide supportive care as no virus-specific treatment has proven effective 1
  • For suspected herpes virus or varicella zoster, immediately administer acyclovir and place patient on liver transplant list 1
• Autoimmune hepatitis:
  • Consider liver biopsy to establish diagnosis 3, 1
  • Treat with corticosteroids (prednisone, 40-60 mg/day) 3, 1
  • Place patients on transplant list even while administering corticosteroids 3, 1
• Acute fatty liver of pregnancy/HELLP syndrome:
  • Consult obstetrical services and perform expeditious delivery 3, 1
  • Provide supportive care after delivery 1
• Wilson disease:
  • Consider urgent transplantation as this condition is uniformly fatal without it 1
  • Use albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange to acutely lower serum copper and limit hemolysis 1
• Drug-induced hepatotoxicity: Discontinue all but essential medications and obtain detailed medication history 1
• Mushroom poisoning: Consider administration of penicillin G and silymarin, and list for transplantation 1

Management of Complications

Neurological Management

• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L to prevent cerebral edema 2
• Perform tracheal intubation and sedation for progressive hepatic encephalopathy to protect the airway 2
• Minimize sedation depth and avoid benzodiazepines and psychotropic drugs like metoclopramide 2

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions, as symptoms may be obscured by encephalopathy 3, 1
• Monitor and supplement phosphate, magnesium, and potassium levels as needed 3, 1
• Initiate enteral feedings early with moderate protein intake (approximately 60 grams per day) 3, 1
• Consider parenteral nutrition if enteral feedings are contraindicated, despite risks of fungal infection 3, 1

Renal Support

• If dialysis support is needed for acute renal failure, use continuous modes rather than intermittent modes 3, 1
• Avoid nephrotoxic drugs, including NSAIDs, to prevent further renal injury 2

Infection Control

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 2
• Obtain periodic surveillance cultures to detect bacterial and fungal infections early 4
• Consider fungal infections in patients not responding to antibiotics, particularly those with prolonged hospitalization 4

Coagulation Management

• Restrict clotting factor administration to cases with active bleeding only 2
• Do not routinely correct coagulation abnormalities unless active bleeding is present 2

Liver Transplantation

• Urgent hepatic transplantation is indicated when prognostic indicators suggest a high likelihood of death 3, 1
• Post-transplant survival rates for ALF have been reported as high as 80-90% 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, 2
  • For acetaminophen-induced ALF: arterial pH <7.3 after adequate volume resuscitation, or PT >100 seconds with serum creatinine >3.4 mg/dL in patients with grade III/IV coma 2
  • For non-acetaminophen ALF: PT >100 seconds irrespective of coma grade 2

Liver Support Systems

• Various liver support systems have been tested with no definitive 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

Pitfalls and Caveats

• Recognize that diagnosing sepsis in hepatic insufficiency is challenging due to impaired lactate clearance, baseline vasodilation, and often absent fever 4
• Symptoms of worsening hepatic decompensation (mental status changes, hyponatremia, acute kidney injury) may indicate underlying infection 4
• Monitor liver enzymes closely in patients receiving antibiotics, as some may worsen hepatic dysfunction 4
• Early contact with a transplant unit is essential to consider liver transplantation options 2, 6