What is the primary goal and initial treatment of supportive medicine in acute liver failure?

Supportive Medicine in Acute Liver Failure

The primary goal of supportive medicine in acute liver failure (ALF) is to maintain adequate intravascular volume and organ perfusion through careful fluid resuscitation, with colloid (albumin) preferred over crystalloid solutions. 1

Initial Hemodynamic Management

• Fluid resuscitation is essential as the first step in management, as low systemic vascular resistance results in hypotension even in fluid-resuscitated patients 1
• Colloid solutions (such as albumin) are preferred over crystalloid solutions (such as saline) for fluid replacement 1
• All solutions should contain dextrose to maintain euglycemia and prevent hypoglycemia, which is common in ALF 1, 2
• Pulmonary artery catheterization should be considered in hemodynamically unstable patients to assess volume status and guide management 1
• If fluid replacement fails to maintain mean arterial pressure (MAP) of 50-60 mm Hg, systemic vasopressor support should be initiated 1
• Epinephrine, norepinephrine, or dopamine (but not vasopressin) should be used as vasopressors 1, 3

Metabolic Management

• Hypoglycemia requires management with continuous glucose infusions, as symptoms may be obscured by encephalopathy 1, 2
• Phosphate, magnesium, and potassium levels are frequently low and require repeated supplementation throughout hospitalization 1, 2
• Enteral nutrition should be initiated early with moderate protein intake (approximately 60 grams per day) 1, 2
• Severe protein restriction should be avoided 1
• If enteral feedings are contraindicated (e.g., severe pancreatitis), parenteral nutrition is an option, despite risks of fungal infection 1

Renal Support

• If dialysis support is needed for acute renal failure, continuous modes rather than intermittent modes should be used 1, 3
• Continuous hemofiltration may be particularly beneficial in specific etiologies like Wilson disease to remove copper 1, 2

Etiology-Specific Considerations

• N-acetylcysteine is indicated for acetaminophen overdose to prevent or lessen hepatic injury 4
• For autoimmune hepatitis, corticosteroids (prednisone 40-60 mg/day) should be administered while simultaneously listing for transplantation 1, 2
• In Wilson disease, acute copper-lowering treatments (albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange) should be implemented 1, 2
• For acute fatty liver of pregnancy/HELLP syndrome, consultation with obstetrical services and expeditious delivery are essential 1, 2
• In herpes virus-related ALF, immediate acyclovir treatment and transplant listing are necessary 2

Liver Transplantation Considerations

• Urgent hepatic transplantation is indicated when prognostic indicators suggest a high likelihood of death 1, 2
• Post-transplant survival rates for ALF have been reported as high as 80-90% 2
• Transplant-free survival has improved over time, from 45.1% to 56.2% in recent years 5

Liver Support Systems

• Artificial liver support systems may provide a "bridge" to transplantation or recovery 1
• The MARS and Prometheus systems have shown improvement in hepatic encephalopathy and hepatorenal syndrome in some studies, but no definitive survival benefit 1
• Recent data suggests artificial liver support systems may improve short-term survival (14-day and 28-day) in patients with multiple organ failure 1

Common Pitfalls and Caveats

• Failure to recognize and treat hypoglycemia due to masked symptoms in encephalopathic patients 1, 2
• Inadequate fluid resuscitation leading to persistent hypotension and organ hypoperfusion 1
• Delayed recognition of specific etiologies requiring targeted interventions (e.g., Wilson disease, autoimmune hepatitis) 1, 2
• Overlooking the need for continuous rather than intermittent dialysis in hemodynamically unstable patients 1, 3
• Delaying transplant evaluation in patients with poor prognostic indicators 2, 6

Recent Advances

• Increased use of N-acetylcysteine even in non-acetaminophen ALF has been associated with improved outcomes 5
• Reductions in blood product transfusions, mechanical ventilation, and vasopressor use correlate with improved survival 5
• Non-invasive techniques for monitoring intracranial pressure are now preferred over invasive monitoring 6
• Overall survival in ALF has improved significantly over the past two decades 5, 6