What is the treatment for acute liver failure?

Treatment of Acute Liver Failure

The management of acute liver failure (ALF) requires immediate etiology-specific treatment, comprehensive supportive care, and early evaluation for liver transplantation, as this remains the definitive life-saving intervention for many patients with ALF. 1

Etiology-Specific Treatments

• Acetaminophen overdose: Administer N-acetylcysteine (NAC) immediately to prevent or lessen hepatic injury, following the Rumack-Matthew nomogram to guide treatment decisions 2
• Viral hepatitis A and B: Provide supportive care as no virus-specific treatment has proven effective for established ALF 1
• Herpes virus or varicella zoster: Immediately treat with acyclovir and place patient on liver transplant list 1
• Wilson disease: Consider urgent liver transplantation as this condition is uniformly fatal without it; use albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange to acutely lower serum copper 1
• Autoimmune hepatitis: Administer corticosteroids (prednisone 40-60 mg/day) and place patient on transplant list 1
• Acute fatty liver of pregnancy/HELLP syndrome: Consult obstetrical services and expedite delivery 1
• Drug-induced hepatotoxicity: Discontinue all but essential medications and obtain detailed medication history 1
• Mushroom poisoning: Consider penicillin G and silymarin administration; list for transplantation 1
• Indeterminate etiology: Consider transjugular liver biopsy to identify specific etiology that might influence treatment 3

Supportive Care Management

Central Nervous System Management

• Monitor mental status frequently and transfer to ICU if level of consciousness declines 3
• Position patient with head elevated at 30 degrees and minimize stimulation 3
• For grades III-IV encephalopathy, intubate for airway protection 3
• Control seizures with phenytoin; avoid benzodiazepines when possible 3
• Consider lactulose administration to reduce ammonia levels, though evidence for improved outcomes is limited 3

Hemodynamic Support

• Pay careful attention to fluid management and hemodynamics 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients 1, 4
• If fluid replacement fails to maintain mean arterial pressure of 50-60 mm Hg, use vasopressors such as epinephrine, norepinephrine, or dopamine 1, 4
• Avoid vasopressin as it may be harmful in ALF 1

Coagulation Management

• Administer vitamin K (at least one dose) 3
• Reserve fresh frozen plasma (FFP) for invasive procedures or active bleeding 3
• Give platelets for counts <10,000/mm³ or before invasive procedures 3
• Consider recombinant activated factor VII for invasive procedures 3

Metabolic Management

• Monitor glucose, potassium, magnesium, and phosphate levels closely 3, 1
• Manage hypoglycemia with continuous glucose infusions 1
• Initiate early enteral nutrition with moderate protein intake (approximately 60 grams per day) 1
• Use parenteral nutrition if enteral feeding is contraindicated 1

Infection Prevention and Management

• Provide prophylaxis for stress ulceration with H2 blockers or proton pump inhibitors 3
• Administer empiric broad-spectrum antibiotics within 1 hour of identifying sepsis 4
• Obtain blood cultures before starting antibiotics, but don't delay antibiotic administration 4
• Consider fungal infections in patients not responding to antibiotics 4

Renal Support

• Avoid nephrotoxic agents 3
• If dialysis is needed, use continuous modes rather than intermittent hemodialysis 3, 1

Liver Transplantation

• Urgent liver transplantation is indicated in ALF where prognostic indicators suggest high likelihood of death 1
• Post-transplant survival rates for ALF can be 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

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 long-term outcomes 1
• Recent studies have shown improved short-term survival for some ALF patients treated with porcine hepatocyte-based bioartificial liver, but further research is needed 1

Common Pitfalls and Caveats

• Systemic corticosteroids are ineffective for general ALF treatment (except in autoimmune hepatitis) 3
• N-acetylcysteine use in non-acetaminophen ALF remains controversial; a large multi-center trial is underway 3
• Changes in aminotransferase levels correlate poorly with prognosis 3
• Malignant infiltration of the liver can mimic ALF; consider this in patients with previous cancer history or massive hepatomegaly 3
• Diagnosing sepsis in hepatic insufficiency is challenging due to impaired lactate clearance, baseline vasodilation, and often absent fever 4