What is the management approach for liver failure?

Management of Liver Failure

The comprehensive management of liver failure requires a multisystem approach focusing on supportive care, treating the underlying cause, and early consideration of liver transplantation for patients with poor prognostic indicators. 1, 2

Diagnostic Evaluation

• Perform blood analysis including serum acetaminophen levels, hepatitis A (IgM VHA) and hepatitis B (HBsAg and anti-HBc IgM) serology, and toxicology screen in urine for substances like amphetamine and cocaine 1, 2
• Conduct hepatic Doppler ultrasound to exclude chronic liver disease and verify vessel permeability 1, 2
• Perform echocardiography, especially when ischemic hepatocellular injury is suspected in patients with cardiac failure or arrhythmias 2
• Measure coagulation parameters (PT/INR, factor V), blood glucose, arterial blood gases, lactate levels, and arterial ammonia to assess disease severity 1, 2

Organ System Management

Central Nervous System

• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L to prevent cerebral edema 1, 2
• Monitor blood glucose at least every 2 hours to prevent hypoglycemia 1, 2
• Perform tracheal intubation and sedation for progressive hepatic encephalopathy (Glasgow <8) to protect the airway 1, 3
• Use propofol as the preferred sedative agent due to its favorable pharmacokinetic profile and minimal impact on hepatic encephalopathy 3
• Avoid benzodiazepines and psychotropic drugs like metoclopramide as they can worsen encephalopathy 1, 3

Cardiovascular System

• Assess volume status, cardiac output, and cardiac function to guide fluid and vasopressor management 1, 2
• Use crystalloid fluids as first choice for fluid expansion to maintain adequate intravascular volume 1
• Administer norepinephrine for refractory hypotension to maintain mean arterial pressure of 50-60 mm Hg 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients to ensure appropriate volume replacement 1, 2

Renal System

• Provide continuous rather than intermittent renal replacement therapy for acute renal failure to improve outcomes 1
• Avoid nephrotoxic drugs, including NSAIDs, to prevent further renal injury 1, 2

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions as symptoms may be obscured by encephalopathy 1
• Supplement phosphate, magnesium, and potassium as levels are frequently low 1
• Initiate enteral nutrition early with approximately 60 grams of protein per day; avoid severe protein restrictions 1
• Consider parenteral nutrition if enteral feeding is contraindicated, despite risks of fungal infection 1

Coagulation Management

• Restrict clotting factor administration to cases with active bleeding only 1, 2
• Do not routinely correct coagulation abnormalities unless active bleeding is present 1, 2

Infection Control

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of SIRS 1, 2

Specific Treatments

• Administer N-acetylcysteine systematically regardless of suspected etiology to improve outcomes and reduce morbidity 2, 4
• Contact a transplant unit early to consider liver transplantation 1, 2
• Provide etiology-specific treatments, such as acyclovir for Herpes simplex virus hepatitis 1
• Consider urgent liver transplantation when prognostic indicators suggest a high likelihood of death 1, 2

Prognostic Considerations and Transplantation Criteria

• Poor prognostic indicators warranting transplantation consideration include:
  • Idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning 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

Common Pitfalls to Avoid

• Delaying N-acetylcysteine administration while awaiting confirmation of acetaminophen toxicity 4
• Using vasopressin for blood pressure support, which may worsen outcomes 1
• Administering lactulose or rifaximin to lower ammonia levels, which lacks evidence in acute liver failure 1
• Delaying contact with transplant centers, which reduces survival chances 1, 5
• Excessive sedation that may mask neurological deterioration 3