What is the treatment for liver failure?

Treatment of Liver Failure

The management of liver failure requires a multidisciplinary approach with early referral to a liver transplantation center, as liver transplantation remains the essential therapy for patients with end-stage liver disease and offers the best chance of survival. 1

Types of Liver Failure

Acute Liver Failure (ALF)

• ALF occurs suddenly in patients without pre-existing liver disease 1
• Characterized by coagulopathy, jaundice, and hepatic encephalopathy 2
• Requires rapid diagnosis and management to prevent mortality 3

Acute-on-Chronic Liver Failure (ACLF)

• Represents acute worsening of pre-existing chronic liver disease 1
• Associated with organ failures and high short-term mortality 1
• Requires specialized management approaches 1

Diagnostic Evaluation

• Perform comprehensive blood analysis including serum acetaminophen levels, hepatitis serology, and toxicology screen to identify specific etiologies 3
• Conduct hepatic Doppler ultrasound to exclude chronic liver disease and verify vessel permeability 3
• Measure coagulation parameters, blood glucose, arterial blood gases, lactate levels, and arterial ammonia to assess disease severity 3
• Consider transjugular liver biopsy in cases of indeterminate etiology 2

General Management Principles

Organ Support

• Monitor encephalopathy frequently and maintain serum sodium levels between 140-145 mmol/L to prevent cerebral edema 3
• Monitor blood glucose at least every 2 hours to prevent hypoglycemia 1
• Perform tracheal intubation for progressive hepatic encephalopathy (grades III-IV) to protect the airway 3
• Provide careful fluid resuscitation to maintain adequate intravascular volume 2
• Use norepinephrine for refractory hypotension to maintain mean arterial pressure of 50-60 mmHg 3
• Implement continuous renal replacement therapy rather than intermittent dialysis for acute renal failure 3
• Avoid nephrotoxic drugs, including NSAIDs, to prevent further renal injury 3

Coagulation Management

• Administer vitamin K to patients with liver failure 2
• Reserve fresh frozen plasma for invasive procedures or active bleeding rather than routine correction of coagulation abnormalities 3
• Consider platelets for counts <10,000/mm³ or before invasive procedures 2

Specific Treatments

Etiology-Specific Treatments

• Administer N-acetylcysteine systematically regardless of suspected etiology to improve outcomes 3
• Provide acyclovir for suspected herpes simplex virus hepatitis 2
• Consider corticosteroids (prednisone, 40-60 mg/day) for autoimmune hepatitis 2
• For Wilson disease-related ALF, consider albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 2
• Discontinue all but essential medications in drug-induced hepatotoxicity 2

Management of Hepatic Encephalopathy

• Lactulose is FDA-approved for the prevention and treatment of portal-systemic encephalopathy 4
• Rifaximin is indicated for reduction in risk of overt hepatic encephalopathy recurrence in adults 5
• In clinical trials of rifaximin for hepatic encephalopathy, 91% of patients were using lactulose concomitantly 5

Liver Support Systems

• The MARS (Molecular Adsorbent Recirculating System) and Prometheus systems have been the most widely studied artificial liver support systems 1
• Post-hoc analysis demonstrated significant improvement in hepatic encephalopathy when using albumin dialysis with MARS versus standard medical therapy 6
• MARS therapy also shows improvement in hepatorenal syndrome 6
• Short-term survival improvement has been observed in patients with ACLF and multiple organ failure treated with liver support systems 1
• These systems may serve as a bridge to liver transplantation 6

Liver Transplantation

• Urgent liver transplantation is indicated when prognostic indicators suggest a high likelihood of death 2
• Post-transplant survival rates for ALF have been reported as high as 80% to 90% 2
• Poor prognostic indicators include idiosyncratic drug injury, non-hepatitis A viral infections, autoimmune hepatitis, mushroom poisoning, Wilson disease, Budd-Chiari syndrome, and indeterminate cause 2
• Early contact with a transplant unit is essential to consider liver transplantation 3

Infection Control

• Administer empirical broad-spectrum antibiotics to patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 3
• Bacterial infections have been documented in 60%-80% of patients with ALF, and fungal infections occur in one-third of patients 1

Pitfalls and Caveats

• Do not delay transfer to a liver transplantation center, as the "transplantation window" is often narrow 1
• Avoid benzodiazepines and psychotropic drugs like metoclopramide as they can worsen encephalopathy 3
• Do not routinely correct coagulation abnormalities unless active bleeding is present 3
• The quality of liver failure guidelines varies significantly; only those established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60% 1