What is the initial management for patients with acute or chronic liver failure?

Initial Management of Acute and Chronic Liver Failure

The initial management of acute liver failure (ALF) requires immediate hospitalization, transfer to an intensive care unit, and comprehensive assessment of coagulation abnormalities and mental status changes. 1

Definition and Diagnosis

• ALF is defined by coagulation abnormality (typically INR ≥1.5) and any degree of mental alteration (encephalopathy) in patients without preexisting cirrhosis with illness duration ≤26 weeks 1
• Immediate measurement of prothrombin time and careful evaluation for subtle alterations in mentation are essential for diagnosis 1
• Hospital admission is mandatory when prothrombin time is prolonged by 4-6 seconds or more (INR ≥1.5) and there is any evidence of altered sensorium 1

Initial Assessment

• Complete history should focus on possible exposures to viral infections, drugs, or toxins 1
• Physical examination must include careful assessment of mental status and search for stigmata of chronic liver disease 1
• Initial laboratory evaluation should include:
  • Prothrombin time/INR 1
  • Complete metabolic panel (sodium, potassium, chloride, bicarbonate, calcium, magnesium, phosphate, glucose) 1
  • Liver function tests (AST, ALT, alkaline phosphatase, GGT, total bilirubin, albumin) 1
  • Arterial blood gases and lactate 2
  • Complete blood count 2
  • Acetaminophen level and toxicology screen 2
  • Viral hepatitis serologies 2

Supportive Care Management

Hemodynamic Support

• Careful attention must be paid to fluid resuscitation and maintenance of adequate intravascular volume 2
• Pulmonary artery catheterization should be considered in hemodynamically unstable patients 2
• If fluid replacement fails to maintain mean arterial pressure of 50-60 mm Hg, use systemic vasopressor support with agents such as epinephrine, norepinephrine, or dopamine (but not vasopressin) 2

Metabolic Management

• Manage hypoglycemia with continuous glucose infusions 2
• Monitor and supplement phosphate, magnesium, and potassium levels as needed 2
• Initiate enteral feedings early with moderate protein intake (approximately 60 grams per day) 2
• If enteral feedings are contraindicated, parenteral nutrition is an option despite risks of fungal infection 2

Central Nervous System Management

• Monitor mental status frequently and transfer to ICU if level of consciousness declines 2
• Position patient with head elevated at 30 degrees and minimize stimulation 2
• For grades III-IV encephalopathy, intubation is recommended for airway protection 2
• Control seizures with phenytoin, avoiding benzodiazepines when possible 2

Coagulation Management

• Administer vitamin K to patients with ALF 2
• Reserve fresh frozen plasma (FFP) for invasive procedures or active bleeding 2
• Give platelets for counts <10,000/mm³ or before invasive procedures 2

Renal Support

• If dialysis support is needed for acute renal failure, use continuous modes rather than intermittent modes 2
• Avoid nephrotoxic agents 2

Infection Prevention and Management

• Prophylaxis for stress ulceration with H2 blockers or proton pump inhibitors is recommended 2

Etiology-Specific Management

Acetaminophen Toxicity

• Administer N-acetylcysteine (NAC) immediately (140 mg/kg orally or via nasogastric tube followed by 70 mg/kg every 4 hours for 17 doses) even if >48 hours since ingestion 2

Viral Hepatitis

• For hepatitis A and B-related ALF, provide supportive care as no virus-specific treatment has proven effective 2
• For patients with known or suspected herpes virus or varicella zoster, immediately place on liver transplant list and treat with acyclovir 2

Wilson Disease

• Wilson disease-related ALF is considered uniformly fatal without transplantation 2
• Treatment to acutely lower serum copper and limit hemolysis should include albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 2
• Penicillamine is not recommended due to risk of hypersensitivity 2

Autoimmune Hepatitis

• Consider liver biopsy to establish diagnosis 1
• Treat with corticosteroids (prednisone, 40-60 mg/day) 1
• Place patients on transplant list even while administering corticosteroids 1

Acute Fatty Liver of Pregnancy/HELLP Syndrome

• Consult obstetrical services and perform expeditious delivery 1
• Recovery is typically rapid after delivery, with supportive care as the only other treatment required 2

Drug-Induced Hepatotoxicity

• Discontinue all but essential medications 2
• Obtain detailed medication history including prescription drugs, non-prescription medications, herbs, and dietary supplements 2

Mushroom Poisoning

• Consider administration of penicillin G and silymarin 2
• List patients for transplantation, as this procedure is often the only lifesaving option 2

Liver Transplantation

• Urgent hepatic transplantation is indicated in ALF where 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

Common Pitfalls and Caveats

• Changes in aminotransferase levels correlate poorly with prognosis in ALF patients 2
• Malignant infiltration of the liver can mimic ALF and should be considered in patients with previous cancer history or massive hepatomegaly 2
• In ischemic hepatitis, serum bilirubin is usually <3 mg/dL despite marked elevations in transaminases and coagulopathy 3
• Bilirubin may be falsely elevated in patients with hemolysis, which should be excluded when evaluating ALF 3