What is the treatment for acute liver injury?

Treatment of Acute Liver Injury

The treatment of acute liver injury should be etiology-specific, with supportive care as the cornerstone of management regardless of cause. 1

Etiology-Specific Management

Drug-Induced Liver Injury

• For acetaminophen-induced liver injury, N-acetylcysteine (NAC) should be administered as soon as possible and within 24 hours of ingestion to prevent or lessen hepatic injury 2
• For non-acetaminophen drug-induced liver injury, discontinue all but essential medications immediately 1
• In cases of mushroom poisoning, administer penicillin G (300,000 to 1 million units/kg/day intravenously) and consider silibinin/silymarin (30-40 mg/kg/day orally or intravenously for 3-4 days) 1
• Patients with acute liver failure due to mushroom poisoning should be listed for transplantation, as this procedure is often the only lifesaving option 1

Viral Hepatitis

• Viral hepatitis A, B, and E-related acute liver failure must be treated with supportive care as no virus-specific treatment has been proven effective 1
• For patients with known or suspected herpes virus or varicella zoster as the cause of acute liver failure, administer acyclovir immediately and place on the liver transplant list 1
• For hepatitis B reactivation, nucleoside analogs should be given prior to and continued for 6 months after completion of chemotherapy in patients with Hepatitis B surface antigen positivity 1

Autoimmune Hepatitis

• Patients with acute liver failure due to autoimmune hepatitis should be treated with corticosteroids (prednisone, 40-60 mg/day) 1
• These patients should be placed on the transplantation list even while corticosteroids are being administered 1

Pregnancy-Related Liver Injury

• For acute fatty liver of pregnancy or HELLP syndrome, consultation with obstetrical services and expeditious delivery are recommended 1

Wilson Disease

• Acute liver failure due to Wilson disease is considered uniformly fatal without transplantation 1
• Treatment to acutely lower serum copper should include albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange 1
• Initiation of treatment with penicillamine is not recommended in acute liver failure due to Wilson disease 1

Ischemic Liver Injury

• In patients with evidence of ischemic injury, cardiovascular support is the treatment of choice 1

Budd-Chiari Syndrome

• Hepatic vein thrombosis with hepatic failure is an indication for liver transplantation, provided underlying malignancy is excluded 1

Supportive Care Measures

Fluid Management and Hemodynamic Support

• Careful attention must be paid to fluid resuscitation and maintenance of adequate intravascular volume 1
• If fluid replacement fails to maintain mean arterial pressure of 50-60 mm Hg, systemic vasopressor support with agents such as epinephrine, norepinephrine, or dopamine (but not vasopressin) should be used 1
• Pulmonary artery catheterization should be considered in hemodynamically unstable patients to ensure appropriate volume replacement 1

Renal Support

• If dialysis support is needed for acute renal failure, continuous modes rather than intermittent modes should be used 1

Nutritional Support

• Enteral feedings should be initiated early 1
• Severe restrictions of protein should be avoided; 60 grams per day of protein is reasonable in most cases 1
• In the absence of contraindications, enteral feeding should be started as soon as possible 1

Metabolic Management

• Hypoglycemia should be managed with continuous glucose infusions 1
• Phosphate, magnesium, and potassium levels frequently require repeated supplementation 1

Coagulation Management

• LMWH-based prophylaxis should be started as soon as possible following trauma 1
• In patients taking anticoagulants, individualization of the risk-benefit balance of anticoagulant reversal is suggested 1

Management of Complications

Intrahepatic Abscesses

• Intrahepatic abscesses should be treated with percutaneous drainage 1

Delayed Hemorrhage

• Delayed hemorrhage without severe hemodynamic compromise may be managed with angiography/angioembolization 1

Biliary Complications

• Symptomatic or infected bilomas should be managed with percutaneous drainage 1
• For post-traumatic biliary complications not suitable for percutaneous management alone, a combination of percutaneous drainage and endoscopic techniques may be considered 1

Liver Transplantation

• Urgent hepatic transplantation is indicated in acute liver failure where prognostic indicators suggest a high likelihood of death 1
• Post-transplant survival rates for acute liver failure have been reported to be as high as 80% to 90% 1

Special Considerations for Liver Trauma

• For hemodynamically stable patients with liver trauma, non-operative management should be the treatment of choice 3
• Hemodynamically unstable patients should undergo operative management with the primary goal of controlling hemorrhage and bile leak 1
• Major hepatic resections should be avoided initially and only considered in subsequent operations 1

Monitoring and Follow-up

• Serial clinical evaluations must be performed to detect changes in clinical status during non-operative management 1
• Early mobilization should be achieved in stable patients 1
• Intensive care unit admission may be required for moderate and severe liver injuries 1

Pitfalls to Avoid

• Delay in administering N-acetylcysteine for acetaminophen overdose (should be given within 24 hours) 2
• Failure to consider liver transplantation early in the course of acute liver failure 1
• Initiating penicillamine in acute Wilson disease (can cause hypersensitivity) 1
• Overlooking herbal preparations and dietary supplements as potential causes of liver injury 1
• Delaying delivery in pregnancy-related liver failure 1