What is the management approach for acute decompensated liver failure?

Management of Acute Decompensated Liver Failure

The management of acute decompensated liver failure requires immediate ICU-level care with a systematic approach targeting cerebral edema prevention, infection surveillance, coagulation support, hemodynamic stabilization, and early transplant evaluation, while avoiding nephrotoxic agents and maintaining strict metabolic monitoring. 1

Initial Assessment and Monitoring

Immediate ICU admission is mandatory when INR ≥1.5 with any altered mental status. 2 The distinction between acute liver failure (no pre-existing cirrhosis, illness ≤26 weeks) and acute-on-chronic liver failure (ACLF, decompensated cirrhosis with organ failures) is critical as it affects prognosis and management strategy. 1

Essential Laboratory Monitoring

• Obtain baseline labs including INR, comprehensive metabolic panel, arterial blood gases, lactate, complete blood count, ammonia level, and liver function tests. 1, 2
• Monitor glucose, potassium, magnesium, and phosphate levels closely with frequent supplementation as needed. 1
• Send daily LFTs, INR, ammonia, and renal function tests to track progression. 1

Encephalopathy and Cerebral Edema Management

The risk of cerebral edema increases dramatically with advancing encephalopathy grade: 25-35% with grade III and 65-75% with grade IV coma. 1

Grade I-II Encephalopathy

• Transfer to liver transplant facility and list for transplantation consideration. 1
• Minimize stimulation and avoid sedation if possible. 1
• Lactulose targeting 2-3 soft bowel movements daily may reduce ammonia levels, though evidence shows only modest survival benefit without clear improvement in encephalopathy severity or overall outcome. 1 The main concern is gaseous abdominal distension potentially complicating subsequent transplant surgery. 1
• Perform brain CT to rule out intracranial hemorrhage or other causes of altered mental status, though it has limited utility for identifying cerebral edema. 1

Grade III-IV Encephalopathy

• Intubate for airway protection (may require short-acting benzodiazepines in small doses for unmanageable agitation). 1, 2
• Elevate head of bed to 30 degrees. 2
• Consider ICP monitoring device placement in specialized centers. 1
• Treat seizures immediately with phenytoin; prophylaxis value is unclear. 1, 2
• Mannitol should be reserved for severe ICP elevation or first clinical signs of herniation. 1
• Hyperventilation effects are short-lived; use only for impending herniation. 1

Infection Prevention and Treatment

Surveillance for and prompt antimicrobial treatment of infection is required, as infections are common precipitants and complications of acute liver failure. 1, 3

• Ceftriaxone 2g IV daily for up to 7 days provides antibiotic prophylaxis in advanced liver failure, particularly with active bleeding. 3 However, routine prophylaxis in all acute liver failure patients is possibly helpful but not definitively proven. 1
• Maintain high index of suspicion for bacterial and fungal infections. 1
• Avoid nephrotoxic antibiotics. 1, 3

Coagulation Management

The approach to coagulopathy must balance bleeding risk against the need to preserve INR as a prognostic marker. 1

• Administer vitamin K at least one dose. 1, 2
• Fresh frozen plasma (FFP) should be given ONLY for invasive procedures or active bleeding, not to correct INR numbers alone. 1, 2 Overuse of blood products may worsen portal hypertension. 3
• Platelets should be given for counts <10,000/mm³ or before invasive procedures. 1, 2
• Recombinant activated factor VII may be considered for invasive procedures. 1, 2
• Omeprazole 40mg IV daily (or H2 blocker) for stress ulcer prophylaxis is recommended. 1, 2

Hemodynamic and Renal Support

Careful fluid management is critical to avoid both hypovolemia and fluid overload. 1, 2

• Pulmonary artery catheterization should be considered in hemodynamically unstable patients. 1, 2
• Maintain mean arterial pressure 50-60 mmHg with volume replacement using crystalloids or colloids. 1, 3, 2
• If fluid replacement fails, use vasopressor support with dopamine, epinephrine, or norepinephrine—NOT vasopressin, which is potentially harmful in acute liver failure. 1, 2
• Avoid nephrotoxic drugs, large volume paracentesis without albumin replacement, and beta-blockers during acute decompensation. 1, 3
• If dialysis is needed, use continuous modes rather than intermittent hemodialysis. 1, 2

Ascites Management

For tense ascites requiring drainage, clamp at ≤5L per day with albumin replacement. 4, 5

• Albumin 6-8g per liter of ascites removed (typically 6g/day for maintenance) helps prevent post-paracentesis circulatory dysfunction. 5 The FDA label indicates albumin is specifically indicated for removal of ascitic fluid in cirrhosis to support blood volume. 5
• Heparin 5000 units subcutaneously may delay hepatic decompensation and improve survival by preventing portal vein thrombosis and reducing intestinal barrier damage. 3 However, this must be balanced against bleeding risk in the setting of coagulopathy.

Metabolic Management

• Manage hypoglycemia aggressively with continuous glucose infusions and frequent monitoring. 1, 2
• Supplement phosphate, magnesium, and potassium as needed. 1
• Initiate early enteral feeding with moderate protein intake (approximately 60g/day) if possible; use parenteral nutrition only if enteral route is contraindicated despite increased fungal infection risk. 1, 2
• Maintain strict intake/output monitoring. 1

Liver Transplantation Evaluation

Urgent hepatic transplantation should be considered early when prognostic indicators suggest high likelihood of death without transplant, with post-transplant survival rates of 80-90%. 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
• Mean pulmonary arterial pressure ≥45 mmHg is an absolute contraindication to liver transplantation. 3
• List patients early even while administering disease-specific treatments (e.g., corticosteroids for autoimmune hepatitis). 2

Etiology-Specific Considerations

While the question focuses on supportive management, identifying and treating the underlying cause is critical:

• For autoimmune hepatitis, consider liver biopsy and treat with prednisone 40-60mg/day while listing for transplant. 2
• For Wilson disease, treatment to lower serum copper (albumin dialysis, plasmapheresis, or plasma exchange) is needed as this is uniformly fatal without transplantation. 2
• For herpes virus/varicella, immediate transplant listing and acyclovir treatment are required. 2

Common Pitfalls

• Lactulose use in acute liver failure is controversial—while it may reduce ammonia, the US ALFSG found only small survival benefit without improvement in encephalopathy severity, and gaseous distension may complicate transplant surgery. 1
• Avoid correcting INR with FFP unless actively bleeding or performing procedures—INR is a critical prognostic marker. 1
• Do not use vasopressin for hemodynamic support—it is potentially harmful in acute liver failure. 1
• Changes in aminotransferase levels correlate poorly with prognosis—focus on clinical parameters and INR. 2
• Malignant infiltration can mimic acute liver failure; consider in patients with cancer history or massive hepatomegaly. 2