What is the treatment for acute liver injury?

Treatment of Acute Liver Injury

All patients with acute liver failure (ALF) should be admitted to an intensive care unit with frequent monitoring, and early contact with a transplant center should be initiated immediately, as these interventions directly impact mortality. 1

Immediate Assessment and Etiology-Specific Treatment

Acetaminophen Toxicity (Most Common Cause in US/Europe)

N-acetylcysteine (NAC) should be administered promptly in any case where acetaminophen overdose is suspected or possible, even if acetaminophen levels are low or undetectable, as this is the only proven antidote and can be beneficial even 48+ hours post-ingestion. 1, 2

Dosing regimens:

• Oral: 140 mg/kg loading dose, then 70 mg/kg every 4 hours for 17 doses 1
• Intravenous: 150 mg/kg over 15 minutes, then 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours 1, 2

For suspected ingestion within 4 hours: Give activated charcoal (1 g/kg) just prior to starting NAC, as this does not reduce NAC effectiveness 1

Key diagnostic indicators:

• Aminotransferases >3,500 IU/L are highly correlated with acetaminophen poisoning even without clear history 1
• Draw acetaminophen levels in all ALF patients regardless of history 1
• Use Rumack-Matthew nomogram only for single acute ingestions ≥4 hours post-ingestion 2

Non-Acetaminophen Drug-Induced Liver Injury

Immediately discontinue all non-essential medications, as continued exposure worsens outcomes. 3

Mushroom Poisoning (Amanita phalloides)

Administer penicillin G and consider silibinin/silymarin, and list immediately for transplantation as this is often the only lifesaving option. 3

Viral Hepatitis

For herpes simplex virus or varicella zoster: Administer acyclovir immediately and list for transplant 3

For hepatitis A, B, and E: Provide supportive care only, as no virus-specific treatment has proven effective 3

For hepatitis B reactivation: Give nucleoside analogs prior to and for 6 months after chemotherapy completion 3

Autoimmune Hepatitis

Treat with corticosteroids while simultaneously listing for transplantation, as medical therapy alone may be insufficient. 3

Pregnancy-Related Liver Failure

For acute fatty liver of pregnancy or HELLP syndrome: Expeditious delivery is the definitive treatment 3

Wilson Disease

This is uniformly fatal without transplantation; initiate albumin dialysis, continuous hemofiltration, plasmapheresis, or plasma exchange to acutely lower serum copper. 3

Do NOT initiate penicillamine in acute Wilson disease, as this is contraindicated. 3

Ischemic Hepatopathy

Cardiovascular support is the primary treatment. 3

Hepatic Vein Thrombosis

Liver transplantation is indicated if underlying malignancy is excluded. 3

Critical Supportive Care Measures

Hemodynamic Management

Maintain mean arterial pressure 50-60 mmHg through aggressive fluid resuscitation; if this fails, use vasopressors (epinephrine, norepinephrine, or dopamine). 3

Consider pulmonary artery catheterization in hemodynamically unstable patients to guide volume replacement. 3

Renal Support

Use continuous renal replacement therapy rather than intermittent hemodialysis if dialysis is needed. 3

Nutritional Support

Initiate enteral feeding early with 60 grams protein daily; avoid severe protein restriction despite encephalopathy. 3, 1

Metabolic Management

Manage hypoglycemia with continuous glucose infusions and repeatedly supplement phosphate, magnesium, and potassium as these frequently become depleted. 3

Thromboprophylaxis

Start LMWH-based prophylaxis as soon as possible, though individualize anticoagulant reversal decisions in patients already on anticoagulants. 1, 3

Management of Specific Complications

Hepatic Abscesses

Treat with percutaneous drainage. 1, 3

Delayed Hemorrhage

Manage with angiography/angioembolization if hemodynamically stable. 1, 3

Hepatic Artery Pseudoaneurysm

Perform angioembolization to prevent rupture. 1, 3

Bilomas

Drain percutaneously if symptomatic or infected; consider combined percutaneous drainage and endoscopic techniques for complex biliary complications. 1, 3

Liver Transplantation

Urgent hepatic transplantation is indicated when prognostic indicators suggest high likelihood of death, with post-transplant survival rates of 80-90%. 3

Early listing is critical, as delay in transplant evaluation is a common pitfall that increases mortality. 3

Special Considerations for Traumatic Liver Injury

Hemodynamically Stable Patients

Non-operative management is the treatment of choice for all grades of injury without other indications for surgery. 1, 4

Perform serial clinical evaluations and laboratory testing to detect deterioration. 1, 4

ICU admission is required only for moderate (AAST III) and severe (AAST IV-V) lesions. 1, 4

Hemodynamically Unstable Patients

Proceed immediately to operative management with primary goals of hemorrhage control and bile leak management. 1, 4

Avoid major hepatic resections initially; use damage control techniques including packing, compression, and topical hemostatic agents. 1, 4

Angioembolization is useful for persistent arterial bleeding after damage control procedures. 1, 4

Consider REBOA as a bridge to definitive hemorrhage control. 1, 4

Common Pitfalls to Avoid

• Delaying transplant center contact in any patient with ALF 1
• Withholding NAC due to low/absent acetaminophen levels or delayed presentation 1
• Overlooking herbal preparations and dietary supplements as potential causes 3
• Initiating penicillamine in acute Wilson disease 3
• Delaying delivery in pregnancy-related liver failure 3
• Severe protein restriction in encephalopathy 3