What is the treatment for acute decompensated liver failure?

Treatment of Acute Decompensated Liver Failure

Patients with acute decompensated liver failure require urgent stabilization with ICU-level supportive care, immediate identification and treatment of precipitating factors (infection, bleeding, drugs), organ system support, and rapid evaluation for liver transplantation, which remains the definitive treatment for those meeting criteria. 1

Immediate Stabilization and Triage

ICU admission is mandatory for patients with acute-on-chronic liver failure (ACLF) or those with organ system failures requiring support. 1 The 28-day mortality for ACLF is ≥20%, compared to ≤5% for decompensated cirrhosis without ACLF, making early intensive care critical. 1, 2

Initial Assessment Priorities

• Identify and treat precipitants immediately: proven microbial infection with sepsis, severe alcohol-related hepatitis, gastrointestinal bleeding, nephrotoxic drugs, or drug-induced liver injury. 1, 3
• Assess organ system failures across six major systems: liver, kidney, brain, coagulation, circulation, and respiration. 1
• Obtain baseline oxygen saturation (SpO2) before any vasoactive therapy—do not initiate treatment in hypoxic patients (SpO2 <90%) until oxygenation improves. 4

Management of Specific Organ Failures

Renal Dysfunction and Hepatorenal Syndrome (HRS)

Withdraw diuretics immediately and provide volume challenge after excluding other causes of acute kidney injury. 1 For HRS-AKI:

• First-line pharmacotherapy: Terlipressin 0.85 mg IV every 6 hours plus albumin is superior to midodrine/octreotide for reversing HRS-1. 1 However, avoid terlipressin in ACLF Grade 3 patients due to significant respiratory failure risk (14% serious/fatal respiratory failure vs. 5% placebo). 4
• Alternative: Norepinephrine shows non-inferiority to terlipressin in reversing HRS-1 and may be preferred in ACLF Grade 3. 1
• Renal replacement therapy (RRT): Use continuous RRT (not intermittent) in hemodynamically unstable patients as a bridge to transplantation—RRT is not recommended as stand-alone therapy for non-transplant candidates. 1

Cardiovascular Support

Maintain mean arterial pressure (MAP) ≥50-60 mmHg with fluid resuscitation first. 1 If vasopressor support is needed:

• Use epinephrine, norepinephrine, or dopamine—dopamine may improve systemic oxygen delivery. 1
• Do not use vasopressin for blood pressure support. 1
• Consider pulmonary artery catheterization in hemodynamically unstable patients to guide volume replacement. 1

Infection Management

Initiate broad-spectrum antibiotics immediately upon suspicion of infection—bacterial infections are a major precipitant of decompensation. 1, 3 For spontaneous bacterial peritonitis:

• Ceftriaxone 1 g/24h for up to 7 days in decompensated cirrhosis or quinolone-resistant settings. 5
• Perform diagnostic paracentesis without delay in all cirrhotic patients with ascites on hospital admission. 5

Gastrointestinal Bleeding

Start vasoactive drugs immediately upon suspicion of variceal bleeding, even before endoscopic confirmation. 5

• Antibiotic prophylaxis is essential: ceftriaxone preferred in decompensated cirrhosis. 5
• Restrictive transfusion strategy: hemoglobin threshold 7 g/dL, target 7-9 g/dL. 5
• Endoscopic band ligation within 12 hours once hemodynamically stable. 5
• TIPS as rescue therapy for persistent bleeding or early rebleeding. 5

Hepatic Encephalopathy

Lactulose remains first-line therapy for hepatic encephalopathy. 5 Identify and treat precipitants including infection, gastrointestinal bleeding, constipation, and nephrotoxic drugs. 3

Respiratory Failure

Monitor continuously with pulse oximetry—respiratory failure occurs in 14% of critically ill patients with decompensated cirrhosis. 4

• Manage volume overload aggressively: reduce or discontinue albumin/fluids, use diuretics judiciously. 4
• Discontinue any vasoconstrictors if SpO2 drops below 90%. 4

Critical Medications to Avoid

Immediately discontinue:

• NSAIDs: convert diuretic-sensitive ascites to refractory ascites. 2, 5
• ACE inhibitors and angiotensin receptor blockers: worsen renal function. 5
• Nephrotoxic agents: aminoglycosides, contrast agents. 5
• Beta-blockers during acute bleeding: may worsen hemodynamics. 2

Metabolic Management

• Continuous glucose infusions for hypoglycemia—symptoms may be obscured by encephalopathy. 1
• Supplement phosphate, magnesium, and potassium frequently throughout hospital course. 1
• Initiate enteral nutrition early: 60 grams protein per day is reasonable—do not severely restrict protein. 1

Liver Transplantation Evaluation

Urgent transplant evaluation is indicated for all patients with ACLF who are potential candidates—liver transplantation is the definitive treatment. 1

• Do not delay referral: patients with high MELD scores (≥35) may not benefit from aggressive medical therapy if transplant-related adverse reactions (respiratory failure, ischemia) make them ineligible. 4
• Simultaneous liver-kidney transplant should be considered for patients requiring RRT >6 weeks pre-transplant. 1

Etiology-Specific Considerations

Wilson Disease

Liver transplantation is life-saving and the only effective option for acute liver failure due to Wilson disease. 1 Bridge therapies until transplantation include plasmapheresis, hemofiltration, or albumin dialysis to protect kidneys from copper-mediated damage. 1

Acetaminophen Overdose

N-acetylcysteine remains the specific antidote and should be initiated immediately in suspected cases. 6

Palliative Care

Refer non-transplant candidates to palliative care if they are non-responders to pharmacotherapy or have refractory complications. 1, 2 Patients with ACLF Grade 3 have particularly poor prognosis and may benefit from early palliative care discussions. 1

Common Pitfalls to Avoid

• Do not wait for endoscopy to start vasoactive drugs in suspected variceal bleeding. 5
• Do not use intermittent hemodialysis in hemodynamically unstable patients—continuous RRT is superior. 1
• Do not initiate terlipressin in hypoxic patients or those with ACLF Grade 3—respiratory failure risk is prohibitive. 4
• Do not perform large-volume paracentesis without albumin replacement—this worsens hemodynamics. 2
• Do not delay transplant evaluation—spontaneous survival is only 40% in acute liver failure. 1