From the Guidelines
Treatment for acute liver failure requires immediate medical attention in an intensive care unit, with a strong recommendation for the use of N-acetylcysteine (NAC) in patients with ALF related to acetaminophen overdose, as supported by the American Gastroenterological Association Institute guidelines 1. The primary goal is to identify and address the underlying cause while providing supportive care to prevent complications.
Key Considerations
- Initial management includes discontinuing all potentially hepatotoxic medications and treating specific causes when identified, such as NAC for acetaminophen overdose at a loading dose of 150 mg/kg over 1 hour, followed by 50 mg/kg over 4 hours, then 100 mg/kg over 16 hours, as recommended by the AASLD position paper 1.
- Supportive care involves:
- Maintaining glucose levels (target 80-120 mg/dL) with dextrose infusions as needed
- Correcting coagulopathy with vitamin K (10 mg IV daily) and possibly fresh frozen plasma for active bleeding
- Managing cerebral edema with mannitol (0.5-1 g/kg IV) or hypertonic saline
- Controlling infections with prophylactic antibiotics
Transplantation Considerations
Patients with progressive encephalopathy, severe coagulopathy, or metabolic acidosis should be evaluated for emergency liver transplantation, which offers the best survival chance for many patients with irreversible liver damage, as noted in the AASLD position paper 1 and the American Gastroenterological Association Institute guidelines 1. Early consultation with a liver transplant center is essential, as the window for successful intervention is narrow. The multisystem approach addresses the cascade of organ dysfunction that occurs when the liver fails to perform its vital metabolic, synthetic, and detoxification functions. Given the high morbidity and mortality associated with ALF, it is crucial to prioritize treatment strategies that improve patient outcomes, such as the use of NAC in acetaminophen-related ALF, as supported by the highest quality evidence available 1.
From the Research
Treatment Options for Acute Liver Failure
- Acute liver failure is a rare and serious disease that may be paracetamol-induced or non-paracetamol-induced, with the latter having a poor prognosis and limited treatment options 2.
- N-acetylcysteine (NAC) has been successful in treating paracetamol-induced acute liver failure and reduces the risk of needing to undergo liver transplantation 2.
Efficacy of N-acetylcysteine in Non-Paracetamol-Induced Acute Liver Failure
- The available evidence is inconclusive regarding the effect of NAC compared with placebo or no NAC, as an adjunct to usual care, on mortality or transplant rate in non-paracetamol-induced acute liver failure 2.
- A meta-analysis of prospective clinical trials found that NAC can prolong patients' survival with native liver without transplantation and survival after transplantation, but it cannot improve the overall survival 3.
- Another study found that NAC significantly improved transplant-free survival in adult patients with non-acetaminophen-induced acute liver failure, but no significant benefit was observed concerning the secondary endpoints of length of hospital stay and incidence of adverse effects 4.
Management of Acute Liver Failure
- Optimal medical management in the ICU is one of the more important factors impacting survival with or without liver transplantation 5.
- The careful management of the patient in the ICU with acute liver failure improves the likelihood of survival, and includes the management of fluid disturbances, coagulopathy, and infection 5.
- Cerebral edema and intracranial hypertension are reasons for high morbidity and mortality, and hypertonic saline and mannitol are recommended for treatment 6.
- Extracorporeal liver support system may serve as a bridge to liver transplantation and may increase liver transplantation-free survival in select cases 6.