As I remind occasional visitors, this blog is simply my medical study notes. And today, I’m reviewing acute liver failure following a recent review of Episodes #100 and #101 on cirrhosis from The Curbsiders (as usual both were outstanding podcasts and the show notes were also, as usual, outstanding – thanks, Curbsiders [this link is to the Curbsiders bio page]).
The American Association For The Study Of Liver Diseases [AASLD] has published the AASLD Position Paper: The Management of Acute Liver Failure: Update 2011 [Link is to the 88 page enhanced PDF].
Our obligation as physicians is to recognize Acute Liver Failure at the earliest opportunity, stabilize the patient, and contact and arrange for safe transport to a liver transplant center.
Here are the first two recommendations with the rationales from the above reference:
Patients with acute liver failure (ALF) should be hospitalized and monitored frequently, preferably in an ICU (III).
Acute liver failure often affects young persons and carries a high morbidity and mortality. Prior to transplantation, most series suggested less than 15% survival. Currently, overall short-term survival (one year) including those undergoing transplantation is greater than 65%.7
Contact with a transplant center and plans to transfer appropriate patients with ALF should be initiated early in the evaluation process (III).
All patients with clinical or laboratory evidence of acute hepatitis should have immediate measurement of prothrombin time and careful evaluation for subtle alterations in mentation. If the prothrombin time is prolonged by ∼4-6 seconds or more (INR ≥1.5) and there is any evidence of altered sensorium, the diagnosis of ALF is established and hospital admission is mandatory. Since the condition may progress rapidly, patients determined to have any degree of encephalopathy should be transferred to the intensive care unit (ICU) and contact with a transplant center made to determine if transfer is appropriate. Transfer to a transplant center should take place for patients with grade I or II encephalopathy (Table 5) because they may worsen rapidly. Early transfer is important as the risks involved with patient transport may increase or even preclude transfer once stage III or IV encephalopathy develops.
CENTRAL NERVOUS SYSTEM
Cerebral edema and intracranial hypertension (ICH) have long been recognized as the most serious complications of acute liver failure.83 Uncal herniation may result and is uniformly fatal. Cerebral edema may also contribute to ischemic and hypoxic brain injury, which may result in long-term neurological deficits in survivors.84 The pathogenic mechanisms leading to the development of cerebral edema and intracranial hypertension in ALF are not entirely understood. It is likely that multiple factors are involved, including osmotic disturbances in the brain and heightened cerebral blood flow due to loss of cerebrovascular autoregulation. Inflammation and/or infection, as well as factors yet unidentified, may also contribute to the phenomenon.85 Several measures have been proposed and used
with varying success to tackle the problem of cerebral edema and intracranial hypertension in patients with ALF. Interventions are generally supported by scant evidence; no uniform treatment protocol has been established.
Because the clinician outside of the transplant center will immediately contact the transplant center for management guidance and for transfer arrangements, supportive care of the patient while awaiting transfer would be given in consultation with the receiving transplant center.
For a review of the likely treatments for acute liver failure, see Table 4 in the enhanced PDF.
And here is Table 4 from the article PDF:
And [note to myself] remember that diagnosis of Acute Liver Failure is not complex — Review Recommendation 2 and Rationale 2 above.
And here is Table 5 from the article PDF:
(1) POSITION PAPER AASLD Position Paper: The Management of Acute Liver Failure: Update 2011 [Full Text Enhanced PDF] from The American Association For The Study Of Liver Diseases [AASLD].
(2) Introduction to the Revised American Association for the Study of Liver Diseases Position Paper on Acute Liver Failure 2011 AND Corrections to the AASLD Position Paper: The Management of Acute Liver Failure: Update 2011 AND AASLD Position Paper: The Management of Acute Liver Failure: Update 2011 [The PDF of all three of the papers].
The PDF of Resource (2), although identical to Resource (1)’s enhanced PDF, is easier to quickly review.